Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications.

Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS "Often" or "Always" only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022. Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians. Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration "Often" or "Always" (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% "Always" review the triage note. Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

Accuracy of the American College of Surgeons Minimum Criteria for Full Trauma Team Activation for Children.

OBJECTIVE: Pediatric trauma centers use reports from emergency medical service providers to determine if a trauma team should be sent to the emergency department to prepare to care for the patient. Little scientific evidence supports the current American College of Surgeons (ACS) indicators for trauma team activation. The objective of this study was to determine the accuracy of the ACS Minimum Criteria for Full Trauma Team Activation for children as well as the accuracy of the modified criteria used at the local sites for trauma activation. METHODS: Emergency medical service providers who transported an injured child aged 15 years or younger to a pediatric trauma center in 1 of 3 cities were interviewed after emergency department arrival. Emergency medical service providers were asked if each of the activation indicators were present based on their evaluation. The need for full trauma team activation was determined through a medical record review using a published criterion standard definition. Undertriage and overtriage rates and positive likelihood ratios (+LRs) were calculated. RESULTS: Emergency medical service provider interviews were conducted and outcome data were obtained for 9483 children. There were 202 (2.1%) cases that met the criterion standard for need for trauma team activation. Based on the ACS Minimum Criteria, 299 (3.0%) cases should have received a trauma activation. The ACS Minimum Criteria undertriaged 44.1% and overtriaged 20% (+LR, 27.9; 95% confidence interval, 23.1-33.7). Based on the actual activation status using the local criteria, 238 cases received a full trauma activation, 45% were undertriaged, and 1.4% were overtriaged (+LR, 40.1; 95% confidence interval, 32.4-49.7). There was 97% agreement between the ACS Minimum Criteria and the actual local activation status at the receiving institution. CONCLUSIONS: The ACS Minimum Criteria for Full Trauma Team Activation for children have a high rate of undertriage. Changes that individual institutions have made to improve the accuracy of activations at their institutions seem to have had a limited effect on decreasing undertriage.

Differential Effects of an Emergency Department-to-Home Care Transitions Intervention in an Older Adult Population: A Latent Class Analysis.

BACKGROUND: Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup. OBJECTIVES: We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect. RESEARCH DESIGN: Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership. SUBJECTS: Participants were ED patients (age 60 y and above) discharged to a community residence. MEASURES: Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors. RESULTS: We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13-2.91; odds ratio: 2.24, 95% CI: 1.25-4.03). CONCLUSIONS: Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.

Multimethod Process Evaluation of a Community Paramedic Delivered Care Transitions Intervention for Older Emergency Department Patients.

OBJECTIVE: We assessed fidelity of delivery and participant engagement in the implementation of a community paramedic coach-led Care Transitions Intervention (CTI) program adapted for use following emergency department (ED) visits. METHODS: The adapted CTI for ED-to-home transitions was implemented at three university-affiliated hospitals in two cities from 2016 to 2019. Participants were aged ≥60 years old and discharged from the ED within 24 hours of arrival. In the current analysis, participants had to have received the CTI. Community paramedic coaches collected data on program delivery and participant characteristics at each transition contact via inventories and assessments. Participants provided commentary on the acceptability of the adapted CTI. Using a multimethod approach, the CTI implementation was assessed quantitatively for site- and coach-level differences. Qualitatively, barriers to implementation and participant satisfaction with the CTI were thematically analyzed. RESULTS: Of the 863 patient participants, 726 (84.1%) completed their home visits. Cancellations were usually patient-generated (94.9%). Most planned follow-up visits were successfully completed (94.6%). Content on the planning for red flags and post-discharge goal setting was discussed with high rates of fidelity overall (95% and greater), while content on outpatient follow-up was lower overall (75%). Differences in service delivery between the two sites existed for the in-person visit and the first phone follow-up, but the differences narrowed as the study progressed. Participants showed a 24.6% increase in patient activation (i.e., behavioral adoption) over the 30-day study period (p < 0.001).Overall, participants reported that the program was beneficial for managing their health, the quality of coaching was high, and that the program should continue. Not all participants felt that they needed the program. Community paramedic coaches reported barriers to CTI delivery due to patient medical problems and difficulties with phone visit coordination. Coaches also noted refusal to communicate or engage with the intervention as an implementation barrier. CONCLUSIONS: Community paramedic coaches delivered the adapted CTI with high fidelity across geographically distant sites and successfully facilitated participant engagement, highlighting community paramedics as an effective resource for implementing such patient-centered interventions.

