Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications.

Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS "Often" or "Always" only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022. Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians. Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration "Often" or "Always" (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% "Always" review the triage note. Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

Multi-Patient Rabies Exposure on a Colorado River Rafting Expedition: Urgent vs. Emergent Transport Decision Making in an Austere Setting.

We present a case of rabies exposure on a private river rafting trip on Grand Canyon National Park's Colorado River. Five individuals were exposed to an erratically acting bat; one of the individuals sustained a direct bite to the upper lip while sleeping. This case illustrates the challenges of austere medical care and evacuation in remote conditions while highlighting the importance of risk mitigation considerations in all austere situations.

Effect of intensive physician oversight on a prehospital rapid-sequence intubation program.

OBJECTIVE: To examine the effects of adding close concurrent and retrospective physician oversight, consistent with National Association of EMS Physicians (NAEMSP) recommendations, to an existing regional prehospital rapid-sequence intubation (RSI) program. METHODS: This study involved a retrospective cohort of patients receiving RSI between January 1, 2004, and July 31, 2008. On January 1, 2007, an updated program including additional concurrent and retrospective physician oversight, increased RSI-specific continuing medical education, and cadaver laboratory training was implemented. Study patients were divided into a preintervention group (group 1) and a postintervention group (group 2) based on date of medical care. Data regarding baseline characteristics, airway management, medication usage, and performance factors were compared between the groups. A retrospective review by two emergency medical services (EMS) physicians assessed whether the RSI was "clearly indicated" based on a predetermined set of criteria. RESULTS: There were 109 RSIs performed in group 1 and 54 in group 2. Absolute increases in the use of both basic life support (BLS) (5%, p = 0.2) and advanced life support (ALS) (41%, p = 0.001) airway techniques were observed. Increases in postintubation administration of midazolam (30%, p = 0.001) and morphine (24%, p = 0.001) and a decrease for vecuronium (-28%, p = 0.001) were observed. There was no statistically significant difference in the intubation success rates (92% vs. 94%) and the frequencies of recognized esophageal endotracheal tube (ETT) placement (5% vs. 6%). The number of unrecognized esophageal ETT placements remained zero. Physician chart review demonstrated an absolute increase in "clearly indicated" RSIs (17%, p = 0.01). CONCLUSIONS: Close concurrent and retrospective physician oversight consistent with recommendations from the NAEMSP is associated with improved cognitive skills in paramedics, including appropriate patient selection for RSI. Further research is warranted to validate this model and optimize where resources are best used to enhance patient safety and improve clinical management for this controversial paramedic skill.