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210: The Impact of Online Medical Direction on Ambulance Transport of Patients Initially Refusing Medical Assistance
Research Forum Abstracts emergency physician survived to discharge. Of the 62 ED MI Alert activations that arrived by ambulance, 13 did not qualify for PCI; the remaining 49 achieved an average D2B time of 72 minutes. Of the 83 out-of-hospital MI-3 activations that arrived by ambulance, 10 did not qualify for PCI; the remaining 73 achieved an average D2B time of 51 minutes, t (122) ⫽ 3.873, p ⫽ 0.010. Mortality, inclusive of all patient modes of arrival, totaled nine (6.4%) of the ED MI Alert activations, and six (6.5%) of the out-of-hospital MI-3 activations. Conclusion: One year after implementation trained ALS providers correctly activated the MI-3 process in the majority of cases. Out-of-hospital implementation of the process resulted in a statistically significant decrease in D2B times.
208
Early Experiences With Electronic Patient Care Reports by Emergency Medical Services Agencies
Landman AB, Lee CH, Sasson C, Van Gelder CM, Curry LA/Yale University, New Haven, CT; University of Michigan, Ann Arbor, MI
Study Objectives: Out-of-hospital electronic patient care reports (e-PCR) have been suggested to improve legibility and timeliness of emergency medical services (EMS) documentation, to enhance quality assurance, and to provide critical data for research. However, adoption of e-PCR at the EMS agency level has been slow. We sought to understand the challenges associated with the adoption and implementation of e-PCR and to identify emerging strategies from EMS agencies using e-PCR. Methods: We conducted twenty qualitative one-on-one interviews with EMS agency leaders to characterize their experiences with e-PCR adoption and implementation. We recruited a purposeful sample of participants through the National Association of EMS Physicians and snowball sampling until thematic saturation was achieved. A standard interview guide was used to facilitate the semistructured in-depth interviews. Interviews lasted approximately 30 minutes, and were recorded and then professionally transcribed. Analysis was conducted by a threeperson team, employing the constant comparative method to generate recurrent themes. Atlas Ti software facilitated data organization and retrieval. Results: Interviewees represented 20 EMS agencies from across the United States and Canada and included medical directors, EMS fellows, administrators, and paramedics. The majority of participating agencies (13, 76.5%) were currently using e-PCR systems. Three recurrent themes emerged: 1) The primary reason for adoption for the EMS agencies was the potential for e-PCR to support quality assurance and improvement efforts and agencies reported positive experiences in this regard; 2) Major challenges to e-PCR adoption and use were organizational (people, policies, costs) and technical (hardware, software, network, integration) factors; and 3) Strategies to address adoption and implementation challenges, such as using a proven, commercial, off the shelf product and having a dedicated information technology support person, are emerging from the field. Conclusion: Potential benefits of e-PCR in quality assurance efforts are a major impetus for e-PCR adoption. EMS agencies seeking to adopt and use e-PCR should anticipate and prepare for a complex set of organizational and technical challenges. The emerging strategies found in our work may help facilitate transition to e-PCR. Additional investigation is needed to understand the barriers and success strategies identified in this exploratory work; evaluation studies are also needed to assess the impact and effectiveness of e-PCR technology on EMS patient care and operations.
209
Use of Capnograms to Assess Ventilation In Pediatric Patients With Three Different Advanced Airway Modalities
Fuzak JK, Rappaport L, Roosevelt G, Bajaj L, Mandt M, Ciarallo C/The Children’s Hospital, University of Colorado Denver, Aurora, CO
Study Objectives: Out-of-hospital pediatric airway management is controversial. Options include bag-valve-mask (BVM), endotracheal tube (ETT), and laryngeal mask airway (LMA). Confirmation of correct placement, adequate ventilation, and recognition of displacement are key. Capnogram tracings provide a measure of realtime ventilation and are used in out-of-hospital and transport medical care but have not been studied in pediatric patients with these modalities. Our objective was to compare capnograms from different airway modalities. Methods: A prospective study in the operating room (OR) of pediatric patients undergoing elective procedures requiring ETT or LMA ventilation. A pediatric anesthesiologist chose the airway modality and performed self-assessed adequate ventilation. Data was collected during controlled BVM ventilation using 2 bag-types (flow-inflating and self-inflating). The ETT or LMA was placed and ventilation with each bag-type repeated. 10 second capnograms were reviewed by blinded
Volume , . : September
anesthesiologists {a general anesthesiologist (GA) and pediatric anesthesiologist (PA)} who assessed ventilation (inadequate, some, adequate) and tried to identify the modality (BVM, ETT, LMA, unsure ) and bag-type (flow-inflating, self-inflating, unsure ) used. Kappa statistic and risk ratios were calculated. Results: 29 patients were enrolled. Median age: 4.4 years (2 mos-16.8 yrs). Of 116 capnograms the GA analyzed 109 and the PA analyzed 114 [Table 1]. Reviewers were unable to differentiate between airway modalities by capnogram and agreed on adequacy of ventilation 77% of the time (kappa 0.6, p⬍0.001). The PA was 8.6 times (1.2,62) and the GA was 4.5 times (0.6,34) more likely to rate BVM as inadequate compared to ETT. There was no difference between ETT and LMA ventilation. Bag-type did not affect assessed adequacy of ventilation. Conclusion: Neither airway modality or bag-type could be differentiated but BVM ventilation was judged inadequate more often than ETT and LMA despite confirmed real-time adequate ventilation by OR anesthesiologist. Capnogram interpretation has a subjective component which could limit utility in the transport medicine without special training. This suggests that use of capnography during BVM may provide valuable information on ventilation and the LMA could play a role in transport of critically ill pediatric patients. Specific training in capnography interpretation may be necessary for transport and out-of-hospital personnel.
