The Safety, Efficacy, and Expediency of Albuterol Nebulizer Administration by BLS Providers.

INTRODUCTION: Many Emergency Medical Service (EMS) systems in the United States restrict albuterol therapy by scope of practice to Advanced Life Support (ALS). The State of Delaware has a two-tiered EMS system in which Basic Life Support (BLS) arrives on scene prior to ALS in the majority of respiratory distress calls. STUDY OBJECTIVE: This study sought to evaluate the safety, efficacy, and expedience of albuterol administration by BLS compared to ALS. METHODS: This retrospective observational study used data collected from July 2015 through January 2017 throughout a State BLS albuterol pilot program. Pilot BLS agencies participated in a training session on the indications and administration of albuterol, and were then authorized to carry and administer nebulized albuterol. Heart rate (HR), respiratory rate (RR), and pulse oximetry (spO2) were obtained before and after albuterol administration by BLS and ALS. The times from BLS arrival to the administration of albuterol by pilot BLS agencies versus ALS were compared. Study encounters required both BLS and ALS response. Data were analyzed using chi-square and t-test as appropriate. RESULTS: Three hundred eighty-eight (388) incidents were reviewed. One hundred eighty-five (185) patients received albuterol by BLS pilot agencies and 203 patients received albuterol by ALS. Of note, the population treated by ALS was significantly older than the population treated by BLS (61.9 versus 51.6 years; P <.001). A comparison of BLS arrival time to albuterol administration time showed significantly shorter times in the BLS pilot group compared to the ALS group (3.50 minutes versus 8.00 minutes, respectively; P <.001). After albuterol administration, BLS pilot patients showed improvements in HR (P <.01), RR (P <.01), and spO2 (P <.01). Alternately, ALS treatment patients showed improvement in spO2 (P <.01) but not RR (P = .17) or HR (P = 1.00). Review by ALS or hospital staff showed albuterol was indicated in 179 of 185 BLS patients and administered correctly in 100% of these patients. CONCLUSION: Patients both received albuterol significantly sooner and showed superior improvements in vital signs when treated by BLS agencies carrying albuterol rather than by BLS agencies who required ALS arrival for albuterol. Two-tiered EMS systems should consider allowing BLS to carry and administer albuterol for safe, effective, and expedient treatment of respiratory distress patients amenable to albuterol therapy.

Prediction model for COVID-19 patient visits in the ambulatory setting.

Objective: Healthcare systems globally were shocked by coronavirus disease 2019 (COVID-19). Policies put in place to curb the tide of the pandemic resulted in a decrease of patient volumes throughout the ambulatory system. The future implications of COVID-19 in healthcare are still unknown, specifically the continued impact on the ambulatory landscape. The primary objective of this study is to accurately forecast the number of COVID-19 and non-COVID-19 weekly visits in primary care practices. Materials and Methods: This retrospective study was conducted in a single health system in Delaware. All patients' records were abstracted from our electronic health records system (EHR) from January 1, 2019 to July 25, 2020. Patient demographics and comorbidities were compared using t-tests, Chi square, and Mann Whitney U analyses as appropriate. ARIMA time series models were developed to provide an 8-week future forecast for two ambulatory practices (AmbP) and compare it to a naïve moving average approach. Results: Among the 271,530 patients considered during this study period, 4,195 patients (1.5%) were identified as COVID-19 patients. The best fitting ARIMA models for the two AmbP are as follows: AmbP1 COVID-19+ ARIMAX(4,0,1), AmbP1 nonCOVID-19 ARIMA(2,0,1), AmbP2 COVID-19+ ARIMAX(1,1,1), and AmbP2 nonCOVID-19 ARIMA(1,0,0). Discussion and Conclusion: Accurately predicting future patient volumes in the ambulatory setting is essential for resource planning and developing safety guidelines. Our findings show that a time series model that accounts for the number of positive COVID-19 patients delivers better performance than a moving average approach for predicting weekly ambulatory patient volumes in a short-term period.

Implementing Antibiotic Stewardship in a Network of Urgent Care Centers.

BACKGROUND: Most antibiotics are prescribed in outpatient settings, including urgent care clinics (UCCs); however, few UCCs have described implementing antibiotic stewardship. This study describes interventions to reduce total antibiotic and azithromycin use in a UCC network. METHODS: The researchers conducted a prospective performance improvement project in five UCCs in Delaware, with > 40 providers and > 75,000 visits annually. In April 2017 all providers received in-person education on guideline-recommended management of common infections. The UCC lead physician performed chart audits and provided group and individual feedback. Individual antibiotic utilization rates were provided beginning in February 2018, and chart audits ceased in May 2018. Patient education included posters in waiting and exam rooms, discharge materials, and external website revisions. The researchers used control charts to analyze trends in prescribing over time, and calculated rate ratios (RRs) between pre-/early, mid- and postintervention periods. RESULTS: Compared to the pre-/early intervention study period (54.7 prescriptions per 100 visits), total antibiotic use declined to 40.2 (RR, 0.74; 95% confidence interval [CI] = 0.72-0.75) in the mid-intervention period and to 35.0 (RR, 0.42; 95% CI = 0.40-0.44) in the postintervention period. Azithromycin use declined from 8.5 prescriptions/100 visits to 3.5 (RR 0.64; 95% CI = 0.63-0.65) and 1.9 (RR 0.22; 95% CI = 0.21-0.24), respectively. The control charts indicated decreasing mean antibiotic prescribing rates as well as decreased variability. CONCLUSION: A multifaceted and iterative approach significantly reduced prescribing of all antibiotics, including azithromycin, regardless of diagnosis. Although the approach was initially resource-intensive, sending prescribing data directly to providers automated the process without an observed rebound in prescribing.

Creation of a Systems-Level Checklist to Address Stress and Violence in Fire-Based Emergency Medical Services Responders.

Between 57 and 93% of Emergency Medical Services (EMS) responders reported having experienced verbal or physical violence at least once in their career. Therefore, the primary goal of this study was to develop a systems-level checklist for violence against fire-based EMS responders using findings from a systematic literature review and outcomes from a national stakeholder meeting. First, a literature review of violence against EMS responders resulted in an extensive list of 162 academic and industrial publications. Second, from these sources, 318 potential candidate items were developed. Third, Q-methodology was employed to categorize, refine, and de-duplicate the items. Fourth, ThinkLet systems facilitated consensus-building, collaboration, and evaluation of the checklist with diverse subject matter experts representing 27 different EMS organizations, government, academia, labor unions, and fire departments during a two-day consensus conference. The final SAVER checklist contains 174 items organized by six phases of EMS response: pre-event, traveling to the scene, scene arrival, patient care, assessing readiness to return to service, and post-event. So called pause points for the individual EMS responder were incorporated at the end of each of phase. Overall, 47.5% of votes across all phases rated items as most feasible, 33.7% as less feasible, and 11.6% as extremely difficult. The SAVER systems-level Checklist is an innovative application of traditional checklists, designed to shift the onus of safety and health from that of the individual first responder to the organization by focusing on actions that leadership can institute through training, policy, and environmental modifications.