Low Utilization of Synchronous Telemedicine in Pediatric Critical Care Interfacility Transport: Barriers and Lessons.

OBJECTIVE: The use of telemedicine has increased and may enhance the care of children during medical transport. We aimed to evaluate the feasibility of synchronous telemedicine connectivity before interfacility transport of critically ill children by a pediatric transport team. METHODS: We performed a prospective, observational feasibility study of the introduction of synchronous telemedicine into an established pediatric transport team from 2019 to 2020. The outcomes examined included connectivity, physician workload, transport team satisfaction, and patient care outcomes. RESULTS: Among 118 eligible transports, telemedicine was considered in 23 transports (19%), including 11 transports in which an attempt to connect was sought and 12 in which telemedicine activation was offered but not attempted. The median connection time was 2.9 minutes (interquartile range, 1.7-4.4 minutes), and clinical care was altered in 1 case. Connection failed in 2 cases (18.2%). In 50% of cases, concurrent medical control physician workload prevented activation. There were no perceived benefits in 41.7% of cases. Team members indicated the desire for future telemedicine use in only 54.6% of cases. CONCLUSIONS: We found low utilization of synchronous telemedicine in interfacility pediatric transport. The identified barriers included reliable connectivity, physician workload, and low perceived benefit. Lessons learned and future research suggestions are presented to mitigate these barriers.

Description of telepharmacy services by emergency medicine pharmacists.

PURPOSE: Utilization of telemedicine and telepharmacy services has become increasingly popular, as specifically noted during the coronavirus disease 2019 (COVID-19) pandemic. This article describes the implementation of and services provided by emergency medicine pharmacists (EMPs) as part of a telemedicine team in the emergency department (ED). SUMMARY: This report describes the telemedicine and telepharmacy services provided to EDs in the Mayo Clinic Health System from the Mayo Clinic Rochester ED. Telepharmacy services provided by EMPs started in 2018. EMPs cover telepharmacy calls as part of their shift within the ED in Rochester. Recommendations and interventions are documented in the electronic medical record. A retrospective review evaluated interventions provided from November 18, 2018, through November 10, 2020. Baseline patient demographics, as well as the type and number of interventions provided by EMPs, hospital site, and time spent on the interventions, were collected. Telepharmacy consults could include multiple interventions and be classified as more than one type of intervention. During this time period, 24 pharmacists worked in the ED and were able to provide telepharmacy services. There were 279 consults included in this study, with 435 interventions. Most of the calls came from critical access hospitals (48.7%). The most common types of interventions documented were medication selection and dosing (n = 238), antimicrobials (n = 141), monitoring and follow-up (n = 65), discharge (n = 56), drug information (n = 55), and allergy review (n = 50). CONCLUSION: Telepharmacy services can provide increased access to emergency medicine specialty pharmacists in areas that would not otherwise have these services.

Addressing Barriers to Telemedicine Use in Rural Emergency Medicine: Leveraging In Situ Simulation.

Introduction: Acute care telemedicine is a critical resource for rural and community Emergency Medicine (EM) providers. To address potential barriers and promote use of these services throughout our health system Emergency Departments (EDs), we embed telemedicine consultations within in situ simulations. Materials and Methods: Care teams in health system EDs participated in multidisciplinary in situ simulations that focused on Difficult Airway management or Obstetric Emergencies. Physicians in EM and Neonatology at the referral center were available for assistance via telemedicine consultation. Participants were then surveyed regarding their experience with the telemedicine consultation during the simulations. Results: Participants reported increased likelihood to use telemedicine as well as increased understanding of the technology, awareness of available consultation services, and comfort interacting with the consultant. Conclusions: Embedding telemedicine consultations into in situ EM simulations is an effective approach to address implementation barriers and may promote increased use of telemedicine services among rural and community EM providers.

A Scalable Framework for Telehealth: The Mayo Clinic Center for Connected Care Response to the COVID-19 Pandemic.

