Time Savings and Safety of EMS Administration of Antibiotics for Open Fractures.

INTRODUCTION: Early administration of antibiotics for open fractures reduces serious bone and soft tissue infections. The effectiveness of antibiotics in reducing these infections is time-dependent, with various surgical associations recommending administration within one hour of injury, or within one hour of patient arrival to the emergency department (ED). The extent to which prehospital antibiotic administration in these situations might reduce the time to treatment has not been previously reported. The purpose of this study was to describe current prehospital use of antibiotics for traumatic injury, to assess the safety of prehospital antibiotic administration, and to estimate the potential time-savings associated with antibiotic administration by EMS clinicians. METHODS: This was a retrospective analysis of the 2019 through 2022 ESO Data Collaborative research data set. Included subjects were patients that had a linked ICD-10 code indicating an open extremity fracture and who received prehospital antibiotics. Time to antibiotic administration was calculated as the elapsed time from EMS dispatch until antibiotic administration. The minimum potential time saved by EMS antibiotic administration was calculated as the elapsed time from administration until ED arrival. To assess safety, epinephrine and diphenhydramine administration were used as proxies for the adverse events of anaphylaxis and minor allergic reactions. RESULTS: There were 523 patients meeting the inclusion criteria. The median (and interquartile range [IQR]) elapsed time from EMS dispatch until antibiotic administration was 31 (IQR: 24-41) minutes. The median potential time savings associated with prehospital antibiotic administration was 15 (IQR: 8-22) minutes. Notably, 144 (27.5%) of the patients who received prehospital antibiotics had total prehospital times exceeding one hour. None of the patients who received antibiotics also received epinephrine for presumed anaphylaxis. CONCLUSIONS: EMS clinicians were able to safely administer antibiotics to patients with open fractures a median of 15 minutes before arrival at the hospital, and 99 percent of the patients receiving antibiotics had them administered within one hour of EMS dispatch. EMS administration of antibiotics may be a safe way to increase compliance with recommendations for early antibiotic administration for open fractures.

The Clinical Role and Activity of Advanced Clinicians in the Out-of-Hospital Environment.

Objective: Recent evolution of the EMS system has resulted in an increased role for specially trained advanced clinicians (physicians, physician assistants, and registered nurses) in out-of-hospital field response. Despite this expansion into the out-of-hospital environment there is a lack of data regarding the actual clinical roles and activity of these clinicians in the United States. We seek to describe the clinical roles of advanced clinicians in the field through description of skills used during both 9-1-1 field responses and interfacility transports in the state of Pennsylvania. Methods: Our data were taken from existing Pennsylvania Department of Health EMS records for all 9-1-1 and interfacility requests for service from January 2018 through June 2020. Descriptive statistics were applied to skills used, medications administered, clinician activity data, and patient demographics for each clinician type in four response categories: 9-1-1 air, 9-1-1 ground, interfacility air, and interfacility ground. Results: There were few statistically significant differences in skill or medication usage between clinician types. There were no statistically significant differences in level of skills (basic life support, ALS, or specialty skills) performed between clinician levels. Patient demographics for each clinician type were similar. Conclusions: Our findings indicate advanced clinicians provide care at the ALS and specialty care levels in similar patient populations with little difference in the roles between clinician types in the out-of-hospital environment. Our data demonstrate successful integration of advanced clinicians into the out-of-hospital environment in Pennsylvania and provide a framework for future planning and expansion of these roles and responsibilities.

The 2019 Core Content of Emergency Medical Services Medicine.

On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.

Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services.

