Efficacy and Safety of Prehospital Diltiazem.

OBJECTIVE: This study assesses the likelihood of clinical improvement and adverse events from EMS-administered diltiazem. Current prehospital protocols direct paramedics to administer diltiazem, a calcium channel blocker, to decrease the heart rate (HR) of symptomatic, hemodynamically stable patients with rapid atrial fibrillation. However, diltiazem can also cause systemic hypotension and bradycardia, which can precipitate end-organ injury. . METHODS: To assess whether the rate control benefit of prehospital diltiazem outweighs the risk of adverse events, we conducted a retrospective chart review of all adult patients who received diltiazem from Maryland Advanced Life Support EMS clinicians between January 1, 2019, and March 31, 2022. Collected data included patient demographics, vital signs, diltiazem dose, transport times, administered medications, and procedures. The main outcomes were clinical improvement (HR <100 beats per minute or ≥20% decrease from the maximum HR) and adverse events (bradycardia or hypotension). Multivariable logistic regression was used for statistical analysis. RESULTS: During the study period, 2396 patients received prehospital diltiazem and 94% of these patients (n = 2254) were included in the study. Overall, 1414 (63.8%) patients improved clinically, 604 (27.3%) patients achieved rate control as defined by a HR of <100 beats per minute, and 78 patients (3.5%) experienced an adverse event. Patients over the age of 50 were less likely to clinically improve with diltiazem administration. Adverse events were more likely in patients with systolic blood pressures (SBP) less than 140 mmHg, patients with maximum HR of less than 120 beats per minute, and patients who received nitroglycerin. CONCLUSIONS: Prehospital diltiazem is effective and safe for most patients. Adverse events are more likely in patients with baseline SBP less than 140 mmHg, HR less than 120 beats per minute, and concurrent nitroglycerin administration. Future opportunities for research include examining the relationship between adverse events and underlying etiology as well as investigating downstream outcomes.

Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes.

OBJECTIVES: Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. METHODS: This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). RESULTS: Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. CONCLUSIONS: In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Safety of Nurse-Managed Inhaled Nitric Oxide During Critical Care Interfacility Transport.

Inhaled nitric oxide (iNO) is an advanced therapy typically managed by physicians and respiratory therapists in order to increase arterial oxygenation and decrease pulmonary arterial pressure. The Johns Hopkins Lifeline Critical Care Transportation Program (Lifeline) initiated a novel nurse-managed iNO protocol in order to optimize the oxygenation of critically ill patients during interfacility transport. This study was a retrospective chart review of adverse events associated with iNO initiation or continuation by Lifeline on patients transported from March 1, 2020, to August 1, 2022. Basic demographic data and adverse events were recorded. Recorded adverse events included hypotension defined as a mean arterial pressure (MAP) < 65 mm Hg, hypoxemia defined as a decrease of ≥ 10% arterial oxygenation saturation measured by pulse oximetry, new bradycardia or tachyarrhythmia, nitrogen dioxide (NO2) levels greater than 1.0 ppm, methemoglobinemia, and cardiac arrest. Fifteen patients were diagnosed with SARS-CoV-2 infection, of which one also had pulmonary emboli, 2 had bacterial pneumonia, 1 suffered cardiogenic shock from occlusive myocardial infarction and were on VA-ECMO, and 2 had significant thoracic trauma resulting in pulmonary contusions and hemopneumothorax. iNO was continued on 10 patients and initiated on 8 patients, 2 of whom were transitioned from inhaled epoprostenol. Hypotension occurred in 3 (16.7%) patients and one (5.56%) of the hypotensive patients subsequently went on to experience new atrial fibrillation with vasopressor titration. No patients developed worsening hypoxemia, elevated NO2 levels, methemoglobinemia, or suffered cardiac arrest. All 3 patients who experienced hypotension were already on vasopressor support and the hypotension resolved with medication titration. This study shows that iNO administration can be safely managed by appropriately trained nurses.

Do prehospital sepsis alerts decrease time to complete CMS sepsis measures?

INTRODUCTION: In an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures. METHODS: This study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L. RESULTS: Median time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61-153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75-189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert. CONCLUSION: This study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.

A Critical Care Transport Program's Innovative Approach to Safety During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has resulted in the frequent transfer of critically ill patients, yet there is little information available to assist critical care transport programs in protecting their clinicians from disease exposure in this unique environment. The Lifeline Critical Care Transport Program has implemented several novel interventions to reduce the risk of staff exposure. METHODS: Several safety interventions were implemented at the beginning of the COVID-19 pandemic. These initiatives included the deployment of a transport safety officer, a receiving clean team for select interfacility transports, and modifications in personal protective equipment. RESULTS: From February 29, 2020, to August 29, 2020, there were 1,041 transports of persons under investigation, 660 (63.4%) of whom were ultimately found to be COVID-19 positive. Approximately one third were ground transports, 11 (1.1%) were by air, and the remainder were intrahospital transports. There were 0 documented staff exposures or illnesses during the study period. CONCLUSION: The adaptation of these safety measures resulted in 0 staff exposures or illnesses while maintaining a high-volume, high-acuity critical care transport program. These interventions are the first of their kind to be implemented during the COVID-19 pandemic and offer a framework for other organizations and future disease outbreaks.

Decision Making and Interventions During Interfacility Transport of High-Acuity Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

OBJECTIVE: There are limited data regarding the typical characteristics of coronavirus disease 2019 (COVID-19) patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision making needed to transport critically ill COVID-19 patients. METHODS: A retrospective chart review of persons under investigation for COVID-19 transported during the first 6 months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction assay were included in the analysis. RESULTS: Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and 1 (0.75%) received an inhaled pulmonary vasodilator. At least 1 ventilator setting change occurred for 59 patients (22.0%), and ventilation mode was changed for 11 patients (4.10%) during transport. CONCLUSION: The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking, and decision making.

