Prehospital transport time intervals for acute stroke patients.

BACKGROUND: Recognizing factors that cause prehospital stroke delays may improve time of presentation to the Emergency Department (ED) and allow earlier treatment of acute stroke patients. STUDY OBJECTIVES: To determine the impact of stroke recognition by emergency medical dispatchers (EMD) and paramedics (PM) on ED arrival time in a large urban Emergency Medical Services system. METHODS: Retrospective study of patients aged 18 years or more identified as having acute stroke by EMD, PM, or stroke neurologists from January 1, 2005 to December 31, 2005. Data were acquired from computer-assisted dispatch records, paramedic assessments, ICD-9 (International Classification of Diseases, 9(th) Revision) databases, and a hospital stroke registry. Paramedic time to scene, scene time, and total run time were computed for patients with final hospital diagnosis of stroke and grouped into missed strokes and identified strokes by EMD and PM. Time intervals were compared between missed and identified strokes as well as between incidents where EMD and PM agreed or disagreed. RESULTS: A total of 1067 patients were eligible for the study; 22 were excluded for missing data. For true strokes, EMD and PM were in agreement 27.3% of the time. The median RT was 2.5 min shorter when there was agreement between the providers than when there was disagreement (36.5 min; interquartile range [IQR] 30-43 vs. 39 min.; IQR 33-45, respectively). CONCLUSIONS: Prehospital scene time and run times for acute strokes are less when there is diagnostic concordance between dispatchers and paramedics. Time intervals did not differ between missed and recognized strokes.

The feasibility of a regional cardiac arrest receiving system.

BACKGROUND: Patients suffering out-of-hospital cardiac arrest (OOHCA) are generally transported to the closest ED, presumably to expedite a hospital level of care and improve the chances of return for spontaneous circulation (ROSC) or provide post-resuscitative care for patients with prehospital ROSC. As hospital-based therapies for survivors of OOHCA are identified, such as hypothermia and emergency primary coronary interventions (PCI), certain hospitals may be designated as cardiac arrest receiving facilities. The safety of bypassing non-designated facilities with such a regional system is not known. OBJECTIVES: To explore the potential ED contribution in OOHCA victims without prehospital ROSC and document the relationship between transport time and outcome in patients with prehospital ROSC. METHODS: This was a prospective, observational study conducted in a large, urban EMS system over an 18-month period. Data were collected using the Utstein template for OOHCA. The incidence of prehospital ROSC was calculated for patients who were declared dead on scene, transported but died in the ED, died in the hospital, and survived to hospital discharge. The relationship between transport time and survival was also explored for patients with prehospital ROSC. RESULTS: A total of 1141 cardiac arrest patients were enrolled over the 18-month period. A strong association between prehospital ROSC and final disposition was observed (chi-square test for trend p<0.001). Only two patients who survived to hospital discharge did not have prehospital ROSC. Mean transport times were not significantly different for patients with prehospital ROSC who were declared dead in the ED (8.3min), died following hospital admission (7.8min), and survived to hospital discharge (8.5min). Outcomes in patients with prehospital ROSC who had shorter (7min or less) versus longer transport times were similar, and receiver-operator curve analysis indicated no predictive ability of transport time with regard to survival to hospital admission (area under the curve=0.52). CONCLUSIONS: In this primarily urban EMS system, the vast majority of survivors from OOHCA are resuscitated in the field. A relationship between transport time and survival to hospital admission or discharge was not observed. This supports the feasibility of developing a regional cardiac arrest system with designated receiving facilities.

Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience.

