- Email: [email protected]
13: Reliability of Dispatch Criteria for Activation of a Helicopter-Based Out-of-Hospital EMS System
ICEM 2008 Scientific Abstract Program time. The aim of this out-of-hospital study was to assess of influence of vasopressin on outcome in CPR of PEA in trauma patients. Methods: Two treatments groups of resuscitated patients in cardiac arrest (with blunt trauma and PEA with electrical activity less than 40/beats /min) and older than 18 years, were compared: in epinephrine (historic) group patients received epinephrine 1 mg IV every three minutes only; in the vasopressin group patients received arginine vasopressin 40 units IV only or followed by epinephrine 1mg every three minutes during and hyperhaes as initial volume resuscitation. BLS and ATLS were performed according to present guidelines. Results: 29 patients (historic -epinephrine group ( January 1998 -November 2002): 18 patients; vasopressin/hyperhaes group (December 2002 -December 2006): 11 patients) were included with no significant demographic or clinical differences between compared groups (sex, age, first monitored rhythm, location of arrest, arrest witnessed, bystander CPR, response time, initial petCO2, Injury Severity Score at admission). In the vasopressin group significantly more pulse restorations ( 9/11 (82%) vrs. 3/18 (17%); p⬍0.01), better 24 hours survival rate was observed (6/11 (55%) vrs. 2/18 (11%) p⫽0.03) and higher discharge rate (3/11 (27%) vs 1/18 (6%), p⫽ 0.27) (Fisher exact test). Average final mean arterial pressure (at admission) were 80.3 ⫹/⫺12.4 mmHg (epinephrine group) vs 100.4 ⫹/⫺11.4 (vasopressin group) and final petCO2 were 2.8 ⫹/⫺ 0.4 kPa vs. 4.5⫹/⫺0.9 kPa (Wilcoxon rank-sum test). Conclusion: Our results suggest that the trauma victims with severe blunt trauma and PEA should be initially treated with vasopressin in combination with hyperhaes volume resuscitation and with other procedures when appropriate. This small study has all the inherent problems associated with observational studies, but despite these limitations suggest a resuscitation strategy.
12
A Randomized Controlled Trial of a Brief Intervention to Reduce Repeat Presentations to the Emergency Department for Suicide Attempt
Beautrais AL, Gibb SJ, Faulkner A, Mulder RT/University of Otago, Christchurch, New Zealand; Canterbury District Health Board, Christchurch, New Zealand
11
S100 Screening: A Cost-Minimization Study for Managing Adult Patients With Mild Traumatic Brain Injury in the Emergency Department
Ruan S, Noyes K, Bazarian JJ/University of Rochester, Rochester, NY
Study Objective: The standard of emergency care for mild traumatic brain injury (mTBI) involves head computed tomography (CT) scanning. The vast majority of patients presenting with mTBI will have a negative CT scan and will be discharged without sequelae. Recently, a serum assay for the astroglial protein S100 has been reported to be a sensitive indicator of traumatic abnormal findings on subsequent CT scan. Studies suggest the S100 assay may reduce unnecessary CT scans by up to 30%. We evaluate serum S100 assay as a screening tool to reduce unnecessary CT scans, and believe that S100 will result in less costly management of mTBI patients in hospital emergency departments (ED). Methods: We perform a cost-minimization study using a decision analytic tree comparing the use of S100 as a screening tool for CT and the current practice of ordering CT scans based on symptoms for patients presenting to EDs with mTBI and a Glasgow Coma Scale (GCS) score of 15. The main outcome of our model is the average direct cost per patient estimated from the hospital perspective. Our base-case input probabilities come from the literature, limited to studies with at least 50 patients published after 1989. National average Medicare reimbursement rates (for Fiscal Year 2007) are used as cost proxies. We perform sensitivity analysis to determine principal cost drivers and to find whether a threshold exists for the ability of S100 to minimize cost. Results: Compared to the current practice of scanning 45-77% of mTBI patients based upon their presenting symptoms, use of S100 as a pre-head CT screen does not lower hospital costs ($360 per encounter using S100 vs. $300 using current practice). Sensitivity analysis suggests that the rates of CT scanning and the prevalence of negative S100 in the patient population are the key factors contributing to ED costs. At a sufficiently high CT scan rate (over 80% of mTBI patients) or with a sufficiently high prevalence of negative S100 (0.434), however, the assay becomes cost-saving. Conclusions: Our model does not support our initial belief. Given the current rates of CT scanning among patients with mTBI and the probability of a negative S100 test (0.24), the assay would not help reduce hospital costs. For those hospitals with higher than average rates of scanning mTBI patients with GCS of 15, however, the S100 assay would be a cost-saving option for the management of such patients.