Scalar Assessment of the Family Caregiver Activation in Transitions Tool: An Exploratory Factor Analysis.

The Family Caregiver Activation in Transitions (FCAT) tool in its current, non-scalar form is not pragmatic for clinical use as each item is scored and intended to be interpreted individually. The purpose of the current study was to create a scalar version of the FCAT to facilitate better care communications between hospital staff and family caregivers. We also assessed the scale's validity by comparing the scalar version of the measure against patient health measures. Data were collected from 463 family caregiver-patient dyads from January 2016 to July 2019. An exploratory factor analysis was performed on the 10-item FCAT, resulting in a statistically homogeneous six-item scale focused on current caregiving activation factors. The measure was then compared against patient health measures, with no significant biases found. The six-item scalar FCAT can provide hospital staff insight into the level of caregiver activation occurring in the patient's health care and help tailor care transition needs for family caregiver-patient dyads. [Journal of Gerontological Nursing, 48(12), 35-42.].

Degree of Bystander-Patient Relationship and Prehospital Care for Opioid Overdose.

BACKGROUND: Across the spectrum of patient care for opioid overdose, an important, yet frequently overlooked feature is the bystander, or witness to the overdose event. For other acute medical events such as cardiac arrest and stroke, research supports that the presence of a bystander is associated with better outcomes. Despite the similarities, however, this well-established conceptual framework has yet to be applied in the context of overdose patient outcomes. The objective of this study was to assess the association between the nature of the bystander-patient relationship and prehospital care measures in patients being treated for opioid overdose. METHODS: A retrospective cohort study was conducted among adults who received naloxone in the prehospital setting for suspected opioid overdose. Patients were identified using a preexisting, longitudinal registry documenting all prehospital administrations of naloxone by first responders in a midsized community. Individuals who received at least one naloxone administration for a suspected opioid overdose between June 1st, 2016 to July 31st, 2018, with available EMS and medical record data were eligible for study inclusion. Bystander type was defined referencing psychology literature and were categorized as: close (spouse/family), proximal (friends), and distal (no relation to patient). The association between bystander type and prehospital patient care measures were estimated using logistic and linear regression models. RESULTS: A total of 602 opioid overdose encounters among 545 patients were identified. Patents tended to be male (67.2%), white (73.6%), and aged 25-44 years (57.1%). Among patients with proximal bystanders present, average time to naloxone administration was 2.4 min less (95% CI = -4.7, -0.2), compared to distal bystanders, after adjusting for covariates. Overdose encounters with 911 dispatch codes more indicative of opioid overdose (i.e., 'overdose/poisoning' vs 'unconscious/fainting') were associated with having a close or proximal bystander present compared to a distal bystander (ORclose vs. distal = 1.8, 95% CI = 1.0, 3.3; ORproximal vs. distal = 3.6, 95% CI = 1.8, 7.1). CONCLUSION: Presence of a proximal bystander during an overdose event is associated with dispatch codes indicative of an overdose and shorter times to naloxone administration compared with those with distal bystanders. These findings offer opportunities for public education and engagement of overdose harm reduction strategies.

Does Mechanism of Injury Predict Trauma Center Need for Children?