BACKGROUND: Performance measures are a key component of implementation, dissemination, and evaluation of evidence-based guidelines (EBGs). We developed performance measures for Emergency Medical Services (EMS) stakeholders to enable the implementation of guidelines for fatigue risk management in the EMS setting. METHODS: Panelists associated with the Fatigue in EMS Project, which was supported by the National Highway Traffic Safety Administration (NHTSA), used an iterative process to develop a draft set of performance measures linked to 5 recommendations for fatigue risk management in EMS. We used a cross-sectional survey design and the Content Validity Index (CVI) to quantify agreement among panelists on the wording and content of draft measures. An anonymous web-based tool was used to solicit the panelists' perceptions of clarity and relevance of draft measures. Panelists rated the clarity and relevance separately for each draft measure on a 4-point scale. CVI scores ≥0.78 for clarity and relevance were specified a priori to signify agreement and completion of measurement development. RESULTS: Panelists judged 5 performance measures for fatigue risk management as clear and relevant. These measures address use of fatigue and/or sleepiness survey instruments, optimal duration of shifts, access to caffeine as a fatigue countermeasure, use of napping during shift work, and the delivery of education and training on fatigue risk management for EMS personnel. Panelists complemented performance measures with suggestions for implementation by EMS agencies. CONCLUSIONS: Performance measures for fatigue risk management in the EMS setting will facilitate the implementation and evaluation of the EBG for Fatigue in EMS.

Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services.

BACKGROUND: Administrators of Emergency Medical Services (EMS) operations lack guidance on how to mitigate workplace fatigue, which affects greater than half of all EMS personnel. The primary objective of the Fatigue in EMS Project was to create an evidence-based guideline for fatigue risk management tailored to EMS operations. METHODS: Systematic searches were conducted from 1980 to September 2016 and guided by seven research questions framed in the Population, Intervention, Comparison, Outcome (PICO) framework. Teams of investigators applied inclusion criteria, which included limiting the retained literature to EMS personnel or similar shift worker groups. The expert panel reviewed summaries of the evidence based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The panel evaluated the quality of evidence for each PICO question separately, considered the balance between benefits and harms, considered the values and preferences of the targeted population, and evaluated the resource requirements/needs. The GRADE Evidence-to-Decision (EtD) Framework was used to prepare draft recommendations based on the evidence, and the Content Validity Index (CVI) was used to quantify the panel's agreement on the relevance and clarity of each recommendation. CVI scores for relevance and clarity were measured separately on a 1-4 scale to indicate consensus/agreement among panel members and conclusion of recommendation development. RESULTS: The EtD framework was applied to all 7 PICO questions, and the panel created 5 recommendations. PICO1: The panel recommends using fatigue/sleepiness survey instruments to measure and monitor fatigue in EMS personnel. PICO2: The panel recommends that EMS personnel work shifts shorter than 24 hours in duration. PICO3: The panel recommends that EMS personnel have access to caffeine as a fatigue countermeasure. PICO4: The panel recommends that, EMS personnel have the opportunity to nap while on duty to mitigate fatigue. PICO5: The panel recommends that EMS personnel receive education and training to mitigate fatigue and fatigue-related risks. The panel referenced insufficient evidence as the reason for making no recommendation linked to 2 PICO questions. CONCLUSIONS: Based on a review of the evidence, the panel developed a guideline with 5 recommendations for fatigue risk management in EMS operations.

Glasgow Coma Scale Motor Component ("Patient Does Not Follow Commands") Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients.

STUDY OBJECTIVE: Trauma victims are frequently triaged to a trauma center according to the patient's calculated Glasgow Coma Scale (GCS) score despite its known inconsistencies. The substitution of a simpler binary assessment of GCS-motor (GCS-m) score less than 6 (ie, "patient does not follow commands") would simplify field triage. We compare total GCS score to this binary assessment for predicting trauma outcomes. METHODS: This retrospective analysis of a statewide trauma registry includes records from 393,877 patients from 1999 to 2013. Patients with initial GCS score less than or equal to 13 were compared with those with GCS-m score less than 6 for outcomes of Injury Severity Score (ISS) greater than 15, ISS greater than 24, death, ICU admission, need for surgery, or need for craniotomy. We judged a priori that differences less than 5% lack clinical importance. RESULTS: The relative differences between GCS and GCS-m scores less than 6 were less than 5% and thus clinically unimportant for all outcomes tested, even when statistically significant. For the 6 outcomes, the differences in areas under receiver operating characteristic curves ranged from 0.014 to 0.048. Total GCS score less than or equal to 13 was slightly more sensitive (difference 3.3%; 95% confidence interval 3.2% to 3.4%) and slightly less specific (difference -1.5%; 95% confidence interval -1.6% to -1.5%) than GCS-m score less than 6 for predicting ISS greater than 15, with similar overall accuracy (74.1% versus 74.2%). CONCLUSION: Replacement of the total GCS score with a simple binary decision point of GCS-m score less than 6, or a patient who "does not follow commands," predicts serious injury, as well as the total GCS score, and would simplify out-of-hospital trauma triage.