474 Annals of Emergency Medicine
Background: Rates of presentations to emergency departments for suicide attempts are increasing in many countries. The risk of repeat presentations for suicide attempts by the same individual is also increasing with repeat visits more likely to occur in the first few months following an index attempt. Study Objectives: To examine the extent to which a simple and low cost intervention (specifically, sending 4 “postcards” in the 6 months following an index suicide attempt) is associated with a significant reduction in re-presentations to the emergency department for suicide attempts in the 6 months following the index attempt. Methods: A randomized controlled trial (RCT) was conducted involving 327 people aged 16 and older who presented consecutively to the emergency department (ED) at Christchurch Hospital, New Zealand, for suicide attempts by any method. The ED at Christchurch Hospital is the sole emergency department for the region, serving a regional population of 450,000 people and receiving 72,000 visits per year. The ED receives all regional suicide attempt presentations. The intervention consisted of mailing 4 “postcards” to patients in the six months following their index presentation to the emergency department. Postcards were sent two weeks after the index presentation, and then at 1 month, 3 months and 6 months after the index visit. Patients assigned to the control condition did not receive postcards. All subjects received treatment as usual. The two outcome measures were: a. the number of repeat presentations per person for suicide attempts in six months, and b. the fraction of patients with one or more repeat suicide attempts in six months. Results: There were no significant sociodemographic differences between patients assigned to the intervention group and those assigned to the control group. The number of repeat presentations was significantly lower in the intervention group (31/ 153, 20.3%) vs. the control group (88/174, 50.6%) (p⬍.010). The fraction of patients who made one or more repeat suicide attempt visits to the ED was significantly lower in the intervention group (21/153, 13.7%) vs. the control group (41/174, 23.6%) (p⬍.01). Conclusions: A simple, low cost, minimal intervention significantly reduced repeat presentations to the ED for suicide attempts, and reduced the fraction of individuals who made repeat suicide attempts.
13
Reliability of Dispatch Criteria for Activation of a Helicopter-Based Out-of-Hospital EMS System
Kehoe A, Sheehan L, Davies G, David L/Royal London Hospital, London, United Kingdom
Study Objectives: The London Helicopter Emergency Medical Service (HEMS) operates in support of the London Ambulance Service (LAS) and undertakes the
Volume , . : April
ICEM 2008 Scientific Abstract Program primary retrieval of major trauma patients using a physician-paramedic team in London (UK). Major trauma represents ⬍1% of all emergency calls received by LAS and a robust dispatch policy is necessary to target this valuable resource accurately. HEMS is dispatched by 3 means: 1. Immediate Dispatch: Aircraft dispatched immediately on mechanism alone. These criteria (summarised in figure 1) are modified from the American College of Surgeons Committee on Trauma guidelines for activation of an in-hospital trauma team and are based on 19 years local experience but have never been locally validated. 2. Interrogation: Dispatch after interrogation of emergency caller by HEMS dispatcher. 3. Crew request: Dispatch at the request of an ambulance crew already attending the patient. This study was conducted to locally validate the immediate dispatch criteria. Methods: A retrospective database search was performed of cases attended between 01/01/07 and 31/07/07. The three categories of dispatch were compared using the outcome measures of survival to discharge, Injury Severity Score (ISS), Revised Trauma Score (RTS), calculated probability of survival, number of ICU days, number of ward days and length of hospital stay. Survival data were available for all cases, other outcome data only for those retrieved to our base hospital. Results: In total, 805 cases were attended during the study period, of whom 335 were retrieved to the base hospital. 22% were immediates, 57% interrogations and 21% crew requests. The 3 groups were well-matched for age and sex. The immediate group consisted predominantly of falls, “one unders” and pedestrians trapped under vehicles. Outcomes did not vary significantly between these sub-groups. Compared with the other two groups the immediate dispatch group had a significantly greater mortality, ISS, ITU days, ward days and overall length of stay and the lowest RTS and probability of survival (see table). Conclusions: In major trauma some mechanism based out-of-hospital dispatch criteria reliably predict cases with greater injury load, physiological burden, utilisation of hospital resources and mortality. This study confirms that established dispatch criteria can be locally modified and validated to produce an effective EMS tool. In our system these criteria effectively target a scarce resource to those who need it most.