OBJECTIVE: To determine if the Mechanism of Injury Criteria of the Field Triage Decision Scheme (FTDS) are accurate for identifying children who need the resources of a trauma center. METHODS: EMS providers transporting any injured child ≤15 years, regardless of severity, to a pediatric trauma center in 3 midsized communities over 3 years were interviewed. Data collected through the interview included EMS observed physiologic condition, suspected anatomic injuries, and mechanism. Patients were then followed to determine if they needed the resources of a trauma center by reviewing their medical record after hospital discharge. Patients were considered to need a trauma center if they received an intervention included in a previously published consensus definition. Data were analyzed with descriptive statistics including positive likelihood ratios (+LR) and 95% confidence intervals (95%CI). RESULTS: 9,483 provider interviews were conducted and linked to hospital outcome data. Of those, 230 (2.4%) met the consensus definition for needing a trauma center. 1,572 enrolled patients were excluded from further analysis because they met the Physiologic or Anatomic Criteria of the FTDS. Of the remaining 7,911 cases, 62 met the consensus definition for needing a trauma center (TC). Taken as a whole, the Mechanism of Injury Criteria of the FTDS identified 14 of the remaining 62 children who needed the resources of a trauma center for a 77% under-triage rate. The mechanisms sustained were 36% fall (16 needed TC), 28% motor vehicle crash (MVC) (20 needed TC), 7% struck by a vehicle (10 needed TC), <1% motorcycle crash (none needed TC), and 29% had a mechanism not included in the FTDS (16 needed TC). Of those who sustained a mechanisms not listed in the FTDS, the most common mechanisms were sport related injuries not including falls (24% of 2,283 cases with a mechanism not included) and assault (13%). Among those who fell from a height greater than 10 feet, 4 needed a TC (+LR 5.9; 95%CI 2.8-12.6). Among those in a MVC, 41 were reported to have been ejected and none needed a TC, while 31 had reported meeting the intrusion criteria and 0 needed a TC. There were 32 reported as having a death in the same vehicle, and 2 needed a TC (+LR 7.42; 95%CI: 1.90-29.0). CONCLUSION: Over a quarter of the children who needed the resources of a trauma center were not identified using the Physiologic or Anatomic Criteria of the Field Triage Decision Scheme. The Mechanism of Injury Criteria did not apply to over a quarter of the mechanisms experienced by children transported by EMS for injury. Use of the Mechanism Criteria did not greatly enhance identification of children who need a trauma center. More work is needed to improve the tool used to assist EMS providers in the identification of children who need the resources of a trauma center.

Prehospital time intervals and management of ischemic stroke patients.

OBJECTIVE: Quantify prehospital time intervals, describe prehospital stroke management, and estimate potential time saved if certain procedures were performed en route to the emergency department (ED). METHODS: Acute ischemic stroke patients who arrived via emergency medical services (EMS) between 2012 and 2016 were identified. We determined the following prehospital time intervals: chute, response, on-scene, transport, and total prehospital times. Proportions of patients receiving the following were determined: Cincinnati Prehospital Stroke Scale (CPSS) assessment, prenotification, glucose assessment, vascular access, and 12-lead electrocardiography (ECG). For glucose assessment, ECG acquisition, and vascular access, the location (on-scene vs. en route) in which they were performed was described. Difference in on-scene times among patients who had these three interventions performed on-scene vs. en route was assessed. RESULTS: Data from 870 patients were analyzed. Median total prehospital time was 39 min and comprised the following: chute time: 1 min; response time: 9 min; on-scene time: 15 min; and transport time: 14 min. CPSS was assessed in 64.7% of patients and prenotification was provided for 52.0% of patients. Glucose assessment, vascular access initiation, and ECG acquisition was performed on 84.1%, 72.6%, and 67.2% of patients, respectively. 59.0% of glucose assessments, 51.2% of vascular access initiations, and 49.8% of ECGs were performed on-scene. On-scene time was 9 min shorter among patients who had glucose assessments, vascular access initiations, and ECG acquisitions all performed en route vs. on-scene. CONCLUSIONS: On-scene time comprised 38.5% of total prehospital time. Limiting on-scene performance of glucose assessments, vascular access initiations, and ECG acquisitions may decrease prehospital time.

Retrospective analysis of the hemodynamic consequences of prehospital supplemental oxygen in acute stroke.

OBJECTIVE: Hyperoxia, the delivery of high levels of supplemental oxygen (sO2) despite normoxia, may increase cerebral oxygenation to penumbral tissue and improve stroke outcomes. However, it may also alter peripheral hemodynamic profiles with potential negative effects on cerebral blood flow (CBF). This study examines the hemodynamic consequences of prehospital sO2 in stroke. METHODS: A retrospective analysis of adult acute stroke patients (aged ≥18 years) presenting via EMS to an academic Comprehensive Stroke Center between January 1, 2013 and December 31, 2017 was conducted using demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects' medical records. Outcomes were compared across three groups based on prehospital oxygen saturation and sO2 administration. Chi-square, ANOVA, and multivariable linear regression were used to determine if sO2 was associated with differences in peripheral hemodynamic profiles. RESULTS: All subjects had similar initial EMS vitals except for oxygen saturation. However, both univariate and multivariable analysis revealed that hyperoxia subjects had slightly lower average ED mean arterial pressures (MAP) compared to normoxia (Cohen's d = 0.313). CONCLUSIONS: Prehospital-initiated hyperoxia for acute stroke is associated with a small, but significant decrease in average ED MAP, without changes in heart rate, compared to normoxia. While limited by the inability to link changes in peripheral hemodynamical profiles directly to changes in CBF, this study suggests that hyperoxia may result in a relative hypotension. Further studies are needed to determine if this small change in peripheral vascular resistance translates into a clinically significant reduced CBF.