National Prehospital Evidence-Based Guidelines Strategy: A Summary for EMS Stakeholders.

Multiple national organizations have recommended and supported a national investment to increase the scientific evidence available to guide patient care delivered by Emergency Medical Services (EMS) and incorporate that evidence directly into EMS systems. Ongoing efforts seek to develop, implement, and evaluate prehospital evidence-based guidelines (EBGs) using the National Model Process created by a multidisciplinary panel of experts convened by the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC). Yet, these and other EBG efforts have occurred in relative isolation, with limited direct collaboration between national projects, and have experienced challenges in implementation of individual guidelines. There is a need to develop sustainable relationships among stakeholders that facilitate a common vision that facilitates EBG efforts. Herein, we summarize a National Strategy on EBGs developed by the National Association of EMS Physicians (NAEMSP) with involvement of 57 stakeholder organizations, and with the financial support of the National Highway Traffic Safety Administration (NHTSA) and the EMS for Children program. The Strategy proposes seven action items that support collaborative efforts in advancing prehospital EBGs. The first proposed action is creation of a Prehospital Guidelines Consortium (PGC) representing national medical and EMS organizations that have an interest in prehospital EBGs and their benefits to patient outcomes. Other action items include promoting research that supports creation and evaluates the impact of EBGs, promoting the development of new EBGs through improved stakeholder collaboration, and improving education on evidence-based medicine for all prehospital providers. The Strategy intends to facilitate implementation of EBGs by improving guideline dissemination and incorporation into protocols, and seeks to establish standardized evaluation methods for prehospital EBGs. Finally, the Strategy proposes that key stakeholder organizations financially support the Prehospital Guidelines Consortium as a means of implementing the Strategy, while together promoting additional funding for continued EBG efforts.

Characteristics of statewide protocols for emergency medical services in the United States.

OBJECTIVE: We sought to categorize and characterize the utilization of statewide emergency medical services (EMS) protocols as well as state recognition of specialty receiving facilities for trauma and time-sensitive conditions in the United States. METHODS: A survey of all state EMS offices was conducted to determine which states use mandatory or model statewide EMS protocols and to characterize these protocols based on the process for authorizing such protocols. The survey also inquired as to which states formally recognize specialty receiving facilities for trauma, STEMI, stroke, cardiac arrest, and burn as well as whether or not states have mandatory or model statewide destination protocols for these specialty centers. RESULTS: Thirty-eight states were found to have either mandatory or model statewide EMS protocols. Twenty-one states had mandatory statewide EMS protocols at either the basic life support (BLS) or advanced life support (ALS) level, and in 16 of these states, mandatory protocols covered both BLS and ALS levels of care. Seventeen states had model statewide protocols at either the BLS or ALS level, and in 14 of these states, the model protocols covered both BLS and ALS levels of care. Twenty states had separate protocols for the care of pediatric patients, while 18 states combined pediatric and adult care within the same protocols. When identified, the median age used to consider a patient for pediatric care was ≤14 years (range ≤8 to ≤17 years). Three states' protocols used a child's height based on a length-based dosage tool as the threshold for identifying a pediatric patient for care using their pediatric protocols. States varied in recognition of receiving centers for EMS patients with special medical needs: 46 recognized trauma centers, 25 recognized burn centers, 22 recognized stroke centers, 11 recognized centers capable of percutaneous coronary intervention for ST-elevation myocardial infarction, and 3 recognized centers for patients surviving cardiac arrest. CONCLUSION: Statewide mandated EMS treatment protocols exist in 21 states, and optional model protocol guidelines are provided by 17 states. There is wide variation in the format and characteristics of these protocols and the recognition of specialty receiving centers for patients with time-sensitive illnesses.