14
Implementation of the 2005 Cardiopulmonary Resuscitation Guidelines and Use of an Impedance Threshold Device Improve Survival From Inhospital Cardiac Arrest
Thigpen K, Simmons L, Hatten K/St. Dominic’s Hospital, Jackson, MS
Study Objective: The 2005 American Heart Association guidelines recommended many new interventions during cardiopulmonary resuscitation (CPR), including a Level IIa recommendation for an impedance threshold device (ITD), which is intended to further optimize circulation during CPR. To date, all data published supporting use of an ITD have been following out-of-hospital cardiac arrest. This study’s objective was to determine the effect that implementing new CPR guidelines,
Volume , . : April
which included use of an ITD, would have on survival to hospital discharge following inhospital cardiac arrest. Methods: Quality assurance data from adult patients (ⱖ 18 years) experiencing an inhospital cardiac arrest at a 571-bed, acute care hospital were analyzed. Survival rates from a historical (control) period (01/2006 - 09/2006) were compared to matched patients in a prospective period (10/2006 - 08/2007) during which the new CPR guidelines and use of an ITD (ResQPOD®, Advanced Circulatory Systems; Minneapolis, Minnesota) were implemented. Per hospital protocol, the ITD was used on both a facemask and/or endotracheal tube in patients regardless of cardiac arrest etiology, unless specifically overridden by physician. Results: In both study populations, patients, on average, were 67 years and 49% were male. The results were as follows: Table: Survival Following Inhospital Cardiac Arrest
Conclusion: Adoption of the new CPR guidelines and an ITD resulted in a 75% increase in initial arrest survival rates and a 62% increase in survival to hospital discharge rates. This first known reporting of data demonstrating the impact of new CPR plus and an ITD following inhospital cardiac arrest represent a currently optimized sequence of therapeutic interventions and support widespread adoption of these therapies.
15
Aeromedical Evacuation Coordination: Are There Decision Criteria?
Duchateau FX, Verner L, Cha O/Mondial Assistance, Paris, France
Study Objectives: Primary objective was to characterize international aeromedical evacuation. Secondary objective was to determine predictive factors of urgent evacuation. Methods: We retrospectively studied all consecutive overseas repatriations over 1 year (August 2006-July 2007) performed by our medical assistance company providing wordwide medical assistance for international travelers and expatriates. Following specific criteria have been recorded: age of the patient, location, developed countries’ sanitary standards (or not) according to World Health Organization, existence of a high standard structure in the country (internal world wide program of medical facilities evaluation), direct medical contact with attending physician, French speaking area, main diagnosis, urgent treatment required, initial local transfer to another hospital for better medical facilities, modalities of aeromedical evacuation. Patients were allocated to 2 groups: decision of immediate aeromedical evacuation with air-ambulance or later repatriation. Data were compared between the 2 groups. Data were expressed as mean ⫾ SD and percentage of patients. Statistical analysis was performed by ANOVA for quantitative data and a Chi-square test for qualitative data. A multivariate analysis was also done. A p ⬍ 0.05 was considered the threshold for significance. We used statistical package Stat-View 5 ® (Abacus Concept, Berkeley, CA, USA). Results: Four-hundred three international aeromedical evacuations were performed during the study period. Location was North-Africa for 29% of patients, sub Saharan Africa for 14% of patients, Asia for 13% of patients, America and Caraibs for 9% of patients and Europe for 35% of patients. Sanitary standards were not developed countries’ standards in 42% of cases. Patients were considered as requiring urgent treatment in 50% of cases. A local transfer to another hospital was initiated by the physician on duty in the coordination center in 23% of cases. Main pathologies encountered were: trauma (40%), cardiac diseases (17%), neurological disorders (14%), respiratory diseases (8%). Fifty percent of patients required urgent therapeutic measures: mostly a surgical intervention (27%). Evacuations were done aboard air-ambulances with advanced life support facilities for 26% of patients, otherwise aboard commercial aircrafts. Oxygen was required for 27% of patients. Age ⬍ 15 (Odds-ratio (OR), 7.0; 95% CI, 1.6-30.6), absence of a high standard structure in the country (OR, 3.6; 95% CI, 1.2-11.1) and location in sub Saharan Africa (OR, 12.6; 95% CI, 2.3-71.4) were independent factors of immediate aeromedical evacuation. Conclusion: Decision whether to evacuate or not is a challenge for physicians of aeromedical evacuation companies. Decision criteria associated with immediate aeromedical evacuation are age, local resources and location. Creation of a specific standardized scoring system based on these criteria may be very valuable.
