Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established Status Epilepticus.

OBJECTIVE: To quantify the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during established status epilepticus, we performed a secondary analysis within the cohort of patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT). METHODS: We evaluated factors associated with the endpoint of endotracheal intubation occurring within 120 minutes of ESETT study drug initiation. We defined a blocked, stepwise multivariate regression, examining 4 phases during status epilepticus management: (1) baseline characteristics, (2) acute treatment, (3) 20-minute neurologic recovery, and (4) 60-minute recovery, including seizure cessation and improving responsiveness. RESULTS: Of 478 patients, 117 (24.5%) were intubated within 120 minutes. Among high-enrolling sites, intubation rates ranged from 4% to 32% at pediatric sites and 19% to 39% at adult sites. Baseline characteristics, including seizure precipitant, benzodiazepine dosing, and admission vital signs, provided limited discrimination for predicting intubation (area under the curve [AUC] 0.63). However, treatment at sites with an intubation rate in the highest (vs lowest) quartile strongly predicted endotracheal intubation independently of other treatment variables (adjusted odds ratio [aOR] 8.12, 95% confidence interval [CI] 3.08-21.4, model AUC 0.70). Site-specific variation was the factor most strongly associated with endotracheal intubation after adjustment for 20-minute (aOR 23.4, 95% CI 6.99-78.3, model AUC 0.88) and 60-minute (aOR 14.7, 95% CI 3.20-67.5, model AUC 0.98) neurologic recovery. CONCLUSIONS: Endotracheal intubation after established status epilepticus is strongly associated with site-specific practice pattern variation, independently of baseline characteristics, and early neurologic recovery and should not alone serve as a clinical trial endpoint in established status epilepticus. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT01960075.

Performance Standards of Comprehensive Airway Management for Emergency Medicine Residents.

BACKGROUND: The Emergency Medicine (EM) Milestone Project provides guidance for assessment of resident trainee airway management proficiency (PC10). Although milestones provide a general structure for assessment, they do not define performance standards. The objective of this project was to establish comprehensive airway management performance standards for EM trainees at both novice and mastery levels of proficiency. METHODS: Comprehensive airway management standards were derived using standard-setting procedures. A panel of residency education and airway management experts was convened to determine how trainees would be expected to perform on 51 individual tasks in a standardized airway management simulation encompassing preparation, endotracheal intubation, backup airway use, and ventilation. Experts participated in facilitated exercises in which they were asked to 1) define which items were critical for patient safety, 2) predict the performance of a "novice" learner, and 3) predict the performance of a "mastery" learner nearing independent practice. Experts were given a worksheet to complete and descriptive statistics were calculated using STATA 14. RESULTS: Experts identified 39 of 51 (76%) airway management items as critical for patient safety. Experts also noted that novice trainees do not need to complete all the items deemed to be critical prior to starting practice since they will be supervised by a board-certified EM physician. In contrast, mastery-level trainees would be expected to successfully complete not only the critical tasks, but also nearly all the items in the assessment (49/51, 96%) since they are nearing independent practice. CONCLUSION: In this study, we established EM resident performance standards for comprehensive airway management during a simulation scenario. Future work will focus on validating these performance standards in current resident trainees as they move from simulation to actual patient care.

A Randomized Comparison of In-hospital Rescuer Positions for Endotracheal Intubation in a Difficult Airway.

INTRODUCTION: Emergency endotracheal intubation (ETI) is a common and critical procedure performed in both prehospital and in-hospital settings. Studies of prehospital providers have demonstrated that rescuer position influences ETI outcomes. However, studies of in-hospital rescuer position for ETI are limited. While we adhere to strict standards for the administration of ETI, we posited that perhaps requiring in-hospital rescuers to stand for ETI is an obstacle to effectiveness. Our objective was to compare in-hospital emergency medicine (EM) trainees' performance on ETI delivered from both the seated and standing positions. METHODS: EM residents performed ETI on a difficult airway mannequin from both a seated and standing position. They were randomized to the position from which they performed ETI first. All ETIs were recorded and then scored using a modified version of the Airway Management Proficiency Checklist. Residents also rated the laryngeal view and the difficulty of the procedure. We analyzed comparisons between ETI positions with paired t-tests. RESULTS: Forty-two of our 49 residents (85.7%) participated. Fifteen (35.7%) were female, and all three levels of training were represented. The average number of prior ETI experiences among our subjects was 44 (standard deviation=34). All scores related to ETI performance were statistically equivalent across the two positions (performance score, number of attempts, time to intubation success, and ratings of difficulty and laryngeal view). We also observed no differences across levels of training. CONCLUSION: The position of the in-hospital provider, whether seated or standing, had no effect on the provider's ETI performance. Since environmental circumstances sometimes necessitate alternative positioning for effective ETI administration, our findings suggest that there may be value in training residents to perform ETI from both positions.

