Patient and Prehospital Predictors of Hospital Admission for Patients With and Without Histories of Diabetes Treated by Paramedics for Hypoglycemia: A Health Record Review Study.

OBJECTIVES: The objectives of this study were to describe the characteristics, management, and outcomes of patients treated by paramedics for hypoglycemia, and to determine the predictors of hospital admission for these patients within 72 hours of the initial hypoglycemia event. METHODS: We performed a health record review of paramedic call reports and emergency department records over a 12-month period. We queried prehospital databases to identify cases, which included all patients ⩾18 years with prehospital glucose readings of <72 mg/dl (<4.0 mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses included descriptive statistics univariate and logistic regression presented as adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). RESULTS: There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, type 1 diabetes 11.6%, on insulin 43.3%, median initial glucose 54.0 mg/dl (3.0 mmol/L), from home 56.4%. They were treated by advanced care paramedics 80.1%, received intravenous D50 37.8%, intramuscular glucagon 17.8%, oral complex carbs/protein 25.7%, and accepted transport to hospital 70.2%. Among those transported, 134 (24.3%) were initially admitted and four more were admitted within 72 hours. One patient was admitted, discharged, and admitted again within 72 hours. Patients without documented histories of diabetes (aOR 2.35, CI 1.13-4.86), with cardiovascular disease (aOR 1.81, CI 1.10-3.00), on corticosteroids (aOR 4.63, CI 2.15-9.96), on oral hypoglycemic agent(s) (aOR 1.92, CI 1.02-3.62), or those given glucagon (aOR 1.77, CI 1.07-2.93) on scene were more likely to be admitted to hospital, whereas patients on insulin (aOR 0.49, CI 0.27-0.91), able to tolerate complex oral carbs/protein (aOR 0.22, CI 0.10-0.48), with final GCS scores of 15 (aOR 0.53, CI 0.34-0.83), or from public locations (aOR 0.40, CI 0.21-0.75) were less likely to be admitted. CONCLUSIONS: There are several patient and prehospital management characteristics which, in combination, could be incorporated into a safe clinical decision tool for patients who present with hypoglycemia.

Estimation of unregistered patients who left without being seen: At an urban mid-sized Canadian community emergency department.

OBJECTIVE: To determine whether changes to the appearance of an emergency department (ED) waiting room influenced the number of patients who left without being seen (LWBS). DESIGN: Retrospective analysis using National Ambulatory Care Reporting System data collected at the time of patient registration. SETTING: The ED of Belleville General Hospital, a mid-sized secondary care community hospital in Ontario with a catchment population of 125 000. PARTICIPANTS: All unscheduled patients registering at the hospital to be seen in the ED from July 1 to December 31, 2016 (control period), and from July 1 to December 31, 2017 (study period). MAIN OUTCOME MEASURES: The volume of patients registering by Canadian Triage and Acuity Scale (CTAS) level to be seen in the ED during the study period compared with the volume of patients registering during the control period, and the number of LWBS during the 2 time periods. RESULTS: The average number of patients registered per month was significantly greater in the study period than in the control period (t 10 = -5.53, P < .01). A total increase of 1881 registrations was recorded in the study period, or 10.47% (increase per month ranged from 9.59% to 11.66%). The proportion of patients with less acute triage scores decreased in the study period; however, the differences in CTAS levels between the 2 years was not statistically significant (χ 2 = 1.05, P = .90). The number of LWBS according to CTAS level was lower in all categories in the study period, including those in the less acute levels, decreasing from 60 in CTAS 5 in 2016 to 45 in 2017, and 585 in CTAS 4 in 2016 to 330 in 2017. Overall, the distribution of LWBS by CTAS level was significantly different between the control and study periods (P < .01). CONCLUSION: The number of patients registering is influenced by the apparent high or low occupancy of the waiting area at the time of registration.

Effect of a physician assistant on quality and efficiency metrics in an emergency department: Population cohort study.