Annals of Emergency Medicine 475
12
A Randomized Controlled Trial of a Brief Intervention to Reduce Repeat Presentations to the Emergency Department for Suicide Attempt
Beautrais AL, Gibb SJ, Faulkner A, Mulder RT/University of Otago, Christchurch, New Zealand; Canterbury District Health Board, Christchurch, New Zealand
11
S100 Screening: A Cost-Minimization Study for Managing Adult Patients With Mild Traumatic Brain Injury in the Emergency Department
Ruan S, Noyes K, Bazarian JJ/University of Rochester, Rochester, NY
Study Objective: The standard of emergency care for mild traumatic brain injury (mTBI) involves head computed tomography (CT) scanning. The vast majority of patients presenting with mTBI will have a negative CT scan and will be discharged without sequelae. Recently, a serum assay for the astroglial protein S100 has been reported to be a sensitive indicator of traumatic abnormal findings on subsequent CT scan. Studies suggest the S100 assay may reduce unnecessary CT scans by up to 30%. We evaluate serum S100 assay as a screening tool to reduce unnecessary CT scans, and believe that S100 will result in less costly management of mTBI patients in hospital emergency departments (ED). Methods: We perform a cost-minimization study using a decision analytic tree comparing the use of S100 as a screening tool for CT and the current practice of ordering CT scans based on symptoms for patients presenting to EDs with mTBI and a Glasgow Coma Scale (GCS) score of 15. The main outcome of our model is the average direct cost per patient estimated from the hospital perspective. Our base-case input probabilities come from the literature, limited to studies with at least 50 patients published after 1989. National average Medicare reimbursement rates (for Fiscal Year 2007) are used as cost proxies. We perform sensitivity analysis to determine principal cost drivers and to find whether a threshold exists for the ability of S100 to minimize cost. Results: Compared to the current practice of scanning 45-77% of mTBI patients based upon their presenting symptoms, use of S100 as a pre-head CT screen does not lower hospital costs ($360 per encounter using S100 vs. $300 using current practice). Sensitivity analysis suggests that the rates of CT scanning and the prevalence of negative S100 in the patient population are the key factors contributing to ED costs. At a sufficiently high CT scan rate (over 80% of mTBI patients) or with a sufficiently high prevalence of negative S100 (0.434), however, the assay becomes cost-saving. Conclusions: Our model does not support our initial belief. Given the current rates of CT scanning among patients with mTBI and the probability of a negative S100 test (0.24), the assay would not help reduce hospital costs. For those hospitals with higher than average rates of scanning mTBI patients with GCS of 15, however, the S100 assay would be a cost-saving option for the management of such patients.