CALM Interventions: Behavioral Health Crisis Assessment, Linkage, and Management Improve Patient Care.

Emergency departments (EDs) have seen rising numbers of patients in psychiatric crises, patient boarding, and throughput delays. This study describes and evaluates the impact of a Crisis Assessment Linkage and Management (CALM) service designed to manage behavioral health crises. A year-to-year comparison was performed before (n = 2211 ED visits) and after implementation of CALM (n = 2387). CALM was associated with reductions in median ED and hospital length of stay (LOS) from 9.5 to 7.3 hours and 46.2 to 31.4 hours, respectively. Mean transformed ED LOS decreased by 32.4% ( P < .001). The CALM model improved patient care and throughput metrics by proactively managing behavioral health crises.

Airway Management Proficiency Checklist for Assessing Paramedic Performance.

OBJECTIVE: To develop and derive an instrument for assessing airway management proficiency for paramedics. METHODS: Using a validated difficult airway model simulation, we recorded responses to a standard traumatic brain injury scenario requiring airway management in 197 certified paramedics. Discrete items (N = 131) were developed by an expert panel, and referenced to three performance standard subscales (i.e., intubation, ventilation, and backup airway). Responses were scored and subjected to an iterative process to create a more practical number of items for the final Airway Management Proficiency Checklist (AMPC). Tetrachoric correlations were used to evaluate items for relevance. Kuder-Richardson Formula 20 reliabilities were used to assess internal consistency among checklist items. Finally, a Rasch analysis on each subscale was performed to evaluate items for measurement quality. Items were retained if they were determined to fit the Rasch Model. RESULTS: Items were deleted from the final AMPC for lack of simulation fidelity (26 items), duplicity (15 items), and poor psychometric quality (39 items). In four additional iterations, items were dropped for lack of equipment options (e.g., single mask), lack of instructional clarity (e.g., calculation of GCS score), high inference on the part of the evaluator (6 items), or inadequate measurement of behavioral performance (e.g., passes blade through lips without contacting mouth or teeth). Thirty seven items and three outcome standards (first pass success of the endotracheal tube; assisted ventilation with no interruption of 30 seconds or greater; successful placement of a backup airway device within one attempt) were retained to form three hypothesized subscales. CONCLUSIONS: The AMPC represents a psychometrically derived instrument that identified important tasks required for comprehensive airway management. The 37-item instrument will contribute to improving training and measuring the performance of paramedic's airway management skills.

Creation and Validation of a Novel Mobile Simulation Laboratory for High Fidelity, Prehospital, Difficult Airway Simulation.

UNLABELLED: Introduction Endotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI. Hypothesis/Problem The availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance. METHODS: The MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis. RESULTS: Nineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts. CONCLUSIONS: The MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers. Bischof JJ , Panchal AR , Finnegan GI , Terndrup TE . Creation and validation of a novel mobile simulation laboratory for high fidelity, prehospital, difficult airway simulation. Prehosp Disaster Med. 2016;31(5):465-470.

Improving Outcomes in Patients With Sepsis.

Sepsis mortality may be improved by early recognition and appropriate treatment based on evidence-based guidelines. An intervention was developed that focused on earlier identification of sepsis, early antimicrobial administration, and an educational program that was disseminated throughout all hospital units and services. There were 1331 patients with sepsis during the intervention period and 1401 patients with sepsis during the control period. After controlling for expected mortality, patients in the intervention period had 30% lower odds of dying (odds ratio = 0.70, 95% confidence interval [CI] = 0.57 to 0.84). They also had 1.07 fewer days on average in the intensive care unit (95% CI = -1.98 to -0.16), 2.15 fewer hospital days (95% CI = -3.45 to -0.86), and incurred on average $1949 less in hospital costs, although the effect on costs was not statistically significant. Continued incremental improvement and sustainment is anticipated through organizational oversight, continued education, and initiation of an automated electronic sepsis alert function.