BACKGROUND: Prehospital personnel in Emergency Medical Service (EMS) systems have varying levels of accuracy in stroke recognition. Identifying the accuracy of emergency medical dispatcher using Medical Priority Dispatch Systems (MPDS) stroke protocol and paramedics may help understand the accuracy of stroke recognition in about 3000 emergency medical dispatch systems and prehospital systems world wide. OBJECTIVE: Our aim was to assess the accuracy of stroke identification in emergency medical dispatchers (EMD) with high compliance to MPDS protocol and paramedics using Cincinnati Prehospital Stroke Scale (CSS). METHODS: This was a retrospective observational study. Data was acquired from a computer assisted dispatch (CAD) system, a computerized paramedic record database and discharge diagnosis from billing records or stroke registry containing all stroke assessments of patients who presented to the participating study hospitals within 12 hours of symptom onset. We included patients 18 years or older, identified as having stroke by EMD and city agency paramedics. We excluded patients taken to hospitals not participating in the study, patients with a dispatch determinant of Stroke (card 28) not transported by City EMS agency (SDMSE) to participating hospitals, patients in the stroke registry not transported by SDMSE or patients with no final outcome data. A stroke neurologist or hospital discharge diagnosis of stroke (physician diagnosis) was used to determine the sensitivity and predictive values of EMD and paramedic recognition of stroke. RESULTS: Of 882 patients with a dispatch determinant of stroke using MPDS Stroke protocol, 367 had a final discharge diagnosis of stroke. This gives a sensitivity of 83% and a positive predictive value of 42% for EMD using MPDS Stroke protocol. Of 477 patients with a paramedic assessment of stroke using CSS, 193 had a final discharge diagnosis of stroke. This gives a sensitivity of 44% and a PPV of 40% for paramedics using CSS. CONCLUSIONS: In our EMS system, EMD using MPDS Stroke protocol with a high compliance has a higher sensitivity than paramedics using CSS.

Central venous access by air medical personnel.

BACKGROUND: Vascular access is vital in the resuscitation of critically ill and injured patients for both fluid resuscitation and the delivery of medications. However, peripheral access is not always possible in patients with hypovolemia or difficult anatomy. Central venous access is an alternative vascular access strategy for air medical crews, offering the advantage of relatively predictable anatomy, even in unstable patients. The success and complication rates for the procedure in the hands of flight air medical personnel must be considered in the decision to institute a central venous access procedure. OBJECTIVE: To explore success and complication rates for central venous access attempts in patients treated by air medical crews. METHODS: This was a retrospective review using advanced procedure quality improvement forms. All air medical patients in whom an attempt at central venous access was made over a 30-month period were included. Femoral and subclavian lines were compared for incidence, success rates, and complications. RESULTS: A total of 50 patients were identified over the 30-month study period. The incidence of femoral and subclavian attempts was approximately equal. The overall success rate was 66% (60% for subclavian, 67% for femoral, and 73% for nonspecified site). The mean number of attempts was 1.2 for each approach. The only reported complication was an arterial placement during a subclavian attempt. CONCLUSIONS: We observed moderate success rates and a low incidence of reported complications with air medical central venous access attempts.

Blood cultures do not change management in hospitalized patients with community-acquired pneumonia.

OBJECTIVES: To determine if blood cultures identify organisms that are not appropriately treated with initial empiric antibiotics in hospitalized patients with community-acquired pneumonia, and to calculate the costs of blood cultures and cost savings realized by changing to narrower-spectrum antibiotics based on the results. METHODS: This was a retrospective observational study conducted in an urban academic emergency department (ED). Patients with an ED and final diagnosis of community-acquired pneumonia admitted between January 1, 2001, and August 30, 2003, were eligible when the results of at least one set of blood cultures obtained in the ED were available. Exclusion criteria included documented human immunodeficiency virus infection, immunosuppressive illness, chronic renal failure, chronic corticosteroid therapy, documented hospitalization within seven days before ED visit, transfer from another hospital, nursing home residency, and suspected aspiration pneumonia. The cost of blood cultures in all patients was calculated. The cost of the antibiotic regimens administered was compared with narrower-spectrum and less expensive alternatives based on the results. RESULTS: A total of 480 patients were eligible, and 191 were excluded. Thirteen (4.5%) of the 289 enrolled patients had true bacteremia; the organisms isolated were sensitive to the empiric antibiotics initially administered in all 13 cases (100%; 95% confidence interval = 75% to 100%). Streptococcus pneumoniae and Haemophilus influenzae were isolated in 11 and two patients, respectively. The potential savings of changing the antibiotic regimens to narrower-spectrum alternatives was only 170 dollars. CONCLUSIONS: Appropriate empiric antibiotics were administered in all bacteremic patients. Antibiotic regimens were rarely changed based on blood culture results, and the potential savings from changes were minimal.

