Evaluation of Physicians' Attitudes Regarding Transport Modalities.

OBJECTIVE: Hospital mergers have made interhospital transfers necessary in the consolidation of medical services. Physicians must make decisions on the level of interfacility transport modalities (ITMs). We sought to assess physician knowledge of and comfort with ITMs. METHODS: A survey was e-mailed to 2,510 physicians in a health care system. Participation was voluntary and anonymous. The mean and median Likert values were calculated overall. Similar calculations were performed for emergency medicine physicians (EMPs) and critical care physicians (CCPs). These calculations were compared with those for noncritical care physicians (NCCPs) using the t-test and Mann-Whitney test. RESULTS: Of the 181 physicians who responded, 169 physicians identified a specialty. Sixty-nine were EMPs/CCPs, whereas 100 were NCCPs. The mean and median Likert values were statistically significantly higher for EMPs/CCPs compared with NCCPs (P < .0001) in the areas of knowledge of ITMs, comfort in choosing ITMs, and knowledge in choosing ground versus air critical care transport (CCT). The most important factor for using ground or air CCT was patient stability. Sixty percent believed air CCT to be faster than ground. CONCLUSION: EMPs/CCPs seem to be more comfortable with ITMs than NCCPs. Further research should evaluate whether educational interventions lead to a more appropriate use of ITMs.

Observational Multicenter Study of a Direct-to-CT Protocol for EMS-transported Patients with Suspected Stroke.

OBJECTIVE: In an effort to decrease door-to-needle times for patients with acute ischemic stroke, some hospitals have begun taking stable EMS patients with suspected stroke directly from the ambulance to the CT scanner, then to an emergency department (ED) bed for evaluation. Minimal data exist regarding the potential for time savings with such a protocol. The study hypothesis was that a direct-to-CT protocol would be associated with decreases in both door-to-CT-ordered and door-to-needle times. METHODS: An observational, multicenter before/after study was conducted of time/process measures at hospitals that have implemented direct-to-CT protocols for patients transported by EMS with suspected stroke. Participating hospitals submitted data on at least the last 50 "EMS stroke alert" patients before the launch of the direct-to-CT protocol, and at least the first 50 patients after. Time elements studied were arrival at the ED, time the head CT was ordered, and time tPA was started. Data were submitted in blinded fashion (patient and hospital identifiers removed); at the time of data analysis, the lead investigator was unaware of which data came from which hospital. Simple descriptive statistics were used, along with the Mann-Whitney test to compare time medians. RESULTS: Seven hospitals contributed data on 1040 patients (529 "before" and 511 "after"); 512 were male, and 627 had final diagnoses of ischemic stroke, of whom 275 received tPA. The median door-to-CT-ordered time for all patients was 7 minutes in the before phase, and 4 minutes after (difference 3 minutes, p = < 0.0001); similarly, the median door-to-CT-started time was 6 minutes "before" and 10 minutes after (p < 0.0001). The median door-to-needle time for all patients given tPA was 42 minutes before, and 44 minutes after (p = 0.78). Four hospitals had modest decreases in door-to-CT-ordered time (of 2, 4, 2, and 5 minutes), and only one hospital had a decrease in door-to-needle time (32 min vs 26 min, p = 0.012). CONCLUSIONS: In this sample from seven hospitals, a minimal reduction in door-to-CT-ordered and door-to-CT-started time, but no change in door-to-needle time, was found for EMS patients with suspected stroke taken directly to the CT scanner, compared to those evaluated in the ED prior to CT.

A survey of patients with bed bugs in the emergency department.

Bed bugs are one of the most important human ectoparasites in the United States, and a growing problem in the emergency department. We evaluated 40 emergency department (ED) patients found with a bed bug. The data show that ED patients with bed bugs are statistically more likely to be male, older, more likely to be admitted to the hospital, have higher triage emergency severity index (ESI) scores, and arrive by ambulance than the general ED patient population (p<0.05). On average bed bugs were found 108min after a patient arrived to the ED, after 35% of subjects had already received a blood draw, and after 23% had already received a radiology study; putting other ED patients and staff at risk for acquiring the infestation. We found that 13% and 18% of subjects had wheezing and a papular rash, respectively on physical exam. Of those patients found with a bed bug in the ED, 42% reported having bed bugs at home and 21% reporting having a possible home infestation.

Emergency Medical Services Provider Self-Reported Occupational Safety.

BACKGROUND: Emergency medical services (EMS) providers are at high risk for occupational violence, and some tactical EMS providers carry weapons. METHODS: Anonymous surveys were administered to tactical and nontactical prehospital providers at 180 prehospital agencies in northeast Ohio between September 2018 and March 2019. Demographics were collected, and survey questions asked about workplace violence and comfort level with tactical EMS carrying weapons. RESULTS: Of 432 respondents, 404 EMS providers (94%) reported a history of verbal or physical assault on scene, and 395 (91%) reported working in a setting with a direct active threat at least rarely. Of those reporting a history of assault on scene, 46.5% reported that it occurred at least sometimes. Higher rates of assault on scene were associated with being younger, white, or an emergency medical technician-paramedic, working in an urban environment, having more frequent direct active threats, and having more comfort with tactical EMS carrying firearms (p ≤ .03). Most respondents (306; 71%) reported that they were prepared to defend themselves from someone who originally called for help. Most (303; 70%) reported a comfort level of 8 or higher (from 1, not comfortable to 10, completely comfortable) with tactical EMS providers carrying weapons. Comfort with tactical EMS providers carrying weapons was associated with being white, not having a bachelor's degree, and feeling prepared to defend oneself from a patient (p ≤ .02). CONCLUSION: EMS providers in the survey report high rates of verbal and physical violence while on scene and are comfortable with tactical EMS providers carrying weapons.

