Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System.

INTRODUCTION: Prehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure. METHODS: Using data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge. RESULTS: We included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success. CONCLUSION: Implementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.

City-Specific Air Quality Warnings for Improved Asthma Self-Management.

INTRODUCTION: This study presents a framework for identifying "high-risk" days for asthma attacks associated with elevated concentrations of criteria pollutants using local information to warn citizens on days when the concentrations differ from Environmental Protection Agency Air Quality Index (AQI) warnings. Studies that consider the unique mixture of pollutants and the health data specific to a city provide additional information for asthma self-management. This framework is applied to air pollution and asthma data to identify supplemental warning days in Houston, Texas. METHODS: A four-step framework was established to identify days with pollutant levels that pose meaningful increased risk for asthma attacks compared with baseline. Historical associations between 18,542 ambulance-treated asthma attacks and air pollutant concentrations in Houston, Texas (2004-2016; analyzed in 2018), were analyzed using a case-crossover study design with conditional logistic regression. Days with historically high associations between pollution and asthma attacks were identified as supplemental warning days. RESULTS: Days with 8-hour maximum ozone >66.6 parts per billion for the 3 previous days and same-day 24-hour nitrogen dioxide >19.3 parts per billion pose an RR of 15% above baseline; concentrations above these levels pose an increased risk of 15% (RR=1.15, 95% CI=1.14, 1.16) and 30% (RR=1.30, 95% CI=1.29, 1.32), respectively. These warnings add an additional 12% days per year over the AQI warnings. CONCLUSIONS: Houston uses this framework to identify supplemental air quality warnings to improve asthma self-management. Supplemental days reflect risk lower than the National Ambient Air Quality Standards and consecutive poor air quality days, differing from the AQI.

Cardiac arrest survival as a function of ambulance deployment strategy in a large urban emergency medical services system.

INTRODUCTION: This study examines the effect of paramedic deployment strategy on witnessed ventricular fibrillation (VF) cardiac arrest outcomes. Our null hypothesis was that there is no difference in survival between an EMS system using targeted response (TR) and one using a uniform or all advanced life support (ALS) response (UR) model. We define targeted response as a system where paramedics are sent to critical incidents while ambulances staffed with basic EMTs are sent to less critical incidents. A secondary outcome measure was paramedic skill proficiency between the systems. METHODS: We conducted a retrospective review of all 1997 VF arrests in a large urban EMS system. The majority of the city is a busy, urban area that uses TR. Outlying areas of the city are suburban and are served by a UR model. All areas have first responders equipped with automated external defibrillators. Outcomes are compared using Utstein criteria. RESULTS: Patient populations were well matched. There were 181 patients in the TR group and 24 in the UR group. Units in the TR area were able to demonstrate shorter response and time to defibrillation intervals than in the UR area. Rates for return of spontaneous circulation (ROSC), admission to the ward/intensive care unit (ICU), survival to discharge and survival to 1 year were all better in the cohort of patients cared for in the TR area than those in the UR area. Rates for successful intubation and IV initiation were also better in the TR areas than in the UR areas. CONCLUSION: This study shows improved outcomes for a subset of patients with cardiac arrest when they are cared for in an area that uses TR compared to an area that uses a UR EMS system.

The perspective of paramedics about on-scene termination of resuscitation efforts for pediatric patients.

OBJECTIVES: The purpose of this study was to assess the attitude of paramedics to on-scene termination of cardiopulmonary resuscitation (T-CPR) efforts in children prior to developing a pediatric T-CPR policy. METHODS: A 26-item anonymous survey was conducted of all of the active paramedics in a large urban EMS system where T-CPR had been practiced routinely for adults. Questions addressed paramedic demographics, training level, experience with adult and pediatric advanced cardiac life support (ACLS), experience with T-CPR in adults, T-CPR case scenarios, and T-CPR in children. RESULTS: All 201 paramedics in the system (mean age=34.2 years; mean years as paramedic = 8.5 ) completed all relevant items of the survey (100% compliance). Two-thirds had provided ACLS for cardiac arrest to >50 adults (93% >10 adults) and more than one-third had performed ACLS on >20 children (72% >5 children). In addition, 90% had participated in T-CPR for adults. The majority of paramedics reported at least occasional (pre-defined) difficulty with adult T-CPR including family confrontation, 43%; personal discomfort, 13%; disagreement with physician decision to continue efforts, 11%; and fear of liability, 10%. Paramedic self ratings of comfort with terminating CPR on a scale from 1 to 10 (1: very comfortable; 10: uncomfortable) for adults and children were 1 and 9, respectively (P<0.001). In addition, the clear majority (72%) responded that children deserve more aggressive resuscitative efforts than adults. CONCLUSIONS: Paramedics feel relatively uncomfortable with the concept of terminating resuscitation efforts in children in the pre-hospital setting.

