- Email: [email protected]
217 EMF Assessing the Need for Protocolized Observation Care for Stroke and Asthma in Rural Haiti
Research Forum Abstracts taught principles of triage; 91% felt triage education to be critical to their medical training. Results of pre/post-tests over 16 months indicate that house staff displayed improvement in case-based triage of emergent and urgent patients after the didactic lecture and discussion. Test scores improved from pre/post on both knowledge-based multiple choice questions and case-based decisionmaking questions (pre-test score was 32% vs 78%, P ¼ .03). Additionally, all 58 residents reported increased confidence in triaging patients. Conclusion: The need for a pediatric emergency triage protocol in an academic tertiary care center in the DR was addressed by integrating a newly designed triage protocol and emergency triage curriculum for house staff. A collaborative approach transitioned responsibility for teaching didactic sessions and monitoring the triage protocol to senior residents at HIRUDAG, achieving sustainability of both the protocol and educational initiative. A 16-month review of pre/post surveys indicates statistically significant improvement in house staff’s knowledge of emergency triage principles and case-based triage classification. Studies are underway to determine effects on resident triage behaviors in the pediatric ED and clinical outcomes.
216 EMF
EFAR motivation. Given the substantial investment in the EFAR program, further research is needed to assess specific barriers and facilitators to EFAR response in Atlantis.
Emergency Scene Responses by African Community-Based Emergency First Aid Responders
Mould-Millman N-K, Dixon J, Holmes J, Crockett D, LeBeau S, De Vries S, Patel H, Ginde A, Haukoos J, Wallis LA/University of Colorado, Aurora, CO; Denver Health, Denver, CO; Emory University, Atlanta, GA; Dartmouth University, Hanover, NH; Western Cape Government Health, METRO EMS, Bellville, South Africa; University of Cape Town, Cape Town, South Africa
Background: An emergency first aid responder (EFAR) program has been implemented in resource-constrained communities in South Africa. EFARs are intended to provide timely basic life-saving care to patients until scarce EMS resources arrive on scene. Atlantis is a medically underserved community of 80,000 people with a high burden of acute disease and 120 EFARs. EFAR medical responses and scene care remain unstudied. Study Objectives: To determine the frequency, characteristics, and distribution of EFAR responses in Atlantis. Methods: We conducted a prospective observational cohort study in Atlantis. From August 1, 2014, to January 31, 2015, de-identified Atlantis EFAR, EMS, and hospital data (clinical and operational) were manually collected using customized paper-based instruments, and entered into a secure electronic study registry. All adults and children who received an ambulance response in the study period were included. Calls for inter-facility transfers were excluded. Response and clinical data were analyzed descriptively. The frequency of EMS and EFAR responses were classified by neighborhood and adjusted for population size. Ethical review was obtained in South Africa and the USA. Results: There were 1892 EMS primary responses in Atlantis during the study period, of which 8 (0.4%) had EFAR responses. Non-EFAR bystanders were on scene in 1273 (67.3%) of cases. 846 (44.7%) of the EMS calls were designated by dispatch as high priority (P-1), 1036 (54.7%) mid priority (P-2), and 1 (0.05%) low priority (P-3). EFARs were present on-scene in 4 P-1 responses, 4 P-2 responses, and 0 P-3. Mean EMS incident-to-scene response interval was 18.8 minutes (range 0-85) for P-1 calls and 76.4 minutes (range 0-968) for P-2 calls compared with 24.0 minutes (range 0-85) for EFAR responses. EFARs utilized first-aid skills during every response: guided EMS to scene (n¼5), communicated with EMS dispatch (n¼2), provided scene control (n¼2), emotional support (n¼4), basic airway management (n¼1), and placed the victim in recovery position (n¼3). Mean number of EMS incidents per 1000 population was 29.7 (range 5.90 - 136.8) (Table 1). EFARs responded in 5 of 11 (45.5%) Atlantis neighborhoods. There were no EFAR responses in the neighborhood with the highest density of EMS responses. Conclusions: There were few EFAR responses (8) relative to the large volume of medical emergencies and EMS responses (1892). This marked discrepancy precludes a robust comparative analysis between EFAR and non-EFAR responses. For P-1 calls, EMS units arrived on scene faster than EFARs which may be one reason few EFARs were noted. EFARs responded in less than half of Atlantis neighborhoods, mostly skewed towards lower EMS response density areas, implying a geographic mismatch or insufficient EFARs. Recommendations to increase EFAR responses include: training EFARs in rural areas with long EMS responses, recruiting EFARs from high incident neighborhoods, and community engagement to sustain
