Virtual Objective Structured Clinical Examination Experiences and Performance in Physical Medicine and Rehabilitation Residency.

BACKGROUND: Virtual education has been described before and during the COVID-19 pandemic. Studies evaluating virtual objective structured clinical examinations with postgraduate learners are lacking. This study (1) evaluated the experiences of all participants in a virtual objective structured clinical examination and (2) assessed the validity and reliability of selected virtual objective structured clinical examination stations for skills in physical medicine and rehabilitation. METHODS: Convergent mixed-methods design was used. Participants included three physical medicine and rehabilitation residency programs holding a joint virtual objective structured clinical examination. Analysis included descriptive statistics and thematic analysis. Performance of virtual to previous in-person objective structured clinical examination was compared using independent t tests. RESULTS: Survey response rate was 85%. No participants had previous experience with virtual objective structured clinical examination. Participants found the virtual objective structured clinical examination to be acceptable (79.4%), believable (84.4%), and valuable for learning (93.9%). No significant differences between in-person and virtual objective structured clinical examination scores was found for three-fourth stations and improved scores in one fourth. Four themes were identified: (1) virtual objective structured clinical examinations are better for communication stations; (2) significant organization is required to run a virtual objective structured clinical examination; (3) adaptations are required compared with in-person objective structured clinical examinations; and (4) virtual objective structured clinical examinations provide improved accessibility and useful practice for virtual clinical encounters. CONCLUSIONS: Utility of virtual objective structured clinical examinations as a component of a program of assessment should be carefully considered and may provide valuable learning opportunities going forward.

Group-based telerehabilitation intervention using Wii Fit to improve walking in older adults with lower limb amputation (WiiNWalk): A randomized control trial.

OBJECTIVE: Determine efficacy of the novel WiiNWalk intervention on walking-related outcomes in older adults with lower limb amputation. DESIGN: Multi-site, parallel, evaluator-masked randomized controlled trial. SETTING: Home-setting in three Canadian cities. PARTICIPANTS: Community-dwelling lower limb prosthesis users over 50 years of age. INTERVENTIONS: The WiiNWalk group (n = 38) used modified Wii Fit activities for prosthetic rehabilitation. The attention control group (n = 33) used Big Brain Academy: Wii Degree, comprising of cognitive activities. Both groups completed a 4-week supervised phase with three 1-h sessions/week in groups of three overseen by a clinician via videoconferencing and a 4-week unstructured and unsupervised phase. MAIN MEASURES: Primary outcome was walking capacity (2 min walk test); secondary outcomes were balance confidence (activities-specific balance confidence scale), dynamic balance (four-step square test), and lower limb functioning (short physical performance battery). Outcomes were compared across time points with repeated measures analysis of covariance, adjusting for baseline and age. RESULTS: Mean age was 65.0 (8.4) years, with 179.5 (223.5) months post-amputation and 80% transtibial amputation. No group difference in a 2 min walk test with an effect size: 1.53 95% CI [-3.17, 6.23] m. Activities balance confidence was greater in the WiiNWalk group by 5.53 [2.53, 8.52]%. No group difference in the four-step square test -0.16 [-1.25, 0.92] s, nor short physical performance battery 0.48 [-0.65, 1.61]. A post-hoc analysis showed the greatest difference in balance confidence immediately after an unsupervised phase. CONCLUSIONS: The WiiNWalk intervention improved balance confidence, but not walking-related physical function in older adult lower limb prosthesis users. Future rehabilitation games should be specific to the amputation context.Clinical Trial Registration number, NCT01942798.

Walking while talking: validation in older adults with lower-limb amputation.

BACKGROUND: Walking while talking (WWT) is a dual-task (cognitive and motor) performance test that has not yet been validated in older adults with lower-limb amputation (LLA). WWT is composed of two sections: WWT-simple (walking while reciting every letter of the alphabet) and WWT-complex (walking while reciting every other letter of the alphabet). OBJECTIVE: To determine the validity, and provide normative data and a new scoring system for the WWT test in older adults with LLA. STUDY DESIGN: Baseline cross-sectional data were collected from 56 community-living older adults (≥50 years old) with LLA at rehabilitation hospitals in Vancouver, BC, London, ON, and Edmonton, AB, Canada. METHODS: Time and number of recited letters and errors during both sections were recorded. A new score was developed based on all these variables. Correlations of the recorded times with the Activities-specific Balance Confidence (ABC) scale and the 2-Minute Walk Test (2MWT) score were used to evaluate the validity of the WWT test. RESULTS: As hypothesized, the times for both sections of the WWT were negatively correlated with both the ABC and 2MWT scores. Positive correlations were observed between the scores developed for both WWT sections with the 2MWT score. CONCLUSION: Times taken to complete each section of the WWT test were correlated with the 2MWT and the ABC scale scores, providing evidence for the validity of the WWT test. We also provided a scoring method that is more objective and in line with the dual-task nature of the test.