Can first responders be sent to selected 9-1-1 emergency medical services calls without an ambulance?

OBJECTIVES: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). METHODS: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. RESULTS: For ALERTs (n = 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n = 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. CONCLUSIONS: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents.

Customer satisfaction in a large urban fire department emergency medical services system.

OBJECTIVES: The purpose of this study was to determine if emergency medical services (EMS) customer satisfaction could be assessed using telephone-survey methods. The process by which customer satisfaction with the EMS service in a large, fire department-based EMS system is reported, and five month results are presented. METHODS: Ten percent of all patients transported during the period of October 15, 2001, through March 15, 2002, were selected for study. In addition, during the same period, all EMS incidents in which a patient was not transported were identified for contact. Customer-service representatives contacted patients via telephone and surveyed them from prepared scripts. RESULTS: A total of 88,528 EMS incidents occurred during the study period. Of these, 53,649 resulted in patient transports and 34,879 did not. Ten percent of patients transported (5,098) were selected for study participation, of which 2,498 were successfully contacted; of these, 2,368 (94.8%) reported overall satisfaction with the service provided. Of the 34,879 incidents without transport, only 5,859 involved patients who were seen but not transported. All of these patients were selected for study. Of these, 2,975 were successfully contacted, with 2,865 (96.3%) reporting overall satisfaction. The most common reason given for nonsatisfaction in both groups was the perception of a long response time. CONCLUSIONS: It is possible to conduct a survey of EMS customer satisfaction using telephone-survey methods. Although difficulties exist in contacting patients, useful information is made available with this method. Such surveys should be an integral part of any EMS system's quality-improvement efforts. In this survey, the overwhelming majority of patients, both transported and not transported, were satisfied with their encounter with EMS.

A tale of two cities: the role of neighborhood socioeconomic status in spatial clustering of bystander CPR in Austin and Houston.

BACKGROUND: Despite evidence to suggest significant spatial variation in out-of-hospital cardiac arrest (OHCA) and bystander cardiopulmonary resuscitation (BCPR) rates, geographic information systems (GIS) and spatial analysis have not been widely used to understand the reasons behind this variation. This study employs spatial statistics to identify the location and extent of clusters of bystander CPR in Houston and Travis County, TX. METHODS: Data were extracted from the Cardiac Arrest Registry to Enhance Survival for two U.S. sites - Austin-Travis County EMS and the Houston Fire Department - between October 1, 2006 and December 31, 2009. Hierarchical logistic regression models were used to assess the relationship between income and racial/ethnic composition of a neighborhood and BCPR for OHCA and to adjust expected counts of BCPR for spatial cluster analysis. The spatial scan statistic was used to find the geographic extent of clusters of high and low BCPR. RESULTS: Results indicate spatial clusters of lower than expected BCPR rates in Houston. Compared to BCPR rates in the rest of the community, there was a circular area of 4.2km radius where BCPR rates were lower than expected (RR=0.62; p<0.0001 and RR=0.55; p=0.037) which persist when adjusted for individual-level patient characteristics (RR=0.34; p=0.027) and neighborhood-level race (RR=0.34; p=0.034) and household income (RR=0.34; p=0.046). We also find a spatial cluster of higher than expected BCPR in Austin. Compared to the rest of the community, there was a 23.8km radius area where BCPR rates were higher than expected (RR=1.75; p=0.07) which disappears after controlling for individual-level characteristics. CONCLUSIONS: A geographically targeted CPR training strategy which is tailored to individual and neighborhood population characteristics may be effective in reducing existing disparities in the provision of bystander CPR for out-of-hospital cardiac arrest.

Prehospital 12-Lead Electrocardiogram within 60 Minutes Differentiates Proximal versus Nonproximal Left Anterior Descending Artery Myocardial Infarction.