Prehospital supplemental oxygen for acute stroke - A retrospective analysis.

OBJECTIVE: Brief early administration of supplemental oxygen (sO2) to create hyperoxia may increase oxygenation to penumbral tissue and improve stroke outcomes. Hyperoxia may also result in respiratory compromise and vasoconstriction leading to worse outcomes. This study examines the effects of prehospital sO2 in stroke. METHODS: This is a retrospective analysis of adult acute stroke patients (aged ≥18 years) presenting via EMS to an academic Comprehensive Stroke Center between January 1, 2013 and December 31, 2017. Demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects' medical records were compared across three groups based on prehospital oxygen saturation and sO2 administration. Chi-square, ANOVA, and multivariate logistic regression were used to determine if sO2 status was associated with neurological outcomes or respiratory complications. RESULTS: 1352 eligible patients were identified. 62.7% (n = 848) did not receive sO2 ("controls"), 10.7% (n = 144) received sO2 due to hypoxia ("hypoxia"), and 26.6% (n = 360) received sO2 despite normoxia ("hyperoxia"). The groups represented a continuum from more severe deficits (hypoxia) to less severe deficits (controls): mean prehospital GCS (hypoxia -12, hyperoxia - 2, controls - 14 p ≤ 0.001), mean initial NIHSS (hypoxia - 15, hyperoxia - 13, controls - 8 p < 0.001). After controlling for potential confounders, all groups had similar rates of respiratory complications and favorable neurological outcomes. CONCLUSIONS: Hyperoxic subjects had no significant increase in respiratory complications, nor did they differ in neurologic outcomes at discharge when controlling for confounders. While limited by the retrospective nature, this suggests brief, early sO2 for stroke may be safe to evaluate prospectively.

Dexamethasone-Related Perineal Burning in the Prehospital Setting: A Case Series.

Dexamethasone is frequently used in the treatment of allergic reactions and airway inflammation because of its potent anti-inflammatory effects and long duration of action. As prehospital use becomes more common, it is important for providers to be aware of unique and potentially distressing associated adverse effects. We report eight cases of intravenous dexamethasone administration associated with perineal or diffuse burning sensation in female patients.

Accuracy of Intravenous Infusion Flow Regulators in the Prehospital Environment.

OBJECTIVE: To assess the accuracy of multiple Intravenous Infusion Flow Regulators (IIFRs) at infusion rates and hanging heights common to the prehospital setting. METHODS: Five different manufacturer's IIFRs were tested over a range of infusion rates while hanging at heights equivalent to the gurney pole, ambulance ceiling hook, and manufacturer's recommended height (if available). Each IIFR was run over a 15-minute period at each infusion rate and height three times. Drip effluent was collected and measured for comparison of volumes. Intra- and inter-device accuracy at different infusion rates and heights was calculated. RESULTS: All devices deviated from the expected infusion volume regardless of infusion rate or height. There was inter-device variability across all IIFRs with some having reproducible though inaccurate volumes. Volumes were consistently below expected at lower heights and above expected at increased heights. Manufacturer recommended height guidelines provided slight improvements in accuracy. CONCLUSIONS: Significant deviations from expected IIFR volume were observed across all devices, flow rates, and heights in a static, laboratory environment. These findings would lend caution to the use of IIFRs as they could lead to inaccurate medication dosing (both over- or under-dosing) in the prehospital environment.

Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention.

OBJECTIVE: The Care Transitions Intervention (CTI) has potential to improve the emergency department (ED)-to-home transition for older adults. Community paramedics may function as the CTI coaches; however, this requires the appropriate knowledge, skills, and attitudes, which they do not receive in traditional emergency medical services (EMS) education. This study aimed to define community paramedics' perceptions regarding their training needs to serve as CTI coaches supporting the ED-to-home transition. METHODS: This study forms part of an ongoing randomized controlled trial evaluating a community paramedic-implemented CTI to enhance the ED-to-home transition. The community paramedics' training covered the following domains: the CTI program, geriatrics, effective coaching, ED discharge processes, and community paramedicine. Sixteen months after starting the study, we conducted audio-recorded semi-structured interviews with community paramedics at both study sites. After transcribing the interviews, team members independently coded the transcripts. Ensuing group analysis sessions led to the development of final codes and identifying common themes. Finally, we conducted member checking to confirm our interpretations of the interview data. RESULTS: We interviewed all 8 participating community paramedics. Participants consisted solely of non-Hispanic whites, included 5 women, and had a mean age of 43. Participants had extensive backgrounds in healthcare, primarily as EMS providers, but minimal experience with community paramedicine. All reported some prior geriatrics training. Four themes emerged from the interviews: (1) paramedics with positive attitudes and willingness to acquire the needed knowledge and skills will succeed as CTI coaches; (2) active rather than passive learning is preferred by paramedics; (3) the existing training could benefit from adjustments such as added content on mental health, dementia, and substance abuse issues, as well as content on coaching subjects with a range of illness severity; and (4) continuing education should address the paramedic coaches' evolving needs as they develop proficiency with the CTI. CONCLUSIONS: Paramedics as CTI coaches represent an untapped resource for supporting ED-to-home care transitions. Our results provide the necessary first step to make the community paramedic CTI coach more successful. These findings may apply to training for similar community paramedicine roles, but additional research must investigate this possibility.