Effect of prior cardiopulmonary resuscitation knowledge on compression performance by hospital providers.

INTRODUCTION: The purpose of this study was to determine cardiopulmonary resuscitation (CPR) knowledge of hospital providers and whether knowledge affects performance of effective compressions during a simulated cardiac arrest. METHODS: This cross-sectional study evaluated the CPR knowledge and performance of medical students and ED personnel with current CPR certification. We collected data regarding compression rate, hand placement, depth, and recoil via a questionnaire to determine knowledge, and then we assessed performance using 60 seconds of compressions on a simulation mannequin. RESULTS: Data from 200 enrollments were analyzed by evaluators blinded to subject knowledge. Regarding knowledge, 94% of participants correctly identified parameters for rate, 58% for hand placement, 74% for depth, and 94% for recoil. Participants identifying an effective rate of ≥100 performed compressions at a significantly higher rate than participants identifying <100 (µ=117 vs. 94, p<0.001). Participants identifying correct hand placement performed significantly more compressions adherent to guidelines than those identifying incorrect placement (µ=86% vs. 72%, p<0.01). No significant differences were found in depth or recoil performance based on knowledge of guidelines. CONCLUSION: Knowledge of guidelines was variable; however, CPR knowledge significantly impacted certain aspects of performance, namely rate and hand placement, whereas depth and recoil were not affected. Depth of compressions was poor regardless of prior knowledge, and knowledge did not correlate with recoil performance. Overall performance was suboptimal and additional training may be needed to ensure consistent, effective performance and therefore better outcomes after cardiopulmonary arrest.

Immediate and 1-year chest compression quality: effect of instantaneous feedback in simulated cardiac arrest.

INTRODUCTION: Several studies have demonstrated subpar chest compression (CC) performance by trained health care professionals. The objective of this study was to determine the immediate and sustained effect of instantaneous audiovisual feedback on CC quality. METHODS: A prospective, randomized, crossover study measuring the effect of audiovisual feedback training on the performance of CCs by health care providers and medical students in a simulated cardiopulmonary arrest scenario was performed. Compression rate, hand placement, depth, and recoil were collected using 60-second epochs of CC on a simulation mannequin. RESULTS: Data from 200 initial enrollments and 100 tested 1 year later were analyzed by evaluators using standard criterion. At initial testing, feedback trainees demonstrated significantly improved depth compliance, recoil compliance, and accuracy of hand placement. One year later, the previous year's control group now receiving feedback demonstrated immediate improvement in depth, hand placement, and rate. In the feedback group, the only statistically significant improvement from initial baseline to the baseline 1 year later was an 18% improvement in depth compliance. However, the same improvement rate was seen in the control group. Improved depth compliance performance was correlated to the number of cardiopulmonary resuscitation training sessions received external to the study. CONCLUSIONS: Instantaneous audiovisual feedback training on CC quality produces immediate improvements in compression rate, hand placement, as well as depth and recoil compliance. These improvements, however, are not retained 1 year later. Improved depth performance may be correlated to an increased training frequency.

Computer simulation as a tool for assessing decision-making in pandemic influenza response training.

INTRODUCTION: We sought to develop and test a computer-based, interactive simulation of a hypothetical pandemic influenza outbreak. Fidelity was enhanced with integrated video and branching decision trees, built upon the 2007 federal planning assumptions. We conducted a before-and-after study of the simulation effectiveness to assess the simulations' ability to assess participants' beliefs regarding their own hospitals' mass casualty incident preparedness. DEVELOPMENT: Using a Delphi process, we finalized a simulation that serves up a minimum of over 50 key decisions to 6 role-players on networked laptops in a conference area. The simulation played out an 8-week scenario, beginning with pre-incident decisions. TESTING: Role-players and trainees (N=155) were facilitated to make decisions during the pandemic. Because decision responses vary, the simulation plays out differently, and a casualty counter quantifies hypothetical losses. The facilitator reviews and critiques key factors for casualty control, including effective communications, working with external organizations, development of internal policies and procedures, maintaining supplies and services, technical infrastructure support, public relations and training. Pre- and post-survey data were compared on trainees. RESULTS: Post-simulation trainees indicated a greater likelihood of needing to improve their organization in terms of communications, mass casualty incident planning, public information and training. Participants also recognized which key factors required immediate attention at their own home facilities. CONCLUSION: The use of a computer-simulation was effective in providing a facilitated environment for determining the perception of preparedness, evaluating general preparedness concepts and introduced participants to critical decisions involved in handling a regional pandemic influenza surge.