Background: The Mayo Clinic Center for Connected Care has an established organizational framework for telehealth care delivery. It provides patients, consumers, care teams, and referring providers access to clinical knowledge through technologies and integrated practice models. Central to the framework are teams that support product management and operational functions. They work together across the asynchronous, synchronous video telemedicine, remote patient monitoring (RPM), and mobile core service lines. Methods: The organizational framework of the Center for Connected Care and Mayo Clinic telehealth response to the COVID-19 pandemic is described. Barriers to telehealth delivery that were addressed by the public health emergency are also reported. This report was deemed exempt from full review by the Mayo Clinic IRB. Results: After declaration of the COVID-19 pandemic, there was rapid growth in established telehealth offerings, including patient online services account creation, secure messaging, inpatient eConsults, express care online utilization, and video visits to home. Census for the RPM program for patients with chronic conditions remained stable; however, its framework was rapidly adapted to develop and implement a COVID-19 RPM service. In addition to this, other new telehealth and virtual care services were created to support the unique needs of patients with COVID-19 symptoms or disease and the health care workforce, including a digital COVID-19 self-assessment tool and video telemedicine solutions for ambulances, emergency departments, intensive care units, and designated medical-surgical units. Conclusion: Rapid growth, adoption, and sustainability of telehealth services through the COVID-19 pandemic were made possible by a scalable framework for telehealth and alignment of regulatory and reimbursement models.

Barrier Enclosure for Endotracheal Intubation in a Simulated COVID-19 Scenario: A Crossover Study.

INTRODUCTION: Barrier enclosures have been developed to reduce the risk of COVID-19 transmission to healthcare providers during intubation, but little is known about their impact on procedure performance. We sought to determine whether a barrier enclosure delays time to successful intubation by experienced airway operators. METHODS: We conducted a crossover simulation study at a tertiary academic hospital. Participants watched a four-minute video, practiced one simulated intubation with a barrier enclosure, and then completed one intubation with and one without the barrier enclosure (randomized to determine order). The primary outcome measure was time from placement of the video laryngoscope at the lips to first delivered ventilation. Secondary outcomes were periprocedural complications and participant responses to a post-study survey. RESULTS: Proceduralists (n = 50) from emergency medicine and anesthesiology had median intubation times of 23.6 seconds with practice barrier enclosure, 20.5 seconds with barrier enclosure, and 16.7 seconds with no barrier. Intubation with barrier enclosure averaged 4.5 seconds longer (95% confidence interval, 2.7-6.4, p < .001) than without, but was less than the predetermined clinical significance threshold of 10 seconds. Three complications occurred, all during the practice intubation. Barrier enclosure made intubation more challenging according to 48%, but 90% indicated they would consider using it in clinical practice. CONCLUSION: Experienced airway operators performed intubation using a barrier enclosure with minimal increased time to procedure completion in this uncomplicated airway model. Given potential to reduce droplet spread, use of a barrier enclosure may be an acceptable adjunct to endotracheal intubation for those familiar with its use.

Development and Implementation of a Community Paramedicine Program in Rural United States.

INTRODUCTION: Community paramedicine (CP) is an innovative care model focused on medical management for patients suffering from chronic diseases or other conditions that result in over-utilization of healthcare services. Despite their value, CP care models are not widely used in United States healthcare settings. More research is needed to understand the feasibility and effectiveness of implementing CP programs. Our objective was to develop a CP program to better meet the needs of complex, high-utilizer patients in a rural setting. METHODS: We conducted an observational descriptive case series in a community, 25-bed, critical access hospital and primary care clinic in a rural Wisconsin county. Multiple stakeholders from the local health system and associated ambulance service were active participants in program development and implementation. Eligible patients receiving the intervention were identified as complex or high need by a referring physician. Primary outcomes included measures of emergency department, hospital, and clinic utilization. Secondary measures included provider and patient satisfaction. RESULTS: We characterized 32 unique patients as high utilizers requiring assistance in medical management. These patients were enrolled into the program and categorized as high utilizers requiring assistance in medical management. The median age was 76 years, and 68.8% were female. After six months, we found a statistically significant decline in patient utilization for primary care (53.3%, p = .006) and ED visits (59.3%, p = .007), but not for hospitalizations (60%, p = .13, non-significant (NS), compared to the six months preceding enrollment. Overall, the total number of healthcare contacts was increased after implementation (623 before vs 790 after, + 167, +26.8%). Implementation of the CP program resulted in increased overall use of local healthcare resources in patients referred by physicians as high utilizers. CONCLUSION: The implementation of an in-home CP program targeting high users of healthcare resources resulted in a decrease in utilization in the hospital, ED, and primary care settings; however, it was balanced and exceeded by the number of CP visits. CP programs align well with population health strategies and could be better leveraged to fill gaps in care and promote appropriate access to healthcare services. Further study is required to determine whether the shift in type of healthcare access reduces or increases cost.