A novel method for continuous environmental surveillance for carbon monoxide exposure to protect emergency medical service providers and patients.

BACKGROUND: Carbon monoxide exposure is an important, but frequently undiagnosed, cause for Emergency Medical Services (EMS) response. Its elusive characteristics and non-specific symptoms make detection difficult without monitoring devices. Consequently, both patients and EMS providers are at increased risk of harm from such exposures. CASE SERIES: We report a series of five cases of carbon monoxide encounters, in which carbon monoxide exposure was not suspected, whereby portable (pager-sized) environmental carbon monoxide detectors, that provide continuous surveillance of the ambient air, were utilized. These devices were carried within, or attached to, the first-in medical jump bags, alerting EMS crews to potentially harmful levels of carbon monoxide. CONCLUSION: This case series highlights the importance of environmental surveillance for carbon monoxide by EMS providers, particularly in such cases where its presence is not suspected. This was, in fact, the case in all the encounters presented herein.

Emergency medical services clinicians in the United States are increasingly exposed to death.

Introduction: Exposure to patient death places healthcare workers at increased risk for burnout and traumatic stress, yet limited data exist exploring exposure to death among emergency medical services (EMS) clinicians. Our objective was to describe changes in EMS encounters involving on-scene death from 2018 to 2021. Methods: We retrospectively analyzed deidentified EMS records for 9-1-1 responses from the ESO Data Collaborative from 2018 to 2021. We identified cases where patient dispositions of death on scene, with or without attempted resuscitation, and without EMS transport. A non-parametric test of trend was used to assess for monotonic increase in agency-level encounters involving on-scene death and the proportion of EMS clinicians exposed to ≥1 on-scene death. Results: We analyzed records from 1109 EMS agencies. These agencies responded to 4,286,976 calls in 2018, 5,097,920 calls in 2019, 4,939,651 calls in 2020, and 5,347,340 calls in 2021.The total number of encounters with death on scene rose from 49,802 in 2018 to 60,542 in 2019 to 76,535 in 2020 and 80,388 in 2021. Agency-level annual counts of encounters involving death on scene rose from a median of 14 (interquartile range [IQR], 4-40) in 2018 to 2023 (IQR, 6-63) in 2021 (P-trend < 0.001). In 2018, 56% of EMS clinicians responded to a call with death on scene, and this number rose to 63% of EMS clinicians in 2021 (P-trend < 0.001). Conclusion: From 2018 to 2021, EMS clinicians were increasingly exposed to death. This trend may be driven by COVID-19 and its effects on the healthcare system and reinforces the need for evidence-based death notification training to support EMS clinicians.

Experience with an anonymous web-based state EMS safety incident reporting system.

BACKGROUND: Patient and provider safety is paramount in all aspects of emergency medical services (EMS) systems. The leaders, administrators, and policymakers of these systems must have an understanding of situations that present potential for harm to patients or providers. OBJECTIVE: This study analyzed reports to a statewide EMS safety event reporting system with the purpose of categorizing the types of incidents reported and identifying opportunities to prevent future safety events. METHODS: This statewide EMS safety incident reporting system is a Web-based system to which any individual can anonymously report any event or situation perceived to impact safety. We reviewed all reports between the system's inception in 2003 through August 2010. A stipulation of the system is that any entry containing information that identifies an EMS provider, agency, or patient will be deleted and thus not included in the analysis. Each event report included the description of the event, the relationship of the reporter, and the year in which the event occurred. Each entry was placed into a category that best represents the situation described. RESULTS: A total of 415 reports were received during the study period, and 186 reports were excluded-163 (39%) excluded by the state because of identifiable information and 23 (6%) excluded by the authors because of nonsensical description. Within the remaining 229 reports, there were 237 distinct safety events. These events were classified as actions/behavior (32%), vehicle/transportation (16%), staffing or ambulance availability (13%), communications (8%), medical equipment (9%), multiple patients/agencies/units and level-of-care issues (7%), medical procedure (6%), medication (5%), accident scene management/scene safety (3%), and protocol issues (1%). EMS providers directly involved in the event represented the largest reporting group (33%). We also provide examples of statewide system and policy changes that were made in direct response to these reports. CONCLUSION: This EMS safety incident reporting system identified situations that occurred in many categories of EMS care. These potential dangers represent opportunity to assess, and ultimately change, policy and procedures to reduce potential safety events and medical errors and improve overall safety. A substantial number of cases were excluded to maintain the promise of anonymity within the system.

Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors.

BACKGROUND: Medications are essential to emergency medical services (EMS) agencies when providing lifesaving care, but the EMS environment has challenges related to safe medication storage when compared with a hospital setting. We developed a structured process, based on common pharmacy practices, to review medications carried by EMS agencies to identify situations that may lead to medication error and to determine some best practices that may reduce potential errors and the risk of patient harm. OBJECTIVE: To provide a descriptive account of EMS practices related to carrying and storing medications that have the potential for causing a medication administration error or patient harm. METHODS: Using a structured process for inspection, an emergency medicine pharmacist and emergency physician(s) reviewed the medication carrying and storage practices of all nine advanced life support ambulance agencies within a five-county EMS region. Each medication carried and stored by the EMS agency was inspected for predetermined and spontaneously observed issues that could lead to medication error. These issues were documented and photographed. Two EMS medical directors reviewed each potential error for the risk of producing patient harm and assigned each to a category of high, moderate, or low risk. Because issues of temperature on EMS medications have been addressed elsewhere, this study concentrated on potential for EMS medication administration errors exclusive of storage temperatures. RESULTS: When reviewing medications carried by the nine EMS agencies, 38 medication safety issues were identified (range 1 to 8 per EMS agency). Of these, 16 were considered to be high risk, 14 moderate risk, and eight low risk for patient harm. Examples of potential issues included carrying expired medications, container-labeling issues, different medications stored in look-alike vials or prefilled syringes in the same compartment, and carrying crystalloid solutions next to solutions premixed with a medication. When reviewing medications stored at the EMS agency stations, eight safety issues were identified (range from 0 to 4 per station), including five moderate-risk and three low-risk issues. No agency had any high-risk medication issues related to storage of medication stock in the station. CONCLUSION: We observed potential medication safety issues related to how medications are carried and stored at all nine EMS agencies in a five-county region. Understanding these issues may assist EMS agencies in reducing the potential for a medication error and risk of patient harm. More research is needed to determine whether following these suggested best practices for carrying medications on EMS vehicles actually reduces errors in medication administration by EMS providers or decreases patient harm.

Comparison of bougie-assisted intubation with traditional endotracheal intubation in a simulated difficult airway.

OBJECTIVE: To compare the success and ease of bougie-assisted intubation (BAI) with those of traditional endotracheal intubation (ETI) in a simulated difficult airway (20.4 seconds for BAI vs. 16.7 seconds for ETI, p = 0.102). METHODS: This was a prospective, randomized, crossover, single-blind study comparing BAI with ETI in a simulated difficult airway. The 35 participants included paramedics, flight nurses, and emergency medicine resident physicians. Participants were already experienced in ETI and received a brief demonstration of BAI. A simulated difficult airway was created using a Laerdal adult intubation manikin. Cervical motion was mechanically limited to provide a grade III Cormack and Lehane glottic view. Participants performed ETI and BAI in randomized order. Successful placement in the trachea and time to successful placement were recorded for both techniques by each participant. After intubating the manikin with both techniques, each participant was asked to complete a Likert-style survey assessing ease of each technique. RESULTS: Of the 35 participants, 27 were successful with both techniques and two failed with both techniques. The remaining six participants all failed at ETI but were able to intubate using BAI. There was significantly greater success in intubating the simulated difficult airway with BAI than with ETI (94% vs. 77%, p = 0.0313). The order of techniques attempted did not influence this conclusion. There was no difference in average time to successful intubation (20.4 seconds for BAI vs. 16.7 seconds for ETI, p = 0.102). Thirty-two (91.4%) of the participants completed the survey regarding ease of performing each technique. Forty-one percent rated the ease of intubation as the same for the two methods, 50% rated BAI as easier, and 9% rated ETI as easier (p = 0.0006). CONCLUSION: In a simulated difficult airway, BAI has a higher success rate than traditional ETI without increasing the time to successful intubation. Intubators perceive BAI as being easier to perform than traditional ETI in this simulated difficult airway scenario.