Multimedia education increases elder knowledge of emergency department care.

INTRODUCTION: Elders who utilize the emergency department (ED) may have little prospective knowledge of appropriate expectations during an ED encounter. Improving elder orientation to ED expectations is important for satisfaction and health education. The purpose of this study was to evaluate a multi-media education intervention as a method for informing independently living elders about ED care. The program delivered messages categorically as, the number of tests, providers, decisions and disposition decision making. METHODS: Interventional trial of representative elders over 59 years of age comparing pre and post multimedia program exposure. A brief (0.3 hour) video that chronicled the key events after a hypothetical 911 call for chest pain was shown. The video used a clinical narrator, 15 ED health care providers, and 2 professional actors for the patient and spouse. Pre- and post-video tests results were obtained with audience response technology (ART) assessed learning using a 4 point Likert scale. RESULTS: Valid data from 142 participants were analyzed pre to post rankings (Wilcoxon signed-rank tests). The following four learning objectives showed significant improvements: number of tests expected [median differences on a 4-point Likert scale with 95% confidence intervals: 0.50 (0.00, 1.00)]; number of providers expected 1.0 (1.00, 1.50); communications 1.0 (1.00, 1.50); and pre-hospital medical treatment 0.50 (0.00, 1.00). Elders (96%) judged the intervention as improving their ability to cope with an ED encounter. CONCLUSION: A short video with graphic side-bar information is an effective educational strategy to improve elder understanding of expectations during a hypothetical ED encounter following calling 911.

Rural Embedded Assistants for Community Health (REACH) network: first-person accounts in a community-university partnership.

Community research and action projects undertaken by community-university partnerships can lead to contextually appropriate and sustainable community improvements in rural and urban localities. However, effective implementation is challenging and prone to failure when poorly executed. The current paper seeks to inform rural community-university partnership practice through consideration of first-person accounts from five stakeholders in the Rural Embedded Assistants for Community Health (REACH) Network. The REACH Network is a unique community-university partnership aimed at improving rural health services by identifying, implementing, and evaluating innovative health interventions delivered by local caregivers. The first-person accounts provide an insider's perspective on the nature of collaboration. The unique perspectives identify three critical challenges facing the REACH Network: trust, coordination, and sustainability. Through consideration of the challenges, we identified several strategies for success. We hope readers can learn their own lessons when considering the details of our partnership's efforts to improve the delivery infrastructure for rural healthcare.

Hospital-based coalition to improve regional surge capacity.

INTRODUCTION: Surge capacity for optimization of access to hospital beds is a limiting factor in response to catastrophic events. Medical facilities, communication tools, manpower, and resource reserves exist to respond to these events. However, these factors may not be optimally functioning to generate an effective and efficient surge response. The objective was to improve the function of these factors. METHODS: Regional healthcare facilities and supporting local emergency response agencies developed a coalition (the Healthcare Facilities Partnership of South Central Pennsylvania; HCFP-SCPA) to increase regional surge capacity and emergency preparedness for healthcare facilities. The coalition focused on 6 objectives: (1) increase awareness of capabilities and assets, (2) develop and pilot test advanced planning and exercising of plans in the region, (3) augment written medical mutual aid agreements, (4) develop and strengthen partnership relationships, (5) ensure National Incident Management System compliance, and (6) develop and test a plan for effective utilization of volunteer healthcare professionals. RESULTS: In comparison to baseline measurements, the coalition improved existing areas covered under all 6 objectives documented during a 24-month evaluation period. Enhanced communications between the hospital coalition, and real-time exercises, were used to provide evidence of improved preparedness for putative mass casualty incidents. CONCLUSION: The HCFP-SCPA successfully increased preparedness and surge capacity through a partnership of regional healthcare facilities and emergency response agencies.

Two patients subdued with a TASER® device: cases and review of complications.