Telehealth dashboard: leverage reporting functionality to increase awareness of high-acuity emergency department patients across an enterprise practice.

BACKGROUND: Emergency Medicine Telehealth (TeleEM) represents an opportunity to work directly with referral centres, rural facilities and underserved areas to mitigate unnecessary testing, optimise resource utilisation and facilitate patient transfers across health systems. To optimise the impact of a TeleEM programme, a tool is needed to remotely monitor patient activity in multiple emergency department facilities, concurrently. METHODS: After identifying data sources for activation criteria put forth by the TeleEM operations group, rules were constructed within the electronic health record to facilitate data checks and ultimately produce a yes/no response if the category's conditions were met. Responses were organised into a table, with functionality allowing end users to drill into the different sites to see patient-specific information for patients meeting activation criteria. CONCLUSIONS: The TeleEM dashboard allows for proactive engagement by the TeleEM physician and strengthens the team-based approach of critically ill.

Ethylene glycol and methanol ingestion cared for by tele-emergency pharmacy and tele-emergency medicine.

We believe this is the first documented case of a critically ill patient managed by telepharmacy in a remote, rural critical access hospital. We outline the case and the benefits of telepharmacy in under-resourced, rural critical access emergency departments.

A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation.

INTRODUCTION: American Heart Association (AHA) guidelines recommend cardiopulmonary resuscitation (CPR) chest compressions 1.5 to 2 inches (3.75-5 cm) deep at 100 to 120 per minute. Recent studies demonstrated that manual CPR by emergency medical services (EMS) personnel is substandard. We hypothesized that transport CPR quality is significantly worse than on-scene CPR quality. METHODS: We analyzed adult patients receiving on-scene and transport chest compressions from nine EMS sites across Minnesota and Wisconsin from May 2008 to July 2010. Two periods were analyzed: before and after visual feedback. CPR data were collected and exported with the Zoll M series monitor and a sternally placed accelerometer measuring chest compression rate and depth. We compared compression data with 2010 AHA guidelines and Zoll RescueNet Code Review software. CPR depth and rate were "above (deep)," "in," or "below (shallow)" the target range according to AHA guidelines. We paired on-scene and transport data for each patient; paired proportions were compared with the nonparametric Wilcoxon signed rank test. RESULTS: In the pre-feedback period, we analyzed 105 of 140 paired cases (75.0%); in the post-feedback period, 35 of 140 paired cases (25.0%) were analyzed. The proportion of correct depths during on-scene compressions (median, 41.9%; interquartile range [IQR], 16.1-73.1) was higher compared to the paired transport proportion (median, 8.7%; IQR, 2.7-48.9). Proportions of on-scene median correct rates and transport median correct depths did not improve in the post-feedback period. CONCLUSION: Transport chest compressions are significantly worse than on-scene compressions. Implementation of visual real-time feedback did not affect performance.

Determinants of Success and Failure in Prehospital Endotracheal Intubation.

INTRODUCTION: This study aimed to identify factors associated with successful endotracheal intubation (ETI) by a multisite emergency medical services (EMS) agency. METHODS: We collected data from the electronic prehospital record for all ETI attempts made from January through May 2010 by paramedics and other EMS crew members at a single multistate agency. If documentation was incomplete, the study team contacted the paramedic. Paramedics use the current National Association of EMS Physicians definition of an ETI attempt (laryngoscope blade entering the mouth). We analyzed patient and EMS factors affecting ETI. RESULTS: During 12,527 emergent ambulance responses, 200 intubation attempts were made in 150 patients. Intubation was successful in 113 (75%). A crew with paramedics was more than three times as likely to achieve successful intubation as a paramedic/emergency medical technician-Basic crew (odds ratio [OR], 3.30; p=0.03). A small tube (≤7.0 inches) was associated with a more than 4-fold increased likelihood of successful ETI compared with a large tube (≥7.5 inches) (OR, 4.25; p=0.01). After adjustment for these features, compared with little or no view of the glottis, a partial or entire view of the glottis was associated with a nearly 13-fold (OR, 12.98; p=0.001) and a nearly 40-fold (OR, 39.78; p<0.001) increased likelihood of successful intubation, respectively. CONCLUSION: Successful ETI was more likely to be accomplished when a paramedic was partnered with another paramedic, when some or all of the glottis was visible and when a smaller endotracheal tube was used.