INTRODUCTION: Acute anterior myocardial infarctions caused by proximal left anterior descending (LAD) artery occlusions are associated with a higher morbidity and mortality. Early identification of high-risk patients via the 12-lead electrocardiogram (ECG) could assist physicians and emergency response teams in providing early and aggressive care for patients with anterior ST-elevation myocardial infarctions (STEMI). Approximately 25% of US hospitals have primary percutaneous coronary intervention (PCI) capability for the treatment of acute myocardial infarctions. Given the paucity of hospitals capable of PCI, early identification of more severe myocardial infarction may prompt emergency medical service routing of these patients to PCI-capable hospitals. We sought to determine if the 12 lead ECG is capable of predicting proximal LAD artery occlusions. METHODS: In a retrospective, post-hoc analysis of the Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization pilot trial, we compared the ECG findings of proximal and nonproximal LAD occlusions for patients who had undergone an ECG within 180 minutes of symptom onset. RESULTS: In this study, 72 patients had anterior STEMIs, with ECGs performed within 180 minutes of symptom onset. In patients who had undergone ECGs within 60 minutes (n = 35), the mean sum of ST elevation (STE) in leads V1 through V6 plus ST depression (STD) in leads II, III, and aVF was 19.2 mm for proximal LAD occlusions and 11.7 mm for nonproximal LAD occlusions (P = 0.007). A sum STE in V1 through V6 plus STD in II, III, and aVF of at least 17.5 mm had a sensitivity of 52.3%, specificity of 92.9%, positive predictive value of 91.7%, and negative predictive value of 56.5% for proximal LAD occlusions. When the ECG was performed more than 60 minutes after symptom onset (n = 37), there was no significant difference in ST-segment deviation between the 2 groups. CONCLUSION: The sum STE (V1-V6) and STD (II, III, aVF) on a 12-lead ECG can be used to predict proximal LAD occlusions if performed within the first hour of symptom onset. This should be considered a high-risk finding and may prompt prehospital direction of such patients to PCI-capable hospitals.

Managing the post-resuscitation patient in the field.

The principal goal after successful resuscitation of a cardiac arrest patient is to maintain the patient's pulse and avoid a pulseless state. Of equal importance in the post-resuscitation patient are efforts to prevent myocardial dysfunction and increase the likelihood of a good neurologic outcome. To optimize cardiac and hemodynamic resuscitation, paramedics should obtain good background information, which could provide clues to factors contributing to the cardiac arrest, such as the use of certain drugs or being overdue for dialysis, and could aid in customizing therapy for rhythm disturbances and hemodynamic aberrations. Treatment of rhythm disturbances depends on the type of arrhythmia identified, the history of present illness, and the resuscitation efforts provided. Common post-resuscitation dysrhythmias are wide-complex tachycardia, narrow-complex tachycardia, and bradycardia. Optimizing neurologic resuscitation is difficult, but evidence suggests that hypertensive reperfusion, hemodilution, and mild hypothermia may be of benefit in improving neurologic outcome after resuscitation. Unfortunately, to date, no proven therapies are available to improve neurologic outcome after resuscitation from cardiac arrest.

The effect of a quality improvement feedback loop on paramedic-initiated nontransport of elderly patients.

OBJECTIVE: To examine the effect of a paramedic educational program and quality improvement feedback loop on paramedic-initiated nontransport of patients 65 years of age and older. METHODS: Prospective observational study. Patients 65 years of age and older who were evaluated but not transported by paramedics were contacted by telephone within two weeks of emergency medical services (EMS) contact and asked: 1) whether the patient sought medical help within 24 hours after contact; 2) whether the patient was admitted to a hospital and, if so, what was the diagnosis; 3) who was responsible for the nontransport decision (patient, paramedic, or mutual); and 4) how satisfied the patient was with the EMS service. After six weeks of data collection, the results were presented in a nonjudgmental fashion to the paramedics. After this intervention, the data collection continued for another five weeks without the paramedics' knowledge. RESULTS: After the intervention, the overall nontransport rate remained constant (11.5% vs. 10.7%). The percentage of patients seeking further medical attention within 24 hours also remained constant (37.1% vs. 33.9%). The percentage of patients who required hospitalization within 24 hours of the nontransport declined from 12.6% to 6.4%. The percentage of patients who refused ambulance transportation by paramedics declined from 9.3% to 3.7%. Overall satisfaction level rose from 94.7% to 100%. CONCLUSION: When paramedics were provided with objective feedback regarding outcome of patients not transported, the paramedic-initiated nontransportation and delayed hospitalization rates decreased, and the patient satisfaction level rose to 100%.