OBJECTIVE: To determine the effect of a physician assistant (PA) working in a secondary care hospital emergency department (ED) on the overall performance of the ED. DESIGN: A retrospective review of ED data from April 1, 2017, to September 30, 2017. SETTING: Belleville General Hospital, a secondary care hospital, ED in Ontario. PARTICIPANTS: A physician assistant, 13 emergency physicians, and 7 family physicians. MAIN OUTCOME MEASURES: Overall ED performance was evaluated using metrics from the Ontario Ministry of Health and Long-Term Care: rate of patients who left without being seen, provider initial assessment time at the 90th percentile, and the average provider initial assessment time for all patients over a 6-month period. RESULTS: In the PA group, there was a lower average daily left without being seen rate (3.4% vs 5.2%; P < .001), a lower provider initial assessment time at the 90th percentile (3.9 hours vs 4.5 hours; P < .001), a lower average provider initial assessment time (114.83 minutes vs 139.46 minutes; P < .001), and a lower average length of stay (313.85 minutes vs 348.91 minutes; P < .001). CONCLUSION: This study suggests that a PA has a statistically significant positive effect on the overall performance of an ED. Future studies should examine the effect of a PA on quality of care and hospital funding.

Characteristics, Prehospital Management, and Outcomes in Patients Assessed for Hypoglycemia: Repeat Access to Prehospital or Emergency Care.

BACKGROUND: In Ontario, Canada, there currently are no prehospital treat-and-release protocols and the safety of this practice remains unclear. We sought to describe the characteristics, management, and outcomes of patients with hypoglycemia treated by paramedics, and to determine the predictors of repeat access to prehospital or emergency department (ED) care within 72 hours of initial paramedic assessment. METHODS: We performed a health record review of paramedic call reports and ED records over a 12-month period. We queried prehospital databases to identify cases, which included all adult patients (≥ 18 years) with a prehospital glucose reading of <72mg/dl (4.0mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses include descriptive statistics with standard deviations, Chi-square, t-tests, and logistic regression with adjusted odds ratios (AdjOR). RESULTS: There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, known diabetic 61.6%, on insulin 46.1%, mean initial glucose 50.0 dl/mg (2.8 mmol/L), from home 56.3%. They were treated by an Advanced Care Paramedic 80.1%, received IV D50W 38.0%, IM glucagon 18.3%, PO complex carbs 26.6%, and accepted transport to hospital 69.4%. Of those transported, 134/556 (24.3%) were admitted and 9 (1.6%) died in the ED. Overall, 43 patients (5.4%) had repeat access to prehospital/ED care, among those, 8 (18.6%) were related to hypoglycemia. Patients on insulin were less likely to have repeat access to prehospital/ED care (AdjOR 0.4; 95%CI 0.2-0.9). This was not impacted by initial (or refusal of) transport (AdjOR 1.1; 95%CI 0.5-2.4). CONCLUSION: Although risk of repeat access to prehospital/ED care for patients with hypoglycemia exists, it was less common among patients taking insulin and was not predicted by an initial refusal of transport.

The Safety of Bypass to Percutaneous Coronary Intervention Facility by Basic Life Support Providers in Patients with ST-Elevation Myocardial Infarction in Prehospital Setting.

BACKGROUND: Most patients transferred from a non-percutaneous coronary intervention (PCI) facility for primary PCI do not meet target reperfusion times. Direct transportation of patients with ST-elevation myocardial infarction (STEMI) from the scene by advanced life support (ALS) paramedics has been shown to improve reperfusion times and outcomes. OBJECTIVE: The aim of this study was to determine whether it is safe to bypass the closest hospital and transport by basic life support (BLS) provider to a PCI facility. METHODS: This was a health records review of consecutive patients transported to a regional PCI center under an STEMI bypass protocol. Under the PCI bypass protocol, patients were eligible if they presented with symptoms of chest pain, a 12-lead electrocardiogram meeting STEMI criteria, and if transported to the regional PCI center within 60 min. The occurrence of predefined adverse events during transport was determined, which included bradycardia < 50 beats/min, tachycardia > 140 beats/min, hypotension, cardiac arrest, and death. RESULTS: There were 46 cases of STEMI bypass between February 2005 and February 2013. Mean transport time was 29.9 min (range 20-62 min). Mean contact-to-balloon time was 95.2 min (range 68-159 min). Twenty-five adverse events occurred in 20 patients during transport. In 16 of the 20 patients, the adverse events were transiently abnormal vital sign requiring no intervention. In 3 of the patients, the adverse event was clinically significant and it is believed that the patient would have benefitted from advanced cardiac life support care not within the scope of practice of the BLS providers. CONCLUSIONS: In our region, STEMI patients can be diagnosed accurately and transported safely on bypass to a PCI center for primary PCI while respecting target reperfusion times.