A Change from a Spinal Immobilization to a Spinal Motion Restriction Protocol was Not Associated with an Increase in Disabling Spinal Cord Injuries.

BACKGROUND: Over the past decade, Emergency Medical Service (EMS) systems decreased backboard use as they transition from spinal immobilization (SI) protocols to spinal motion restriction (SMR) protocols. Since this change, no study has examined its effect on the neurologic outcomes of patients with spine injuries. OBJECTIVES: The object of this study is to determine if a state-wide protocol change from an SI to an SMR protocol had an effect on the incidence of disabling spinal cord injuries. METHODS: This was a retrospective review of patients in a single Level I trauma center before and after a change in spinal injury protocols. A two-step review of the record was used to classify spinal cord injuries as disabling or not disabling. A binary logistic regression was used to determine the effects of protocol, gender, age, level of injury, and mechanism of injury (MOI) on the incidence of significant disability from a spinal cord injury. RESULTS: A total of 549 patients in the SI period and 623 patients in the SMR period were included in the analysis. In the logistic regression, the change from an SI protocol to an SMR protocol did not demonstrate a significant effect on the incidence of disabling spinal injuries (OR: 0.78; 95% CI, 0.44 - 1.36). CONCLUSION: This study did not demonstrate an increase in disabling spinal cord injuries after a shift from an SI protocol to an SMR protocol. This finding, in addition to existing literature, supports the introduction of SMR protocols and the decreased use of the backboard.

Validity of measures for life space mobility and physical activity in older adults with lower-limb amputation.

BACKGROUND: Older adults with lower-limb amputations (LLAs) often experience lack of confidence and poor balance, which limits their mobility. There are few validated measures for assessing these outcomes in the LLA population. OBJECTIVES: To assess the validity of the Life Space Assessment (LSA) and the Physical Activity Scale for the Elderly (PASE) for older adults with LLA. STUDY DESIGN: Secondary analyses of cross-sectional data. METHODS: Sixty-eight older adults with LLA across Canada were recruited to complete the LSA and the PASE. Validity was assessed via correlations with the Activities-specific Balance Confidence (ABC), Four-Square Step Test (FSST), and Two-Minute Walk Test (2-MWT). RESULTS: As hypothesized, the LSA was positively correlated with the ABC (ρ = 0.36, 95% confidence interval [CI] [0.17, 0.62]) and 2-MWT (r = 0.49, 95% CI [0.27, 0.70]) and negatively correlated with FSST (ρ = -0.39, 95% CI [-0.56, -0.10]). The PASE was positively correlated with the ABC (ρ = 0.34, 95% CI [0.10, 0.56]) and 2-MWT (ρ = 0.32, 95% CI [0.05, 0.52]), and negatively correlated with FSST (ρ = -0.36, 95% CI [-0.53, -0.07]). CONCLUSIONS: The LSA has validity in measuring life space mobility. The PASE captures the physical activity with weaker support of validity in older adults with LLA. CLINICAL RELEVANCE: The LSA and PASE are quick low-cost tools for clinicians to assess mobility-related functional health and physical activity, respectively, in older adults with LLA. However, the PASE may contain activities that are not common among older adults with LLA.

Changes in Field Termination of Resuscitation and Survival Rates After an Educational Intervention to Promote on Scene Resuscitation for Out-of-Hospital Cardiac Arrest.