A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

BACKGROUND: Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. METHODS: This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. DISCUSSION: This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015.

Establishing Recommendations for Stroke Systems in the Thrombectomy Era: The Upstate New York Stakeholder Proceedings.

BACKGROUND AND PURPOSE: The American Heart Association/American Stroke Association and Department of Health Stroke Coverdell Program convened a stakeholder meeting in upstate NY to develop recommendations to enhance stroke systems for acute large vessel occlusion. METHODS: Prehospital, hospital, and Department of Health leadership were invited (n=157). Participants provided goals/concerns and developed recommendations for prehospital triage and interfacility transport, rating each using a 3-level impact (A [high], B, and C [low]) and implementation feasibility (1 [high], 2, and 3 [low]) scale. Six weeks later, participants finalized recommendations. RESULTS: Seventy-one stakeholders (45% of invitees) attended. Six themes around goals/concerns emerged: (1) emergency medical services capacity, (2) validated prehospital screening tools, (3) facility capability, (4) triage/transport guidelines, (5) data capture/feedback tools, and (6) facility competition. In response, high-impact (level A) prehospital recommendations, stratified by implementation feasibility, were (1) use of online medical control for triage (6%); (2) regional transportation strategy (31%), standardized emergency medical services checklists (18%), quality metrics (14%), standardized prehospital screening tools (13%), and feedback for performance improvement (7%); and (3) smartphone application algorithm for screening/decision-making (6%) and ambulance-based telemedicine (6%). Level A interfacility transfer recommendations were (1) standardized transfer process (32%)/timing goals (16%)/regionalized systems (11%), performance metrics (11%), image sharing capabilities (7%); (2) provider education (9%) and stroke toolbox (5%); and (3) interfacility telemedicine (7%) and feedback (2%). CONCLUSIONS: The methods used and recommendations generated provide models for stroke system enhancement. Implementation may vary based on geographic need/capacity and be contingent on establishing standard care practices. Further research is needed to establish optimal implementation strategies.

Effect of the 2011 Revisions to the Field Triage Guidelines on Under- and Over-Triage Rates for Pediatric Trauma Patients.

BACKGROUND: In 2011, revised Field Triage Guidelines were released jointly by the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons - Committee on Trauma (ACS-COT). It is unknown how the modifications will affect the number of injured children identified by EMS providers as needing transport to a trauma center. OBJECTIVE: To determine the change in under- and over-triage rates when the 2011 Field Triage Guidelines are compared to the 2006 and 1999 versions. METHODS: EMS providers in charge of care for injured children (<15 years) transported to pediatric trauma centers in 3 mid-sized cities were interviewed immediately after completing transport. Patients were included regardless of injury severity. The interview included patient demographics and each criterion from the Field Triage Guidelines' physiologic status, anatomic injury, and mechanism of injury steps. Included patients were followed through hospital discharge. The 1999, 2006, and 2011 Guidelines were each retrospectively applied to the collected data. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics. RESULTS: EMS interviews were conducted for 5,610 children and outcome data was available for 5,594 (99.7%). Average age was 7.6 years; 5% of children were identified as needing a trauma center using the study outcome. Applying the 1999, 2006, or 2011 Guidelines to the EMS interview data the over-triage rate was 32.6%, 27.9%, and 28.0%, respectively. The under-triage rate was 26.5%, 35.1%, and 34.8%, respectively. The 2011 Guidelines resulted in an 8.2% (95% CI 0.6-15.9%) absolute increase in under-triage and a 4.6% (95% CI 2.8-6.3%) decrease in over-triage compared to 1999 Guidelines. CONCLUSION: Use of the Field Triage Guidelines for children resulted in an unacceptably high rate of under-triage regardless of the version used. Use of the 2011 Guidelines increased under-triage compared to the 1999 version. Research is needed to determine how to better assist EMS providers in identifying children who need the resources of a trauma center.