210
The Impact of Online Medical Direction on Ambulance Transport of Patients Initially Refusing Medical Assistance
Niegelberg E, Pesce K, Cox L, Thode Jr HC, Singer AJ/Stony Brook University, Stony Brook, NY
Study Objectives: To evaluate the impact that online medical direction has on ambulance transport of hospital patients refusing medical aid (RMA). Methods: This was a retrospective descriptive analysis of the online Medical Control RMA database for Suffolk County, NY for the period 2007 to 2009. The RMA process requires online medical direction contact for any high risk patient refusing medical aid (⬍ 18 years of age or 70⫹ years of age; chief complaint of altered mental status, chest pain, or respiratory complaints; and/or abnormal vital signs). Out-of-hospital care providers were also urged to contact medical direction for any patient refusing medical aid who, in the determination of the out-of-hospital care provider, should be brought to the hospital even if the patient did not meet any high risk criteria. Descriptive analysis was performed using means and proportions with 95% confidence intervals (95% CI). Results: There were 10732 patients who were referred to online Medical Control over the study period. 2272 (21.2%, 95% CI 20.4-22.0) of these patients were transported by ambulance to a hospital. 81.3% (95% CI 79.7-82.9) of these had high risk criteria, compared to 80.9% (95% CI 80.0-81.7) of those who were not transported. Of the 2,272 patients who were transported to the hospital, ED discharge data was not available for 585. Of the remaining 1687 cases, 1108 were discharged from the ED, 485 (28.8%, 95% CI 26.2-31.0) were admitted or transferred, one died in the emergency department, and 93 left the ED AMA. Reasons for admission included stroke, MI, intracerebral hemorrhage, CHF, and atrial fibrillation. Conclusion: Online medical direction reduced the rate of RMAs by approximately 20%. One of four patients subsequently transported to a hospital were admitted suggesting the benefit of online medical control in cases of RMA.
211
Comparison of Motor Vehicle Crash Severity and Injury Estimations Between Physicians and Out-ofHospital Personnel
Cleveland NJ, Colwell C, Douglass E, Hopkins E, Haukoos J/Denver Health Residency in Emergency Medicine, Denver, CO; Denver Health Medical Center, Denver, CO
Study Objectives: To determine whether emergency physicians and out-ofhospital emergency medical systems (EMS) personnel differ in their assessment of
Annals of Emergency Medicine S69
208
Early Experiences With Electronic Patient Care Reports by Emergency Medical Services Agencies
Landman AB, Lee CH, Sasson C, Van Gelder CM, Curry LA/Yale University, New Haven, CT; University of Michigan, Ann Arbor, MI
Study Objectives: Out-of-hospital electronic patient care reports (e-PCR) have been suggested to improve legibility and timeliness of emergency medical services (EMS) documentation, to enhance quality assurance, and to provide critical data for research. However, adoption of e-PCR at the EMS agency level has been slow. We sought to understand the challenges associated with the adoption and implementation of e-PCR and to identify emerging strategies from EMS agencies using e-PCR. Methods: We conducted twenty qualitative one-on-one interviews with EMS agency leaders to characterize their experiences with e-PCR adoption and implementation. We recruited a purposeful sample of participants through the National Association of EMS Physicians and snowball sampling until thematic saturation was achieved. A standard interview guide was used to facilitate the semistructured in-depth interviews. Interviews lasted approximately 30 minutes, and were recorded and then professionally transcribed. Analysis was conducted by a threeperson team, employing the constant comparative method to generate recurrent themes. Atlas Ti software facilitated data organization and retrieval. Results: Interviewees represented 20 EMS agencies from across the United States and Canada and included medical directors, EMS fellows, administrators, and paramedics. The majority of participating agencies (13, 76.5%) were currently using e-PCR systems. Three recurrent themes emerged: 1) The primary reason for adoption for the EMS agencies was the potential for e-PCR to support quality assurance and improvement efforts and agencies reported positive experiences in this regard; 2) Major challenges to e-PCR adoption and use were organizational (people, policies, costs) and technical (hardware, software, network, integration) factors; and 3) Strategies to address adoption and implementation challenges, such as using a proven, commercial, off the shelf product and having a dedicated information technology support person, are emerging from the field. Conclusion: Potential benefits of e-PCR in quality assurance efforts are a major impetus for e-PCR adoption. EMS agencies seeking to adopt and use e-PCR should anticipate and prepare for a complex set of organizational and technical challenges. The emerging strategies found in our work may help facilitate transition to e-PCR. Additional investigation is needed to understand the barriers and success strategies identified in this exploratory work; evaluation studies are also needed to assess the impact and effectiveness of e-PCR technology on EMS patient care and operations.