Knowledge, Experience, and Concerns Regarding Bed Bugs Among Emergency Medical Service Providers.

Introduction Bed bugs are commonly encountered by emergency medical service (EMS) providers. The objective of this study was to determine the frequency with which EMS providers encountered bed bugs, assess their knowledge about bed bugs, and analyze the actions they take after finding bed bugs. Methods We anonymously surveyed 407 EMS providers from 180 EMS agencies in northeast Ohio between September 1, 2018, through March 31, 2019. Results Among the providers surveyed, 21% (n = 84) of the EMS providers reported seeing bed bugs at least monthly, and 6% (n = 24) reported seeing bed bugs at least weekly. Being younger, male, and working in an urban environment (vs. rural) were associated with EMS providers reporting more frequent bed bug encounters (p: ≤.05). The mean level of concern for encountering bed bugs among EMS providers was 3.54 (SD: 1.15; scale: 1 = no concern, 5 = very concerned). Among the EMS providers who reported seeing bed bugs at least monthly, 30% took the affected EMS stretcher out of service when they encounter a bed bug, 43% took the EMS rig out of service, 83% cleaned the EMS stretcher with a disinfectant, and 88% notified the ED that their patient has bed bugs. EMS providers scored poorly (mean: 69% correct responses) in a seven-question assessment of basic bed bug biology and public health. Conclusion Based on our findings, we concluded that EMS knowledge and behavior related to bed bugs are suboptimal.

Diagnosis and satisfaction scores in emergency department patients who return a mailed survey.

Previous studies of patient satisfaction scores (PSS) have been of insufficient size to examine the influence of diagnosis on PSS. Our objective was to utilize a large database to determine if PSS for patients who return a widely used mailed proprietary survey differ with different diagnoses. We retrospectively analyzed a cohort at 11 hospital emergency departments of non-admitted patients who returned a mailed satisfaction survey. We grouped patients according to International Classification of Diseases, 9(th) Revision (ICD9) diagnoses and calculated mean scores for each diagnostic group. We rank-ordered by mean scores all ICD diagnoses having at least 50 survey responses. Scores were compared using analysis of variance. We analyzed 14,098 surveys. Among all diagnoses, 65 had at least 50 responses. The analysis of variance for the scores showed significant differences (p < 0.0001). Scores differ with respect to diagnosis. This could be used to choose interventions to improve scores of patients who return a mailed survey.

Safety and efficacy of prehospital diltiazem.

INTRODUCTION: Very few studies exist on the use of diltiazem in the prehospital setting. Some practitioners believe this medication is prone to causing hypotension in this setting. Our goals were to determine whether the prehospital administration of diltiazem induced hypotension and to evaluate the efficacy of the drug. METHODS: Our two-tiered system is located in a suburban region of New Jersey with advanced life support (ALS) care provided by fly-car units. The ALS units do not transport patients, and all of them are hospital based. The ALS providers are employed by the hospital system. In New Jersey, all ALS care requires online medical control, including the administration of diltiazem. We retrospectively reviewed patient care records for those who were believed to be in rapid atrial fibrillation and were given diltiazem in a suburban emergeny medical services system over a 22-month period. We examined the differences between heart rate (HR) and blood pressure (BP) on the initial evaluation and on arrival to the emergency department (ED). A hypotensive response was defined as a final systolic BP (SBP) less than 90 mmHg and a drop in SBP of at least 10 mmHg. Diltiazem was considered effective if the ED HR was <100 beats per minute (bpm) or if it decreased ≥20%. RESULTS: During the study period, 26,979 patients were transported. Of these patients, 2,488 had a documented rhythm of atrial fibrillation or atrial flutter. Of the 320 patients who received diltiazem, 42 patient encounters were excluded for incomplete data, yielding 278 patients for analysis. The average initial SBP was 139 mmHg and the average diastolic BP was 84 mmHg. The average diltiazem dosage was 16.7 mg. Two patients became hypotensive. The average initial HR was 154 bpm. On arrival to the ED, 33% of the patients had an HR < 100 bpm and 69% had a drop in HR ≥ 20%. The overall efficacy of prehospital diltiazem was 73%. CONCLUSION: In the prehospital setting, diltiazem is associated with a very low rate of hypotension and appears to be effective in decreasing HR adequately. Prospective studies are needed to confirm these findings.

The effect of temperature on illness severity in emergency department congestive heart failure patients.

INTRODUCTION: Previous studies revealed fewer visits for congestive heart failure (CHF) to emergency departments (EDs) in New Jersey, USA and fewer admissions for CHF to a Southern Indian and an Israeli hospital during warmer months. Using hospital admission rate for CHF as a marker for illness severity, we hypothesized that CHF would also be less severe in warmer months. MATERIALS AND METHODS: This is a retrospective cohort study which included all ED visits from 1 January 2004 to 31 January 2006. We analysed the monthly CHF hospital admission rates. We a priori chose to compare the admission rates for the 4 warmest to the 4 coldest months. RESULTS: Of a total of 136,347 ED visits, 1083 (0.8%) were accounted for CHF. Hospital admission rate was 55.8%. Although there was a statistically significant increase in ED visits for CHF during the colder months, the 4 warmer months from June to September had 1.15 times higher hospital admission rate than the 4 coldest months from November to February. CONCLUSIONS: Contrary to our hypothesis, we found a statistically significant increase in the percentage of CHF visits admitted to the hospital during the warmer months. This suggests that although there are less ED CHF visits in the warmer months, a greater percentage tend to be severe.