A retrospective comparison of helicopter transport versus ground transport in patients with severe sepsis and septic shock.

BACKGROUND: Helicopter emergency medical services (HEMS) extend the reach of a tertiary care center significantly. However, its role in septic patients is unclear. Our study was performed to clarify the role of HEMS in severe sepsis and septic shock. METHODS: This is a single-center retrospective cohort study. This study was performed at Mayo Clinic, Rochester, MN, in years 2007-2009. This study included a total of 181 consecutive adult patients admitted to the medical intensive care unit meeting criteria for severe sepsis or septic shock within 24 h of admission and transported from an acute care facility by a helicopter or ground ambulance. The primary predictive variable was the mode of transport. Multiple demographic, clinical, and treatment variables were collected and analyzed with univariate analysis followed by multivariate analysis. RESULTS: The patients transported by HEMS had a significantly faster median transport time (1.3 versus 1.7 h, p < 0.01), faster time to meeting criteria for severe sepsis or septic shock (1.2 versus 2.9 h, p < 0.01), a higher SOFA score (9 versus 7, p < 0.01), higher incidence of acute respiratory distress syndrome (38 versus 18 %, p = 0.013), higher need for invasive mechanical ventilation (60 versus 41 % p = 0.014), higher ICU mortality (13.3 versus 4.1 %, p = 0.024), and an increased hospital mortality (17 versus 30 %, p = 0.04) when compared to those transported by ground. Distance traveled was not an independent predictor of hospital mortality on multivariate analysis. CONCLUSIONS: HEMS transport is associated with faster transport time, carries sicker patients, and is associated with higher hospital mortality compared with ground ambulance services for patients with severe sepsis or septic shock.

Prehospital peripheral intravenous vascular access success rates in children.

OBJECTIVE: Achieving successful peripheral intravenous (PIV) vascular access in children can be difficult. In the prehospital setting, opportunities are rare. Obtaining access becomes vital in emergent and life-threating conditions, such as seizures, hypoglycemia, and cardiac arrest. This study examines prehospital pediatric PIV attempts, success rates, and the impact of patient age. METHODS: This was a retrospective chart review of patients aged 18 years or younger receiving prehospital PIV attempts from January 1, 2003, through May 31, 2011. Included cases were identified by querying electronic patient care reports for PIV attempts within the specified age range. The documentation of PIV attempts and successes was reported by emergency medical service providers. This study was approved by an institutional review board. RESULTS: Throughout the 101-month study period, there were 261,008 ambulance responses. PIV attempts were made in 4188 patients aged 18 years or younger. PIV placement was successful in 3699 patients (88.3%) and failed in 489 (11.7%). Age was significantly associated with success. Each 1-year increase in age was associated with an 11% increase in odds of PIV success (odds ratio, 1.11; 95% CI, 1.09-1.12; p < 0.001). Success was lowest in patients younger than 2 years old, with an overall success rate of 64.1% (141/220). Accounting for multiple attempts, success was achieved in 53.0% of attempts (141/266). CONCLUSIONS: Prehospital PIV attempts are uncommon (2% of emergent responses). Success rates are significantly associated with patient age in the pediatric population and lowest in those aged 2 years or less. Consideration of alternative forms of vascular access in this population may be beneficial.

Logistical concerns for helicopter emergency medical services response to the injured police officer.