Ability of the Physiologic Criteria of the Field Triage Guidelines to Identify Children Who Need the Resources of a Trauma Center.

BACKGROUND: There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center. OBJECTIVE: To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center. METHODS: EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion. RESULTS: Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4-3.2). Glasgow Coma Score (GCS) < 14 had a +LR of 14.3 (95% CI 11.2-18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS < 14 had an initial ED GCS < 14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8-2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP) < 90 had a +LR of 3.5 (95% CI 2.5-5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children <1 year, 46% 1-4 years, 7% 5-9 years, and 2% 10-15 years. A total of 19% of those with an EMS SBP < 90 had an initial ED SBP < 90. CONCLUSIONS: The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria.

An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management.

OBJECTIVES: The aim of this study was to quantitatively assess the prevalence of newly identified barriers and enablers to prehospital narcotic analgesic administration in a sample of paramedics and determine whether these barriers and enablers differ between new and experienced paramedics. METHODS: We surveyed a convenience sample of paramedics from urban, suburban, and rural practice settings in an emergency medical services system. Descriptive statistics were calculated to describe responses, and differences between new (≤5 years) and experienced (>5 years) providers were assessed. RESULTS: There were 127 surveys analyzed; 67% of our sample was experienced and 86% considered treating pain important. Notable barriers for analgesic administration include causing more pain from intravenous catheter insertion, parental influences, difficulty assessing pain, and worry about allergic reactions. Notable enablers include belief that analgesic administration is important, education to administer analgesics, and support from agency leadership. There were statistically significant differences between new and experienced providers in the distribution of responses for survey items regarding how the importance of treating pain in children was learned, overall comfort with pediatric patients, receiving negative responses from superiors about giving pediatric patients analgesics, and usefulness of the Broselow tape for dosing fentanyl for children. Other barriers and enablers were not significantly different between new and experienced providers. CONCLUSIONS: Top barriers to prehospital pediatric analgesic administration are related to skills and knowledge deficits, whereas enablers include support from agency leadership and personal views on analgesics. This information can be used to guide interventions to improve the management of pain in children.

Evaluation of a Consensus-Based Criterion Standard Definition of Trauma Center Need for Use in Field Triage Research.

Research on field triage of injured patients is limited by the lack of a widely used criterion standard for defining trauma center need. Injury Severity Score (ISS) >15 has been a commonly used outcome measure in research for determining trauma center need that has never been validated. A multidisciplinary team recently published a consensus-based criterion standard definition of trauma center need, but this measure has not yet been validated. The objective was to determine if the consensus-based criterion standard can be obtained by medical record review and compare patients identified as needing a trauma center by the consensus-based criterion standard vs. ISS >15. A subanalysis of data collected during a 2-year prospective cohort study of 4,528 adult trauma patients transported by EMS to a single trauma center was conducted. These data included ICD-9-CM codes, treatment times, and other patient care data. Presence of the consensus-based criterion standard was determined for each patient. ISS was calculated based on ICD-9-CM codes assigned for billing. The consensus-based criterion standard could be applied to 4,471 (98.7%) cases. ISS could be determined for 4,506 (99.5%) cases. Based on an ISS >15, 8.9% of cases were identified as needing a trauma center. Of those, only 48.2% met the consensus-based criterion standard. Almost all patients that did not meet the consensus-based criterion standard, but had an ISS >15 were diagnosed with chest (rib fractures (100/205 cases)/pneumothorax (57/205 cases), closed head (without surgical intervention 88/205 cases), vertebral (without spinal cord injury 45/205 cases), and/or extremity injuries (39/205 cases). There were 4,053 cases with an ISS <15. 5.0% of those with an ISS <15 met the consensus-based criterion standard with the majority requiring surgery (139/203 cases) or a blood transfusion (60/203 cases). The kappa coefficient of agreement for ISS and the consensus-based criterion standard was 0.43. We determined that the consensus-based criterion standard could be identified through a medical record review. Use of the consensus-based criterion standard for field triage research will more accurately identify injured patients who need the resources of a trauma center when compared to ISS.

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital.

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.