474 Annals of Emergency Medicine
Background: Rates of presentations to emergency departments for suicide attempts are increasing in many countries. The risk of repeat presentations for suicide attempts by the same individual is also increasing with repeat visits more likely to occur in the first few months following an index attempt. Study Objectives: To examine the extent to which a simple and low cost intervention (specifically, sending 4 “postcards” in the 6 months following an index suicide attempt) is associated with a significant reduction in re-presentations to the emergency department for suicide attempts in the 6 months following the index attempt. Methods: A randomized controlled trial (RCT) was conducted involving 327 people aged 16 and older who presented consecutively to the emergency department (ED) at Christchurch Hospital, New Zealand, for suicide attempts by any method. The ED at Christchurch Hospital is the sole emergency department for the region, serving a regional population of 450,000 people and receiving 72,000 visits per year. The ED receives all regional suicide attempt presentations. The intervention consisted of mailing 4 “postcards” to patients in the six months following their index presentation to the emergency department. Postcards were sent two weeks after the index presentation, and then at 1 month, 3 months and 6 months after the index visit. Patients assigned to the control condition did not receive postcards. All subjects received treatment as usual. The two outcome measures were: a. the number of repeat presentations per person for suicide attempts in six months, and b. the fraction of patients with one or more repeat suicide attempts in six months. Results: There were no significant sociodemographic differences between patients assigned to the intervention group and those assigned to the control group. The number of repeat presentations was significantly lower in the intervention group (31/ 153, 20.3%) vs. the control group (88/174, 50.6%) (p⬍.010). The fraction of patients who made one or more repeat suicide attempt visits to the ED was significantly lower in the intervention group (21/153, 13.7%) vs. the control group (41/174, 23.6%) (p⬍.01). Conclusions: A simple, low cost, minimal intervention significantly reduced repeat presentations to the ED for suicide attempts, and reduced the fraction of individuals who made repeat suicide attempts.
13
Reliability of Dispatch Criteria for Activation of a Helicopter-Based Out-of-Hospital EMS System
Kehoe A, Sheehan L, Davies G, David L/Royal London Hospital, London, United Kingdom
Study Objectives: The London Helicopter Emergency Medical Service (HEMS) operates in support of the London Ambulance Service (LAS) and undertakes the
Volume , . : April
ICEM 2008 Scientific Abstract Program primary retrieval of major trauma patients using a physician-paramedic team in London (UK). Major trauma represents ⬍1% of all emergency calls received by LAS and a robust dispatch policy is necessary to target this valuable resource accurately. HEMS is dispatched by 3 means: 1. Immediate Dispatch: Aircraft dispatched immediately on mechanism alone. These criteria (summarised in figure 1) are modified from the American College of Surgeons Committee on Trauma guidelines for activation of an in-hospital trauma team and are based on 19 years local experience but have never been locally validated. 2. Interrogation: Dispatch after interrogation of emergency caller by HEMS dispatcher. 3. Crew request: Dispatch at the request of an ambulance crew already attending the patient. This study was conducted to locally validate the immediate dispatch criteria. Methods: A retrospective database search was performed of cases attended between 01/01/07 and 31/07/07. The three categories of dispatch were compared using the outcome measures of survival to discharge, Injury Severity Score (ISS), Revised Trauma Score (RTS), calculated probability of survival, number of ICU days, number of ward days and length of hospital stay. Survival data were available for all cases, other outcome data only for those retrieved to our base hospital. Results: In total, 805 cases were attended during the study period, of whom 335 were retrieved to the base hospital. 22% were immediates, 57% interrogations and 21% crew requests. The 3 groups were well-matched for age and sex. The immediate group consisted predominantly of falls, “one unders” and pedestrians trapped under vehicles. Outcomes did not vary significantly between these sub-groups. Compared with the other two groups the immediate dispatch group had a significantly greater mortality, ISS, ITU days, ward days and overall length of stay and the lowest RTS and probability of survival (see table). Conclusions: In major trauma some mechanism based out-of-hospital dispatch criteria reliably predict cases with greater injury load, physiological burden, utilisation of hospital resources and mortality. This study confirms that established dispatch criteria can be locally modified and validated to produce an effective EMS tool. In our system these criteria effectively target a scarce resource to those who need it most.