BACKGROUND: Emergency medical services (EMS) agencies with higher field termination-of-resuscitation (TOR) rates tend to have higher survival rates from out-of-hospital cardiac arrest (OHCA). Whether EMS agencies can improve survival rates through efforts to focus on resuscitation on scene and optimize TOR rates is unknown. OBJECTIVE: The goal of this study was to determine if an EMS agency's efforts to enhance on-scene resuscitation were associated with increased TOR and OHCA survival with favorable neurologic outcome. METHODS: A single-city, retrospective analysis of prospectively collected 2017 quality assurance data was conducted. Patient demographics, process, and outcome measures were compared before and after an educational intervention to increase field TOR. The primary outcome measure was survival to hospital discharge with favorable neurologic status. RESULTS: There were 320 cases that met inclusion criteria. No differences in age, gender, location, witnessed arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, or presumed cardiac etiology were found. After the intervention, overall TOR rate increased from 39.6% to 51.1% (p = 0.06). Among subjects transported without return of spontaneous circulation (ROSC), average time on scene increased from 26.4 to 34.2 min (p = 0.02). Rates of sustained ROSC and survival to hospital admission were similar between periods. After intervention, there was a trend toward increased survival to hospital discharge rate (relative risk [RR] 2.09; 95% confidence interval [CI] 0.74-5.91) and an increase in survival with favorable neurologic status rate (RR 5.96; 95% CI 0.80-44.47). CONCLUSION: This study described the association between an educational intervention focusing on optimization of resuscitation on scene and OHCA process and outcome measures. Field termination has the potential to serve as a surrogate marker for aggressively treating OHCA patients on scene.

Self-directed usage of an in-home exergame after a supervised telerehabilitation training program for older adults with lower-limb amputation.

BACKGROUND: While home-based exergames help overcome accessibility barriers to rehabilitation, it is unclear what constitutes effective intervention design in using exergames to support self-efficacy and engagement. OBJECTIVE: Examine usage of an in-home exergame, compared to control, unsupervised after supervised training by older persons with lower-limb amputation. STUDY DESIGN: Secondary analysis of a multi-site parallel evaluator-masked randomized control trial. METHODS: WiiNWalk uses the WiiFit and teleconferencing for in-home group-based exergame therapy with clinical supervision. Participants engaged in a 4-week supervised training phase followed by a 4-week unsupervised phase in experimental (WiiNWalk) and attention control groups. Usage between phases and between groups was compared using unsupervised/supervised ratio of session count (over 4 weeks) and session time (mean min/session over 4 weeks) for each phase. RESULTS: Participants: n=36 experimental, n=28 control, unilateral lower-limb amputation, age > 50 years, prosthesis usage ≥ 2 hours/day. Session count ratio unsupervised/supervised, median and interquartile range (IQR), was less than parity (p<0.01) for experimental (0.25, IQR 0.00 -0.68) and control (0.18, IQR 0.00 -0.67) groups, with no different between groups (p=0.92). Experimental session time unsupervised/supervised showed consistency (1.12, IQR 0.80 -1.41) between phases (p=0.24); control showed lower (0.76, IQR 0.57 -1.08) ratios compared to experimental (p=0.027). CONCLUSIONS: Unsupervised exercise duration remained consistent with supervised, but frequency was reduced. Social and clinical guidance features may remain necessary for sustained lower-limb amputation exergame engagement at home. CLINICAL RELEVANCE: This study provides context regarding when prosthesis users are more likely to use exergames such as Wii Fit for exercise therapy. Clinicians may consider our results when applying exergames in their practice or when developing new exergame intervention strategies.

Transport Home and Terminal Extubation by Emergency Medical Services: An Example of Innovation in End-of-Life Care.

For most terminally ill patients, the preferred place of death is home. Previous literature has demonstrated the feasibility of at-home terminal extubation performed by critical care and hospice physicians. This case report describes a terminal extubation performed by a paramedic under the direct supervision of an Emergency Medical Services physician in the patient's home. Guided by a comprehensive plan and logistical support from a team of hospice providers, a successful out-of-hospital terminal extubation is possible. To truly achieve patient-centered care at end of life, the choice for an out-of-hospital death is necessary.

Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study.