In the United States, an increasing number of law enforcement agencies have employed the use of TASER® (TASER International Inc., Scottsdale, AZ) devices to temporarily immobilize violent subjects. There are reports in the lay press of adverse outcomes occurring in patients on whom TASER® devices have been deployed. Rhabdomyolysis has been associated with patients sustaining a TASER® shock, with a 1% incidence rate in subjects subdued with earlier versions of the device and then brought to the Emergency Department (ED). We present the cases of 2 patients who were seen in our ED after exhibiting violent behavior and receiving TASER® shocks. Both were hospitalized and received treatment for mild rhabdomyolysis. Both patients had multiple other characteristics that have been found to have an association with the development of rhabdomyolysis, in addition to the shocks they received. A review and discussion of the available medical literature on the subject follows, describing several complications that have been documented in patients after receiving TASER® shocks. Although a direct link between the TASER® and the reported adverse effects has not been established, patients who undergo restraint via this device frequently have pre-existing conditions or have exhibited behavior that places them at risk for the development of those effects. Such awareness of these possible complications is vital because the evaluation and management of patients developing adverse effects after these events will commonly occur in the ED.

Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements.

STUDY OBJECTIVE: Survival after out-of-hospital cardiac arrest depends on the links in the chain of survival. The Utstein elements are designed to assess these links and provide the basis for comparing outcomes within and across communities. We assess whether these measures sufficiently predict survival and explain outcome differences. METHODS: We used an observational, prospective data collection, case-series of adult persons with nontraumatic out-of-hospital cardiac arrest from December 1, 2005, through March 1, 2007, from the multisite, population-based Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. We used logistic regression, receiver operating curves, and measures of variance to estimate the extent to which the Utstein elements predicted survival to hospital discharge and explained outcome variability overall and between 7 Resuscitation Outcomes Consortium sites. Analyses were conducted for all emergency medical services-treated cardiac arrests and for the subset of bystander-witnessed patient arrests because of presumed cardiac cause presenting with ventricular fibrillation or ventricular tachycardia. RESULTS: Survival was 7.8% overall (n=833/10,681) and varied from 4.6% to 14.7% across Resuscitation Outcomes Consortium sites. Among bystander-witnessed ventricular fibrillation or ventricular tachycardia, survival was 22.1% overall (n=323/1459) and varied from 12.5% to 41.0% across sites. The Utstein elements collectively predicted 72% of survival variability among all arrests and 40% of survival variability among bystander-witnessed ventricular fibrillation. The Utstein elements accounted for 43.6% of the between-site survival difference among all arrests and 22.3% of the between-site difference among the bystander-witnessed ventricular fibrillation subset. CONCLUSION: The Utstein elements predict survival but account for only a modest portion of outcome variability overall and between Resuscitation Outcomes Consortium sites. The results underscore the need for ongoing investigation to better understand characteristics that influence cardiac arrest survival.

Developing consensus on appropriate standards of disaster care for children.

BACKGROUND: Neither professional consensus nor evidence exists to guide the choice of essential hospital disaster interventions. The objective of our study was to demonstrate a method for developing consensus on hospital disaster interventions that should be regarded as essential, quantitatively balancing needs and resources. METHODS: A panel of pediatric acute care practitioners developed consensus using a modified Delphi process. Interventions were chosen such that workload per staff member would not exceed the previously validated maximum according to the Therapeutic Intervention Scoring System. Based on published models, it was assumed that the usual numbers of staff would care for a disaster surge of 4 times the usual number of intensive care and non-intensive care hospital patients. RESULTS: Using a single set of assumptions on constrained resources and overwhelming needs, the panel ranked and agreed on essential interventions. A number of standard interventions would exceed crisis workload constraints, including detailed recording of vital signs and fluid balance, administration of vasoactive agents, invasive monitoring of pressures (central venous, intraarterial, intracranial), dialysis, and tube feedings. CONCLUSIONS: The quantitative methodology and consensus development process described in the present report may have utility in future planning. Groups with appropriate expertise must develop action plans according to authority within each jurisdiction, addressing likely disaster scenarios, according to the needs in each medical service region, using available regional resources, and accounting for the capabilities of each institution.

Resuscitation Outcomes Consortium (ROC) PRIMED cardiac arrest trial methods part 1: rationale and methodology for the impedance threshold device (ITD) protocol.