The i-gel® supraglottic airway device compared to endotracheal intubation as the initial prehospital advanced airway device: A natural experiment during the COVID-19 pandemic.

Objective: Unlike randomized controlled trials, practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings where there may be reluctance to adopt new practices. We present the results of a natural experiment that was driven by mandated COVID-19 pandemic-driven shift from endotracheal intubation (ETI) to the i-gel® supraglottic airway (SGA) as a primary advanced airway management device in the prehospital setting to reduce emergency medical services (EMS) personnel exposure to potentially infectious secretions. The objective was to compare first-pass success and timing to successful airway placement between ETI and the i-gel® SGA under extenuating circumstances. Methods: This pre/post study compared airway placement metrics in prehospital patients requiring advance airway management for non-trauma-related conditions. Data from EMS records were extracted over 2 years, 12 months pre-pandemic, and 12 months post-pandemic. During the pre-COVID-19 year, the EMS protocols utilized ETI as the primary advanced airway device (ETI group). Post-pandemic paramedics were mandated to utilize i-gel® SGA as the primary advanced airway device to reduce exposure to secretions (SGA group). Results: There were 199 adult patients, 83 (42%) in the ETI group and 116 (58%) in the SGA group. First-pass success was significantly higher with SGA 96% (92%-99%) than ETI 68% (57%-78%) with paramedics citing the inability to visualize the airway in 52% of ETI cases. Time to first-pass success was significantly shorter in the SGA group (5.9 min [5.1-6.7 min]) than in the ETI group (8.3 min [6.9-9.6 min]), as was time to overall successful placement at 6.0 min (5.1-6.8 min) versus 9.6 min (8.2-11.1 min), respectively. Multiple placement attempts were required in 26% of ETI cases and 1% of the SGA cases. There were no statistically significant differences in the number and types of complications between the cohorts. Return of spontaneous circulation (on/before emergency department [ED] arrival), mortality at 28 days, intensive care unit length of stay, or ventilator-free days between the groups were not statistically different between the groups. Conclusion: In this natural experiment, the SGA performed significantly better than ETI in first-pass airway device placement success and was significantly faster in achieving first-pass success, and overall airway placement, thus potentially reducing exposure to respiratory pathogens. Practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings and in systems with a low frequency of tracheal intubations.

Implementation of a prehospital whole blood program: Lessons learned.

Early blood administration by Emergency Medical Services (EMS) to patients suffering from hemorrhagic shock improves outcomes. Prehospital blood programs represent an invaluable resuscitation capability that directly addresses hemorrhagic shock and mitigates subsequent multiple organ dysfunction syndrome. Prehospital blood programs must be thoughtfully planned, have multiple safeguards, ensure adequate training and credentialing processes, and be responsible stewards of blood resources. According to the 2022 best practices model by Yazer et al, the four key pillars of a successful prehospital program include the following: (1) the rationale for the use and a description of blood products that can be transfused in the prehospital setting, (2) storage of blood products outside the hospital blood bank and how to move them to the patient in the prehospital setting, (3) prehospital transfusion criteria and administration personnel, and (4) documentation of prehospital transfusion and handover to the hospital team.  This concepts paper describes our operational experience using these four pillars to make Maryland's inaugural prehospital ground-based low-titer O-positive whole blood program successful. These lessons learned may inform other EMS systems as they establish prehospital blood programs to help improve outcomes and enhance mass casualty response.

From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings.

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.

Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital.

Importance: The capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for adults but not pediatric patients. Objective: To estimate the potential of reverse triage for surge capacity in an academic pediatric hospital. Design, Setting, and Participants: In this retrospective cohort study, a blocked, randomized sampling scheme was used including inpatients from 7 units during 196 mock disaster days distributed across the 1-year period from December 21, 2012, through December 20, 2013. Patients not requiring any critical interventions for 4 successive days were considered to be suitable for low-risk immediate reverse triage. Data were analyzed from November 1, 2014, through November 21, 2016. Main Outcomes and Measures: Proportionate contribution of reverse triage to the creation of surge capacity measured as a percentage of beds newly available in each unit and in aggregate. Results: Of 3996 inpatients, 501 were sampled (268 boys [53.5%] and 233 girls [46.5%]; mean [SD] age, 7.8 [6.6] years), with 10.8% eligible for immediate low-risk reverse triage and 13.2% for discharge by 96 hours. The psychiatry unit had the most patients eligible for immediate reverse triage (72.7%; 95% CI, 59.6%-85.9%), accounting for more than half of the reverse triage effect. The oncology (1.3%; 95% CI, 0.0%-3.9%) and pediatric intensive care (0%) units had the least effect. Gross surge capacity using all strategies (routine patient discharges, full use of staffed and unstaffed licensed beds, and cancellation of elective and transfer admissions) was estimated at 57.7% (95% CI, 38.2%-80.2%) within 24 hours and 84.1% (95% CI, 63.9%-100%) by day 4. Net surge capacity, estimated by adjusting for routine emergency department admissions, was about 50% (range, 49.1%-52.6%) throughout the 96-hour period. By accepting higher-risk patients only (considering only major critical interventions as limiting), reverse triage would increase surge capacity by nearly 50%. Conclusions and Relevance: Our estimates indicate considerable potential pediatric surge capacity by using combined strategic initiatives. Reverse triage adds a meaningful but modest contribution and may depend on psychiatric space. Large volumes of pediatric patients discharged early to the community during disasters could challenge pediatricians owing to the close follow-up likely to be required.