OBJECTIVE: St. Paul's Early Discharge Rule was derived to determine which patients could be safely discharged from the emergency department after a 1-hour observation period following naloxone administration for opiate overdose. The rule suggested that patients could be safely discharged if they could mobilize as usual and had a normal oxygen saturation, respiratory rate, temperature, heart rate, and Glasgow Coma Scale score. Validation of the St. Paul's Early Discharge Rule is necessary to ensure that these criteria are appropriate to apply to patients presenting after an unintentional presumed opioid overdose in the context of emerging synthetic opioids and expanded naloxone access. METHODS: In this prospective, observational validation study, emergency medicine providers assessed patients 1 hour after administration of prehospital naloxone. Unlike in the derivation study the threshold for normal oxygen saturation was set at 95% and patients were not immediately discharged after a normal 1-hour evaluation. Patients were judged to have a normal 1-hour evaluation if all six criteria of the rule were met. Patients were judged to have an adverse event (AE) if they had one or more of the preestablished AEs. RESULTS: A total of 538 patients received at least one administration of prehospital naloxone, were transported to the study hospital, and had a 1-hour evaluation performed by a provider. AEs occurred in 82 (15.4%) patients. The rule exhibited a sensitivity of 84.1% (95% confidence interval [CI] = 76.2%-92.1%), a specificity of 62.1% (95% CI = 57.6%-66.5%), and a negative predictive value of 95.6% (95% CI = 93.3%-97.9%). Only one patient with a normal 1-hour evaluation subsequently received additional naloxone following a presumed heroin overdose. CONCLUSION: This rule may be used to risk stratify patients for early discharge following naloxone administration for suspected opioid overdose.

Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound.

OBJECTIVES: Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation. METHODS: A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience. RESULTS: During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location. CONCLUSION: Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed. LemaPC, O'BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB. Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med. 2018;33(4):406-410.

The usefulness of electrodiagnostic studies in the diagnosis and management of neuromuscular disorders.

INTRODUCTION: This study seeks to evaluate the usefulness of electrodiagnostic (EDX) studies in terms of the patient's diagnosis and subsequent management and to identify patient groups in which EDX is particularly useful. METHODS: The records of new patients referred to a single tertiary hospital EDX laboratory during 1 calendar year were reviewed to determine whether results of EDX studies led to a changed diagnosis and/or management plan. Logistic regression was used to determine whether any factors were associated with changed diagnosis or management. RESULTS: Results of EDX studies led to a change in diagnosis and a confirmation in diagnosis in 51.5% and 46.5% of the cases, respectively. Results of EDX studies led to a change in the management plan in 63.4% of all cases. The diagnosis and management plan were more likely to be changed in older patients and patients referred in hospital. DISCUSSION: EDX studies seem useful for confirming or changing the diagnosis and in guiding management in patients with suspected neuromuscular disorders. Muscle Nerve 58: 191-196, 2018.

Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging.

BACKGROUND: Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging. METHODS: This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016. RESULTS: There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02). CONCLUSION: A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest.

INTRODUCTION: Guidelines endorse intravenous (IV) and intraosseous (IO) medication administration for cardiac arrest treatment. Limited clinical evidence supports this recommendation. A multiagency, retrospective study was performed to determine the association between parenteral access type and return of spontaneous circulation (ROSC) in out of hospital cardiac arrest. METHODS: This was a structured, retrospective chart review of emergency medical services (EMS) records from three agencies. Data was analyzed from adults who suffered OHCA and received epinephrine through EMS established IV or IO access during the 18-month study period. Per regional EMS protocols, choice of parenteral access type was at the provider's discretion. Non-inferiority analysis was performed comparing the association between first access type attempted and ROSC at time of emergency department arrival. RESULTS: 1310 subjects met inclusion criteria and were included in the analysis. Providers first attempted parenteral access via IV route in 788 (60.15%) subjects. Providers first attempted parenteral access via IO route in 552 (39.85%) subjects. Rates of ROSC at time of ED arrival were 19.67% when IV access was attempted first and 19.92% when IO access was attempted first. An IO first approach was non-inferior to an IV first approach based on the primary end point ROSC at time of emergency department arrival (p=0.01). CONCLUSION: An IO first approach was non-inferior to an IV first approach based on the end point ROSC at time of emergency department arrival.

Women in Emergency Medicine Residency Programs: An Analysis of Data From Accreditation Council for Graduate Medical Education-approved Residency Programs.

OBJECTIVE: Understanding the factors associated with attracting women to a residency program would help residency program leadership build programs that are appealing to women candidates. The objective of this study was to identify factors associated with the percentage of women residents in emergency medicine (EM) residency programs. METHODS: A list of 161 Accreditation Council for Graduate Medical Education-approved EM residencies was compiled. The public websites for each of the residencies was queried for information on the following variables: residency region (Midwest, Northeast, South, West), residency length (3 years vs. 4 years), sex of the department chair, sex of the program director (PD), percentage of women faculty, and the number of residents by graduation class and sex. RESULTS: The websites of 161 EM residencies were reviewed. Complete data were available from a total of 143 programs representing 4,547 residents from the studied classes of 2014, 2015, and 2016. Overall, 38% were women (n = 1,743). The percentage of women residents per program varied from 0% to 68% across residency programs. There was no association between the percentage of women residents and residency region, sex of the department chair, and sex of the PD. CONCLUSIONS: In this study, there was no evidence that EM residencies with a greater percentage of women faculty and women in select leadership roles had a greater percentage of women residents. There was also no evidence for regional variability in women's selection of residency programs. This study was limited to publicly available data and cannot address the many other complex factors which may play a role in women's decision making when choosing a residency.

Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care.

OBJECTIVES: What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. PROCEDURES: MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the "other instructions" section were submitted to content analysis. RESULTS: Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for "comfort measures only" seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. CONCLUSIONS: Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

Patients Immobilized with a Long Spine Board Rarely Have Unstable Thoracolumbar Injuries.

Most Emergency Medical Services (EMS) protocols require spine immobilization with both a cervical collar and long spine board for patients with suspected spine injuries. The goal of this research was to determine the prevalence of unstable thoracolumbar spine injuries among patients receiving prehospital spine immobilization: a 4-year retrospective review of adult subjects who received prehospital spine immobilization and were transported to a trauma center. Prehospital and hospital records were linked. Data was reviewed to determine if spine imaging was ordered, whether acute thoracolumbar fractures, dislocations, or subluxations were present. Thoracolumbar injuries were classified as unstable if operative repair was performed. Prehospital spine immobilization was documented on 5,593 unique adult subjects transported to the study hospital. A total of 5,423 (97.0%) prehospital records were successfully linked to hospital records. The subjects were 60.2% male, with a mean age of 40.6 (SD = 17.5) years old. An total of 5,286 (97.4%) subjects had sustained blunt trauma. Hospital providers ordered imaging to rule out spine injury in 2,782 (51.3%) cases. An acute thoracolumbar fracture, dislocation, or subluxation was present in 233 (4.3%) cases. An unstable injury was present in 29 (0.5%) cases. No unstable injuries were found among the 951 subjects who were immobilized following ground level falls. Hospital providers ordered at least one spine x-ray or CT in most patients, and a thoracolumbar imaging in half of all patients immobilized. Only 0.5% of patients who received prehospital spine immobilization had an unstable thoracolumbar spine injury.

Prehospital Naloxone Administration as a Public Health Surveillance Tool: A Retrospective Validation Study.

BACKGROUND: Abuse or unintended overdose (OD) of opiates and heroin may result in prehospital and emergency department (ED) care. Prehospital naloxone use has been suggested as a surrogate marker of community opiate ODs. The study objective was to verify externally whether prehospital naloxone use is a surrogate marker of community opiate ODs by comparing Emergency Medical Services (EMS) naloxone administration records to an independent database of ED visits for opiate and heroin ODs in the same community. METHODS: A retrospective chart review of prehospital and ED data from July 2009 through June 2013 was conducted. Prehospital naloxone administration data obtained from the electronic medical records (EMRs) of a large private EMS provider serving a metropolitan area were considered a surrogate marker for suspected opiate OD. Comparison data were obtained from the regional trauma/psychiatric ED that receives the majority of the OD patients. The ED maintains a de-identified database of narcotic-related visits for surveillance of narcotic use in the metropolitan area. The ED database was queried for ODs associated with opiates or heroin. Cross-correlation analysis was used to test if prehospital naloxone administration was independent of ED visits for opiate/heroin ODs. RESULTS: Naloxone was administered during 1,812 prehospital patient encounters, and 1,294 ED visits for opiate/heroin ODs were identified. The distribution of patients in the prehospital and ED datasets did not differ by gender, but it did differ by race and age. The frequency of naloxone administration by prehospital providers varied directly with the frequency of ED visits for opiate/heroin ODs. A monthly increase of two ED visits for opiate-related ODs was associated with an increase in one prehospital naloxone administration (cross-correlation coefficient [CCF]=0.44; P=.0021). A monthly increase of 100 ED visits for heroin-related ODs was associated with an increase in 94 prehospital naloxone administrations (CCF=0.46; P=.0012). CONCLUSIONS: Frequency of naloxone administration by EMS providers in the prehospital setting varied directly with frequency of opiate/heroin OD-related ED visits. The data correlated both for short-term frequency and longer term trends of use. However, there was a marked difference in demographic data suggesting neither data source alone should be relied upon to determine which populations are at risk within the community.