INTRODUCTION: Although infrequent, helicopter emergency medical services (HEMS) have been activated to transport police officers injured in the line of duty. The purpose of this study was to query current industry operating procedures in terms of law enforcement training and operations, specifically in terms of firearms restrictions and cotransport of injured officers and suspects. METHODS: This is a survey-based study of air medical emergency medical services program managers in 2010. Descriptive statistics and the Fisher exact test were used to analyze the results. RESULTS: Fifty-eight programs (78.4%) reported transporting officers injured in the line of duty. Sixty-three respondents (85.1%) maintained a written policy addressing the presence of weapons aboard the aircraft; 58.8% of respondents replied that this restriction applied to sworn law enforcement personnel on active duty. Nearly a quarter of programs with written firearms policies have not informed the law enforcement agencies affected by these policies. Two programs reported having cotransported an injured officer and a suspect. CONCLUSION: HEMS will continue to play an important role in the care and transportation of injured officers. HEMS programs may have specific policies that impact law enforcement operations. Open communication of these policies and interagency training are critical to effective interaction during high-stress incidents.

The Airtraq Optical Laryngoscope in helicopter emergency medical services: a pilot trial.

OBJECTIVE: To determine the degree of success helicopter emergency medical services personnel have in placing an endotracheal tube using a relatively new device for endotracheal intubation (ETI) known as the Airtraq (AT) Optical Laryngoscope (King Systems Corp, Noblesville, IN), and to determine the frequency with which flight crews had to resort to other means for advanced airway management. METHODS: This prospective, observational pilot trial evaluated the critical care flight team's ability to perform ETI using the AT as a first-line device in the prehospital setting. Flight crews were instructed to use the AT for any patient needing ETI. Teams completed a 30-minute training session followed by mannequin practice. They documented situations and outcomes: reason for ETI, success in placing the AT, reason for unsuccessful placement, end-tidal carbon dioxide concentration in expired air (ETCO2), and where patients were when they underwent intubation (field, ambulance, aircraft, hospital). Data were abstracted and analyzed using JMP software version 7.0 (SAS Institute, Inc, Cary, NC). RESULTS: Fifty cases involving use of the AT were analyzed. Median patient age was 51.5 years (range, 15-90; interquartile range, 36-64.5). Most patients were male (n = 37 [74%]). The primary reasons for intubation were unresponsiveness and altered loss of consciousness (n = 23 [46%]), respiratory distress or apnea (n = 8 [16%]), cardiac arrest (n = 10 [20%]), and combative behavior (n = 7 [14%]). AT was successful (n = 31[62%]) in 1 to 2 attempts. The primary reason for AT failure was blood or vomit in the airway (n = 8 [42.1%]); 48.1% (n = 25) of patients required a different management mode. CONCLUSIONS: HEMS crews had difficulty placing successful ET tubes with this device after minimal education with a single regular-sized device. Difficulty was pronounced when blood or vomit was present and obstructing the optical view. Further study is needed to evaluate the implementation time, training time required, and possible design advantages of the AT compared with those of traditional emergent airway management techniques.

Population-based study of severe hypoglycemia requiring emergency medical service assistance reveals unique findings.

OBJECTIVE: The objective is to report a contemporary population-based estimate of hypoglycemia requiring emergency medical services (EMS), its burden on medical resources, and its associated mortality in patients with or without diabetes mellitus (DM, non-DM), which will enable development of prospective strategies that will capture hypoglycemia promptly and provide an integrated approach for prevention of such episodes. METHODS: We retrieved all ambulance calls activated for hypoglycemia in Olmsted County, Minnesota, between January 1, 2003 and December 31, 2009. RESULTS: A total of 1473 calls were made by 914 people (DM 8%, non-DM 16%, unknown DM status 3%). Mean age was 60 ± 16 years with 49% being female. A higher percentage of calls were made by DM patients (87%) with proportionally fewer calls coming from non-DM patients (11%) (chi-square test, p < .001), and the remaining 2% calls by people with unknown DM status. Emergency room transportation and hospitalization were significantly higher in non-DM patients compared to DM patients (p < .001) and type 2 diabetes mellitus compared to type 1 diabetes mellitus (p < .001). Sulphonylureas alone or in combination with insulin varied during the study period (p = .01). The change in incidence of EMS for hypoglycemia was tracked during this period. However, causality has not been established. Death occurred in 240 people, 1.2 (interquartile range 0.2-2.7) years after their first event. After adjusting for age, mortality was higher in non-DM patients compared with DM patients (p < .001) but was not different between the two types of DM. CONCLUSIONS: The population burden of EMS requiring hypoglycemia is high in both DM and non-DM patients, and imposes significant burden on medical resources. It is associated with long-term mortality.

