A Comparison of Efficacy of Treatment and Time to Administration of Naloxone by BLS and ALS Providers.

INTRODUCTION: The administration of naloxone therapy is restricted by scope of practice to Advanced Life Support (ALS) in many Emergency Medical Services (EMS) systems throughout the United States. In Delaware's two-tiered EMS system, Basic Life Support (BLS) often arrives on-scene prior to ALS, but BLS providers were not previously authorized to administer naloxone. Through a BLS naloxone pilot study, the researchers sought to evaluate BLS naloxone administration and timing compared to ALS. HYPOTHESIS: After undergoing specialized training, BLS providers would be able to appropriately administer naloxone to opioid overdose patients in a more timely manner than ALS providers. METHODS: This was a retrospective, observational study using data collected from February 2014 through May 2015 throughout a state BLS naloxone pilot program. A total of 14 out of 72 state BLS agencies participated in the study. Pilot BLS agencies attended a training session on the indications and administration of naloxone, and then were authorized to carry and administer naloxone. Researchers then compared vital signs and the time of BLS arrival to administration of naloxone by BLS and ALS. Data were analyzed using paired and independent sample t-tests, as well as chi-square, as appropriate. RESULTS: A total of 131 incidents of naloxone administration were reviewed. Of those, 62 patients received naloxone by BLS (pilot group) and 69 patients received naloxone by ALS (control group). After naloxone administration, BLS patients showed improvements in heart rate (HR; P < .01), respiratory rate (RR; P < .01), and pulse oximetry (spO2; P < .01); ALS patients also showed improvement in RR (P < .01), and in spO2 (P = .005). There was no significant improvement in HR for ALS providers (P = .189).There was a significant difference in arrival time of BLS to the time of naloxone administration between the two groups, with shorter times in the BLS group compared to the ALS group (1.9 minutes versus 9.8 minutes; P < .01); BLS administration was 7.8 minutes faster when compared to ALS administration (95% CI, 6.2-9.3 minutes). CONCLUSIONS: Patients improved similarly and received naloxone therapy sooner when treated by BLS agencies carrying naloxone than those who awaited ALS arrival. All EMS systems should consider allowing BLS to carry and administer naloxone for an effective and potentially faster naloxone administration when treating respiratory compromise related to opiate overdose.

Observational Study on Safety of Prehospital BLS CPAP in Dyspnea.

Introduction Continuous positive airway pressure (CPAP) improves outcomes in patients with respiratory distress. Additional benefits are seen with CPAP application in the prehospital setting. Theoretical safety concerns regarding Basic Life Support (BLS) providers using CPAP exist. In Delaware's (USA) two-tiered Emergency Medical Service (EMS) system, BLS often arrives before Advanced Life Support (ALS). Hypothesis This study fills a gap in literature by evaluating the safety of CPAP applied by BLS prior to ALS arrival. METHODS: This was a retrospective, observational study using Quality Assurance (QA) data collected from October 2009 through December 2012 throughout a state BLS CPAP pilot program; CPAP training was provided to BLS providers prior to participation. Collected data include pulse-oximetry (spO2), respiratory rate (RR), heart rate (HR), skin color, and Glasgow Coma Score (GCS) before and after CPAP application. Pre-CPAP and post-CPAP values were compared using McNemar's and t-tests. Advanced practitioners evaluated whether CPAP was correctly applied and monitored and whether the patient condition was "improved," "unchanged," or "worsened." RESULTS: Seventy-four patients received CPAP by BLS; CPAP was correctly indicated and applied for all 74 patients. Respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved and 4.1% worsened; CPAP significantly reduced the proportion of patients with SpO224, and cyanosis (P<.01). The GCS improved from mean (standard deviation [SD]) 13.9 (SD=1.9) to 14.1 (SD=1.9) after CPAP (mean difference [MD]=0.17; 95% CI, -0.49 to 0.83; P=.59). The HR decreased from 115.7 (SD=53) to 105.1 (SD=37) after CPAP (MD=-10.9; 95% CI, -3.2 to -18.6; P<.01). The SpO2 increased from 80.8% (SD=11.4) to 96.9% (SD=4.2) after CPAP (MD=17.8; 95% CI, 14.2-21.5; P<.01). CONCLUSION: The BLS providers were able to determine patients for whom CPAP was indicated, to apply it correctly, and to appropriately monitor the status of these patients. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training. Sahu N , Matthews P , Groner K , Papas MA , Megargel R . Observational study on safety of prehospital BLS CPAP in dyspnea. Prehosp Disaster Med. 2017;32(6):610-614.

Delaware's inclusive trauma system: impact on mortality.

BACKGROUND: The impact of implementing an inclusive state trauma system on injury-related mortality for patients with life-threatening injuries was assessed. METHODS: Using the state trauma registry, trauma patients evaluated in all of Delaware's acute care hospitals from 1998 to 2007 were identified. Patients were categorized by injury severity score (ISS) groups (1-9, 10-15, 16-24, and >24). Each category was analyzed by mortality and interfacility transfer rate to the Level I trauma center for each year. An analysis of the National Trauma Data Bank (NTDB) for these ISS groups and mortality was performed to provide a comparative benchmark. Chi(2) and analysis of variance were used where appropriate (p 24 group. For this group, there was an incremental mortality decrease from 45.7% (1998) to 20.5% (2007) (p 24 group managed at the Level I hospital significantly increased over the same period. CONCLUSION: Since its inception, Delaware's trauma system, in which all acute care hospitals participate, has been associated with an incremental, significant decrease in mortality of the most critically injured patients. This decrease is more substantial than that experienced nationally as depicted within the NTDB. These findings and our evolving experience support the concept and benefits of an "inclusive" trauma system.