Expert witness qualifications and ethical guidelines for emergency medical services litigation: resource document for the National Association of EMS Physicians position statement.

The clinical provision of medical care by emergency medical services (EMS) providers in the out-of-hospital environment and the operation of EMS systems to provide that care are unique in the medical arena. There is a substantive difference in the experience of individuals who provide medical care in the out-of-hospital setting and the experience of those who provide similar care in the hospital or other clinical settings. Furthermore, physicians who provide medical direction for EMS personnel have a clinical and oversight relationship with EMS personnel. This relationship uniquely qualifies EMS medical directors to provide expert opinions related to care provided by nonphysician EMS personnel. Physicians without specific EMS oversight experience are not uniformly qualified to provide expert opinion regarding the provision of EMS. This resource document reviews the current issues in expert witness testimony in cases involving EMS as these issues relate to the unique qualifications of the expert witness, the standard of care, and the ethical expectations.

EMS agencies with high rates of field termination of resuscitation and longer scene times also have high rates of survival.

AIM: Out-of-hospital cardiac arrest (OOHCA) management dichotomizes strategies to (1) "scoop-and-run" to a higher level of care or (2) "treat on the X" with the goal of return of spontaneous circulation (ROSC) before transport, with field termination of resuscitation (FTOR) of unsuccessful resuscitations. We hypothesized that EMS agencies with greater average time on-scene and higher rates of field termination of resuscitation would have more favorable outcomes. METHODS: The Cardiac Arrest Registry to Enhance Survival (CARES) was used to identify OOHCA cases from 2013 to 2018. Agencies in the top and bottom quartiles of on-scene time were categorized as high (HiOST) and low (LoOST); in the top and bottom quartiles of field termination rate were categorized as high (HiTOR) and low (LoTOR). Generalized estimating equation models compared top and bottom quartiles. RESULTS: We classified 95 agencies as HiOST (average > 25.1 min) or LoOST (average < 19.3 min). We classified 95 agencies as HiTOR (average > 46.5% FTOR) or LoTOR (average < 23.5% FTOR). Controlling for agency characteristics, HiOST had a higher survival to discharge for transported patients (28.1% vs 23.1%, OR = 2.8, 95 %CI 2.1-3.6, p < 0.001), ROSC on emergency department arrival, and favorable neurologic outcome than LoOST. HiTOR had a higher survival to discharge for transported patients (25.6% vs 19.3%, OR = 3.3, 95 %CI 2.5-4.4, p < 0.001), ROSC on emergency department arrival, and favorable neurologic outcome than LoTOR. CONCLUSION: EMS agencies with higher rates of FTOR and longer on-scene times for patients with OOHCA have higher overall patient survival, ROSC, and favorable neurologic function.

Out-of-hospital chest escharotomy: a case series and procedure review.

Initial care for the burned trauma patient focuses on the rapid assessment and stabilization of airway, breathing, and circulation. Circumferential chest burns may restrict respiratory effort and inhibit adequate ventilation. When this occurs, chest escharotomy is the recommended treatment to restore chest expansion and therefore ventilation. Emergency medical services (EMS) providers infrequently encounter patients with circumferential chest burns, and escharotomy is generally not included in their scope of practice. The authors could not locate any documentation of other escharotomies performed in the out-of-hospital setting. This case series describes the care of two patients that required out-of-hospital chest escharotomy by physician members of a helicopter medical crew. The procedures of chest and neck escharotomies are reviewed, and the logistics of performing escharotomy in the prehospital setting are described.