Progesterone as a predictor of ectopic pregnancy when the ultrasound is indeterminate.

The objective of this study was to evaluate a progesterone cutpoint of 5.0 ng/mL ability to identify abnormal pregnancy (abnormal intrauterine pregnancy and ectopic pregnancy) as well as ectopic pregnancy alone in 2 subclasses of indeterminate ultrasounds. This was a prospective observational study of emergency department patients with abdominal pain or vaginal bleeding and an indeterminate transvaginal ultrasound. Two subclasses of indeterminate ultrasounds were eligible: those with an empty uterus and a beta-human chorionic gonadotropin value <3,000 mIU/mL and those with a nonspecific fluid collection. Patients were enrolled if a progesterone assay was collected the day of the emergency department visit. Patients were excluded if lost to follow-up. One hundred sixty patients were enrolled. Of these, 24 were diagnosed with ectopic pregnancy. The sensitivity and specificity of progesterone identifying abnormal pregnancy were 84% and 97%, respectively. The sensitivity and specificity of progesterone identifying ectopic pregnancy were 88% and 40%, respectively. In the 2 subclasses, the progesterone cutpoint was both sensitive and specific in identifying abnormal pregnancy and was sensitive but only moderately specific for identifying ectopic pregnancy.

Nonoccupational postexposure HIV prevention: emergency physicians' current practices, attitudes, and beliefs.

STUDY OBJECTIVE: We surveyed emergency physicians to determine current practices, knowledge, attitudes, and beliefs regarding nonoccupational postexposure prevention practices. METHODS: Two thousand randomly selected practicing emergency physicians from the American College of Emergency Physicians' national database and all graduating emergency medicine residents in 2000 were surveyed. Knowledge, role responsibility, self-efficacy, and attitudes and beliefs were measured and composite scores developed. Differences in responses between supporters and nonsupporters were compared for each category. RESULTS: Eight hundred eighty-nine responded, representing 60% (67/113) of emergency medicine residencies, 32% (347/1095) of emergency medicine residents, and 27% (542/2000) of emergency physicians. Responders recommend nonoccupational postexposure prevention for sexual assault (35%), unintentional needle stick (25%), and, rarely (<15%), for unsafe sexual practices and injection drug use. Knowledge of Centers for Disease Control and Prevention recommendations or the time when treatment may be most beneficial is poor (15.5% and 13.7%, respectively). Most agree their role includes providing nonoccupational postexposure prevention drugs and referring patients for counseling (76.5% and 75.6%, respectively). Confidence in assessing need for nonoccupational postexposure prevention varied with exposure type (sexual assault [61.6%], unintentional needle stick [54.8%], unsafe sexual practices [40.4%], and injection drug use [49.7%]). Supporters of nonoccupational postexposure prevention (64.1%) are more likely to have nonoccupational postexposure prevention available (69.3% versus 42.9%; 95% confidence interval [CI] 19.7 to 33.1), written protocols (42.5% versus 33.0%; 95% CI 2.8 to 16.2), and higher mean composite scores than nonsupporters in all categories: knowledge, self-efficacy, role responsibility, and attitudes. CONCLUSION: Most emergency physicians surveyed agree that offering nonoccupational postexposure prevention is feasible and within their role responsibility. Establishing nonoccupational postexposure prevention protocols and providing educational programs are important first steps in changing practice.