Impact of Expanding the Prehospital Stroke Bypass Time Window in a Large Geographic Region.

BACKGROUND AND PURPOSE: The Ontario Acute Stroke Medical Redirect Paramedic Protocol (ASMRPP) was revised to allow paramedics to bypass to designated stroke centers if total transport time would be <2 hours and total time from symptom onset <3.5 hours. We sought to evaluate the impact and safety of implementing the Revised ASMRPP. METHODS: We conducted a 12-month implementation study involving prehospital patients presenting with possible stroke symptoms. A total of 1317 basic and advanced life support paramedics, of 9 land services in 10 rural counties and 5 cities, used the Revised ASMRPP to take appropriate patients directly to 6 designated stroke centers. RESULTS: We enrolled 1277 patients with 98.8% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect criteria and had these characteristics: mean age 72.1 (range 16-101), male 51.1%, mean time scene to hospital 16.7 minutes (range 0-92). Paramedics demonstrated excellent interobserver agreement (κ, 0.94; 95% confidence interval, 0.91-0.96) and 97.9% accuracy in interpretation of the Revised ASMRPP. Prehospital adverse events occurred in 14.7% of patients, but few were life-threatening. Overall, 71.4% of 755 cases had a stroke code activated at the hospital and 23.2% received thrombolysis. For the 189 potential stroke patients picked up in 1 city, the ASMRPP classified thrombolysis administration with sensitivity 100% and specificity 37.3% and a final diagnosis of stroke, with sensitivity 86.1% and specificity 41.9%. CONCLUSIONS: In a large urban-rural area with 9 paramedic services, we demonstrated accurate, safe, and effective implementation of the Revised ASMRPP. These revisions will allow more patients with stroke to benefit from early treatment.

Effect of fasting on cocaine-amphetamine-regulated transcript, neuropeptide Y, and leptin receptor expression in the non-human primate hypothalamus.

Leptin is a cytokine produced by white adipose tissue that circulates in direct proportion to adiposity and is an important signal of energy balance. Leptin inhibits food intake in rodents by inhibiting the orexigenic neuropetides neuropeptide Y (NPY) and agouti regulated peptide (AgRP) and stimulating the anorexigenic neuropeptides alpha-melanocyte-stimulating hormone (alpha-MSH) and cocaine-amphetamine-regulated transcript (CART). In order to extend our understanding of neuroendocrine regulation of appetite in the primate, we determined the effect of a metabolic challenge on CART, NPY, and leptin receptor (Ob-R) messenger ribonucleic acid (mRNA) in the nonhuman primate (NHP) hypothalamus. Ten adult female rhesus monkeys were either maintained on a regular diet or fasted for two days before euthanasia. CART, NPY, and Ob-R mRNA were measured by in situ hybridization histochemistry (ISHH). A 2-day fast decreased CART expression in the ARC, increased NPY gene expression in the supraoptic nucleus (SON) and paraventricular nucleus (PVN), and increased Ob-R expression in the ventromedial nucleus (VMN). This is the first report that fasting inhibits CART expression and stimulates Ob-R expression in monkeys. Increased NPY expression in the SON and PVN, but not the ARC of fasted monkeys also is novel. With some exceptions, our observations are confirmatory of findings in rodent studies. Similarities in the neuroendocrine responses to a metabolic challenge in monkeys and rodents support extending existing hypotheses of neuroendocrine control of energy homeostasis to primates.