14
Implementation of the 2005 Cardiopulmonary Resuscitation Guidelines and Use of an Impedance Threshold Device Improve Survival From Inhospital Cardiac Arrest
Thigpen K, Simmons L, Hatten K/St. Dominic’s Hospital, Jackson, MS
Study Objective: The 2005 American Heart Association guidelines recommended many new interventions during cardiopulmonary resuscitation (CPR), including a Level IIa recommendation for an impedance threshold device (ITD), which is intended to further optimize circulation during CPR. To date, all data published supporting use of an ITD have been following out-of-hospital cardiac arrest. This study’s objective was to determine the effect that implementing new CPR guidelines,
Volume , . : April
which included use of an ITD, would have on survival to hospital discharge following inhospital cardiac arrest. Methods: Quality assurance data from adult patients (ⱖ 18 years) experiencing an inhospital cardiac arrest at a 571-bed, acute care hospital were analyzed. Survival rates from a historical (control) period (01/2006 - 09/2006) were compared to matched patients in a prospective period (10/2006 - 08/2007) during which the new CPR guidelines and use of an ITD (ResQPOD®, Advanced Circulatory Systems; Minneapolis, Minnesota) were implemented. Per hospital protocol, the ITD was used on both a facemask and/or endotracheal tube in patients regardless of cardiac arrest etiology, unless specifically overridden by physician. Results: In both study populations, patients, on average, were 67 years and 49% were male. The results were as follows: Table: Survival Following Inhospital Cardiac Arrest
Conclusion: Adoption of the new CPR guidelines and an ITD resulted in a 75% increase in initial arrest survival rates and a 62% increase in survival to hospital discharge rates. This first known reporting of data demonstrating the impact of new CPR plus and an ITD following inhospital cardiac arrest represent a currently optimized sequence of therapeutic interventions and support widespread adoption of these therapies.
15
Aeromedical Evacuation Coordination: Are There Decision Criteria?
Duchateau FX, Verner L, Cha O/Mondial Assistance, Paris, France
Study Objectives: Primary objective was to characterize international aeromedical evacuation. Secondary objective was to determine predictive factors of urgent evacuation. Methods: We retrospectively studied all consecutive overseas repatriations over 1 year (August 2006-July 2007) performed by our medical assistance company providing wordwide medical assistance for international travelers and expatriates. Following specific criteria have been recorded: age of the patient, location, developed countries’ sanitary standards (or not) according to World Health Organization, existence of a high standard structure in the country (internal world wide program of medical facilities evaluation), direct medical contact with attending physician, French speaking area, main diagnosis, urgent treatment required, initial local transfer to another hospital for better medical facilities, modalities of aeromedical evacuation. Patients were allocated to 2 groups: decision of immediate aeromedical evacuation with air-ambulance or later repatriation. Data were compared between the 2 groups. Data were expressed as mean ⫾ SD and percentage of patients. Statistical analysis was performed by ANOVA for quantitative data and a Chi-square test for qualitative data. A multivariate analysis was also done. A p ⬍ 0.05 was considered the threshold for significance. We used statistical package Stat-View 5 ® (Abacus Concept, Berkeley, CA, USA). Results: Four-hundred three international aeromedical evacuations were performed during the study period. Location was North-Africa for 29% of patients, sub Saharan Africa for 14% of patients, Asia for 13% of patients, America and Caraibs for 9% of patients and Europe for 35% of patients. Sanitary standards were not developed countries’ standards in 42% of cases. Patients were considered as requiring urgent treatment in 50% of cases. A local transfer to another hospital was initiated by the physician on duty in the coordination center in 23% of cases. Main pathologies encountered were: trauma (40%), cardiac diseases (17%), neurological disorders (14%), respiratory diseases (8%). Fifty percent of patients required urgent therapeutic measures: mostly a surgical intervention (27%). Evacuations were done aboard air-ambulances with advanced life support facilities for 26% of patients, otherwise aboard commercial aircrafts. Oxygen was required for 27% of patients. Age ⬍ 15 (Odds-ratio (OR), 7.0; 95% CI, 1.6-30.6), absence of a high standard structure in the country (OR, 3.6; 95% CI, 1.2-11.1) and location in sub Saharan Africa (OR, 12.6; 95% CI, 2.3-71.4) were independent factors of immediate aeromedical evacuation. Conclusion: Decision whether to evacuate or not is a challenge for physicians of aeromedical evacuation companies. Decision criteria associated with immediate aeromedical evacuation are age, local resources and location. Creation of a specific standardized scoring system based on these criteria may be very valuable.
Annals of Emergency Medicine 475