209
Use of Capnograms to Assess Ventilation In Pediatric Patients With Three Different Advanced Airway Modalities
Fuzak JK, Rappaport L, Roosevelt G, Bajaj L, Mandt M, Ciarallo C/The Children’s Hospital, University of Colorado Denver, Aurora, CO
Study Objectives: Out-of-hospital pediatric airway management is controversial. Options include bag-valve-mask (BVM), endotracheal tube (ETT), and laryngeal mask airway (LMA). Confirmation of correct placement, adequate ventilation, and recognition of displacement are key. Capnogram tracings provide a measure of realtime ventilation and are used in out-of-hospital and transport medical care but have not been studied in pediatric patients with these modalities. Our objective was to compare capnograms from different airway modalities. Methods: A prospective study in the operating room (OR) of pediatric patients undergoing elective procedures requiring ETT or LMA ventilation. A pediatric anesthesiologist chose the airway modality and performed self-assessed adequate ventilation. Data was collected during controlled BVM ventilation using 2 bag-types (flow-inflating and self-inflating). The ETT or LMA was placed and ventilation with each bag-type repeated. 10 second capnograms were reviewed by blinded
Volume , . : September
anesthesiologists {a general anesthesiologist (GA) and pediatric anesthesiologist (PA)} who assessed ventilation (inadequate, some, adequate) and tried to identify the modality (BVM, ETT, LMA, unsure ) and bag-type (flow-inflating, self-inflating, unsure ) used. Kappa statistic and risk ratios were calculated. Results: 29 patients were enrolled. Median age: 4.4 years (2 mos-16.8 yrs). Of 116 capnograms the GA analyzed 109 and the PA analyzed 114 [Table 1]. Reviewers were unable to differentiate between airway modalities by capnogram and agreed on adequacy of ventilation 77% of the time (kappa 0.6, p⬍0.001). The PA was 8.6 times (1.2,62) and the GA was 4.5 times (0.6,34) more likely to rate BVM as inadequate compared to ETT. There was no difference between ETT and LMA ventilation. Bag-type did not affect assessed adequacy of ventilation. Conclusion: Neither airway modality or bag-type could be differentiated but BVM ventilation was judged inadequate more often than ETT and LMA despite confirmed real-time adequate ventilation by OR anesthesiologist. Capnogram interpretation has a subjective component which could limit utility in the transport medicine without special training. This suggests that use of capnography during BVM may provide valuable information on ventilation and the LMA could play a role in transport of critically ill pediatric patients. Specific training in capnography interpretation may be necessary for transport and out-of-hospital personnel.
210
The Impact of Online Medical Direction on Ambulance Transport of Patients Initially Refusing Medical Assistance
Niegelberg E, Pesce K, Cox L, Thode Jr HC, Singer AJ/Stony Brook University, Stony Brook, NY
Study Objectives: To evaluate the impact that online medical direction has on ambulance transport of hospital patients refusing medical aid (RMA). Methods: This was a retrospective descriptive analysis of the online Medical Control RMA database for Suffolk County, NY for the period 2007 to 2009. The RMA process requires online medical direction contact for any high risk patient refusing medical aid (⬍ 18 years of age or 70⫹ years of age; chief complaint of altered mental status, chest pain, or respiratory complaints; and/or abnormal vital signs). Out-of-hospital care providers were also urged to contact medical direction for any patient refusing medical aid who, in the determination of the out-of-hospital care provider, should be brought to the hospital even if the patient did not meet any high risk criteria. Descriptive analysis was performed using means and proportions with 95% confidence intervals (95% CI). Results: There were 10732 patients who were referred to online Medical Control over the study period. 2272 (21.2%, 95% CI 20.4-22.0) of these patients were transported by ambulance to a hospital. 81.3% (95% CI 79.7-82.9) of these had high risk criteria, compared to 80.9% (95% CI 80.0-81.7) of those who were not transported. Of the 2,272 patients who were transported to the hospital, ED discharge data was not available for 585. Of the remaining 1687 cases, 1108 were discharged from the ED, 485 (28.8%, 95% CI 26.2-31.0) were admitted or transferred, one died in the emergency department, and 93 left the ED AMA. Reasons for admission included stroke, MI, intracerebral hemorrhage, CHF, and atrial fibrillation. Conclusion: Online medical direction reduced the rate of RMAs by approximately 20%. One of four patients subsequently transported to a hospital were admitted suggesting the benefit of online medical control in cases of RMA.
211
Comparison of Motor Vehicle Crash Severity and Injury Estimations Between Physicians and Out-ofHospital Personnel
Cleveland NJ, Colwell C, Douglass E, Hopkins E, Haukoos J/Denver Health Residency in Emergency Medicine, Denver, CO; Denver Health Medical Center, Denver, CO
Study Objectives: To determine whether emergency physicians and out-ofhospital emergency medical systems (EMS) personnel differ in their assessment of
Annals of Emergency Medicine S69