AIM: The primary aim of this study is to compare survival to hospital discharge with a modified Rankin score (MRS)< or =3 between standard cardiopulmonary resuscitation (CPR) plus an active impedance threshold device (ITD) versus standard CPR plus a sham ITD in patients with out-of-hospital cardiac arrest. Secondary aims are to compare functional status and depression at discharge and at 3 and 6 months post-discharge in survivors. DESIGN: Prospective, double-blind, randomized, controlled, clinical trial. POPULATION: Patients with non-traumatic out-of-hospital cardiac arrest treated by emergency medical services (EMS) providers. SETTING: EMS systems participating in the Resuscitation Outcomes Consortium. SAMPLE SIZE: Based on a one-sided significance level of 0.025, power=0.90, a survival with MRS< or =3 to discharge rate of 5.33% with standard CPR and sham ITD, and two interim analyses, a maximum of 14,742 evaluable patients are needed to detect a 6.69% survival with MRS< or =3 to discharge with standard CPR and active ITD (1.36% absolute survival difference). CONCLUSION: If the ITD demonstrates the hypothesized improvement in survival, it is estimated that 2700 deaths from cardiac arrest per year would be averted in North America alone.

Agroterrorism: where are we in the ongoing war on terrorism?

The U.S. agricultural infrastructure is one of the most productive and efficient food-producing systems in the world. Many of the characteristics that contribute to its high productivity and efficiency also make this infrastructure extremely vulnerable to a terrorist attack by a biological weapon. Several experts have repeatedly stated that taking advantage of these vulnerabilities would not require a significant undertaking and that the nation's agricultural infrastructure remains highly vulnerable. As a result of continuing criticism, many initiatives at all levels of government and within the private sector have been undertaken to improve our ability to detect and respond to an agroterrorist attack. However, outbreaks, such as the 1999 West Nile outbreak, the 2001 anthrax attacks, the 2003 monkeypox outbreak, and the 2004 Escherichia coli O157:H7 outbreak, have demonstrated the need for improvements in the areas of communication, emergency response and surveillance efforts, and education for all levels of government, the agricultural community, and the private sector. We recommend establishing an interdisciplinary advisory group that consists of experts from public health, human health, and animal health communities to prioritize improvement efforts in these areas. The primary objective of this group would include establishing communication, surveillance, and education benchmarks to determine current weaknesses in preparedness and activities designed to mitigate weaknesses. We also recommend broader utilization of current food and agricultural preparedness guidelines, such as those developed by the U.S. Department of Agriculture and the U.S. Food and Drug Administration.

Available ventilation monitoring methods during pre-hospital cardiopulmonary resuscitation.

High quality cardiopulmonary resuscitation (CPR) in the pre-hospital setting has been associated with improved survival rates during cardiopulmonary arrest (CPA). Recent documentation of hyperventilation associated deterioration in hemodynamics during CPR, suggests that guided or controlled ventilation strategies may contribute to improved hemodynamics and increased survival. This article briefly reviews the mechanical methods, advantages, and disadvantages of the available ventilation monitoring methods currently available for clinical use, with an emphasis on pre-hospital implementation. We recommend that more objective measurement of ventilation during CPR be performed, with emphasis on a strategy for measuring both attempted ventilation frequency (f) and delivered tidal volume (VT). The use of improved thoracic impedance pneumography and capnography are appealing for such monitoring because of the widespread availability, but modifications to existing software and clinical data compared to a clinical standard would be required before general acceptance is possible. Other methods listed may offer advantages over these in select circumstances.

Research methods of inquiry.

Incidents of significant consequence that create surge may require special research methods to provide reliable, generalizable results. This report was constructed through a process of literature review, expert panel discussion at the journal's consensus conference, and iterative development. Traditional clinical research methods that are well accepted in medicine are exceptionally difficult to use for surge incidents because the incidents are very difficult to reliably predict, the consequences vary widely, human behaviors are heterogeneous in response to incidents, and temporal conditions prioritize limited resources to response, rather than data collection. Current literature on surge research methods has found some degree of reliability and generalizability in case-control, postincident survey methods, and ethnographical designs. Novel methods that show promise for studying surge include carefully validated simulation experiments and survey methods that produce validated results from representative populations. Methodologists and research scientists should consider quasi-experimental designs and case-control studies in areas with recurrent high-consequence incidents (e.g., earthquakes and hurricanes). Specialists that need to be well represented in areas of research include emergency physicians and critical care physicians, simulation engineers, cost economists, sociobehavioral methodologists, and others.