Effect of an onboard event recorder and a formal review process on ambulance driving behaviour.

BACKGROUND: Onboard event recorders in vehicles record external and internal video before and after when preset g-force limits are exceeded. The use of these recorders in a fleet of ambulances, along with formal review, may decrease the number of unsafe driving events. The aim of this study was to evaluate the number of driving events since the inception of DriveCam technology in a fleet. METHODS: 54 vehicles were outfitted with DriveCam event recorders in 2003. Events were captured and assigned a categorical severity score of 1-4 (1 being the lowest severity) when the vehicle exceeded preset g-force limits. An event was assigned a score of 'good' if the review determined that the driver demonstrated good judgement. A review and feedback process was implemented in August 2006 and analysed through June 2008. RESULTS: During the study period, 2 979 891 miles were driven for 115 019 ambulance responses, with 6009 events captured. Events were categorised as follows: 2008 (33.4%) level 1; 3726 (62.0%) level 2; 175 (2.9%) level 3; 3 (0.05%) level 4; and 97 (1.6%) good events. The proportion of all events per mile and all events per response decreased over time with use of the recorder and review and feedback. CONCLUSIONS: The institution of video event recorder technology along with formal review and feedback resulted in a change in driving behaviour. Given that call volumes increased and driving events decreased, these measures may serve as surrogates for improvements in safety and maintenance costs. Economic analysis is necessary for conclusions on fiscal impact.

Semiautomatic intraosseous devices in pediatric prehospital care.

BACKGROUND: Intraosseous (IO) access is attempted when intravenous access cannot be established during an emergency. The U.S. Food and Drug Administration-cleared semiautomatic IO access device (EZ-IO; Vidacare Corp., Shavano Park, TX) has been shown to be safe and effective. OBJECTIVE: To examine the characteristics of pediatric patients receiving IO infusions, primary clinical impressions of emergency medical services providers, success rates, and subsequent treatment after use of a manual IO device or the semiautomatic IO device. METHODS: A midwestern, 12-site, statewide ambulance service began using the semiautomatic device instead of a manual IO device in 2007. Retrospective review included analysis of device placement rates and subsequent treatment of children (younger than 18 years) who underwent an IO access procedure with either the manual device (January 2003 through February 2007) or the semiautomatic device (March 2007 through May 2009). RESULTS: First-attempt success was achieved in 80.6% of patients (25 of 31) in the manual device group and in 83.9% of patients (52 of 62) in the semiautomatic device group (p = 0.98). In the manual device group, there were 37 attempts for 25 successful device placements (67.6% success), and in the semiautomatic group, there were 72 attempts for 58 successful placements (80.6% success) (p = 0.52). Intravenous attempts were made before IO attempts in 35.5% of patients (11 of 31) in the manual group and in 1.7% of patients (1 of 60) in the semiautomatic group (p < 0.001). Treatment (medication use, excluding lidocaine for local anesthetic purposes and intravenous crystalloid) was administered IO in 84.0% of the patients (21 of 25) in the manual device group and in 73.2% of the patients (41 of 56) in the semiautomatic device group. CONCLUSIONS: For the pediatric cohort, use of a semiautomatic IO access device in place of a manual device offered no statistically significant difference in first-attempt success (3.3%) or in success per attempt (13.0%). However, the rate at which IO access was used by emergency medical services providers more than tripled with use of the semiautomatic device.

Prehospital diagnosis of ST-segment elevation myocardial infarction using an "all-posterior" 12-lead electrocardiogram.

A prehospital 12-lead electrocardiogram (ECG) is commonly used for patients with suspected ST-segment elevation myocardial infarction (STEMI). This case report describes how paramedics diagnosed inferior STEMI with all ECG leads positioned on a patient's back (i.e., "all-posterior" positioning). The patient was hemodynamically stable but morbidly obese and markedly diaphoretic. Owing to severe back pain, he refused to lie in the supine position for assessment or transport. At the emergency department, a 12-lead ECG with the patient in lateral recumbency confirmed the diagnosis of inferior STEMI. This case shows that an all-posterior 12-lead ECG can be used to identify STEMI when optimal patient positioning is not possible.