S80 Annals of Emergency Medicine
217 EMF
Assessing the Need for Protocolized Observation Care for Stroke and Asthma in Rural Haiti
Rouhani S, Marsh RH, Baugh C, Cheridor JE, Schuur J/Brigham and Women’s Hospital, Boston, MA; Hopital Universitaire de Mirebalais, Mirebalais, Haiti
Study Objectives: Emergency departments (EDs) in low-resource settings face high patient volumes with limited ED space, inpatient space, and staffing. In high-resource settings, observation medicine (OBS) has been shown to decrease patient length of stay while preserving quality of care. It is unknown if the same benefits would be seen in low-resource settings. Methods: This is the first portion of a quality improvement study on the implementation of OBS protocols at L’Hôpital Universitaire de Mirebalais, an academic hospital in rural Haiti with a 15-bed ED and 6-bed ED OBS unit. This is a descriptive study of patients who would be potentially eligible for two OBS protocols (stroke and asthma), to evaluate baseline quality and efficiency of care prior to protocol implementation. Patient visits from January-December 2014 were identified by diagnoses from electronic ED consult notes. No OBS protocols were in use during this time. Charts were manually reviewed to verify the patient’s length of stay (LOS) was at least 4 hours and that the patient would have met ED OBS protocol criteria, had the protocols existed at the time. Stroke inclusion criteria were absence of a hemorrhagic stroke, oxygen saturation >90%, BP < 240/120, conscious, and no evidence of atrial fibrillation. Asthma inclusion criteria were wheezing and dyspnea, age over 1 year, room air oxygen saturation >88%, respiratory rate <45, and blood pressure >90/50. Charts were reviewed using an explicit tool and entered into a RedCAP database. LOS was the time from ED check-in to hospital departure (from ED or inpatient service). Quality metrics for stroke were aspirin administration, a documented swallow study, and physical therapy consult, and for asthma were recording and monitoring of peak flow and receipt of systemic steroids. Results: Of 149 ED stroke patients reviewed, 71 were eligible for inclusion. Of these patients, 9 were admitted with the remainder managed in the ED. Average LOS among stroke patients was 24 hours (range 5-94 hours) for those managed exclusively in the ED, and 16.5 days or 395 hours (range 139-904 hours) for those on the inpatient service. A minority, 15%, of stroke patients received aspirin in the ED and 15% received physical therapy consults. Only 7% had a swallow study documented. Of 93 asthma visits reviewed, only 21 were eligible, as most did not meet the minimum LOS. Most were managed in the ED; only 1 was admitted. For asthma patients, average LOS was 16 hours (range 4-61 hours). No asthma patients had a peak flow recorded, and only 11/21 (52%) received systemic steroids. Conclusion: This baseline data shows significant variability in length of stay among asthma and stroke patients potentially eligible for ED OBS protocols. Notably, few patients achieved target quality of care markers. This indicates a need to focus on quality improvement and standardization of practice when implementing ED observation protocols.
Volume 66, no. 4s : October 2015
216 EMF
EFAR motivation. Given the substantial investment in the EFAR program, further research is needed to assess specific barriers and facilitators to EFAR response in Atlantis.
Emergency Scene Responses by African Community-Based Emergency First Aid Responders
Mould-Millman N-K, Dixon J, Holmes J, Crockett D, LeBeau S, De Vries S, Patel H, Ginde A, Haukoos J, Wallis LA/University of Colorado, Aurora, CO; Denver Health, Denver, CO; Emory University, Atlanta, GA; Dartmouth University, Hanover, NH; Western Cape Government Health, METRO EMS, Bellville, South Africa; University of Cape Town, Cape Town, South Africa
Background: An emergency first aid responder (EFAR) program has been implemented in resource-constrained communities in South Africa. EFARs are intended to provide timely basic life-saving care to patients until scarce EMS resources arrive on scene. Atlantis is a medically underserved community of 80,000 people with a high burden of acute disease and 120 EFARs. EFAR medical responses and scene care remain unstudied. Study Objectives: To determine the frequency, characteristics, and distribution of EFAR responses in Atlantis. Methods: We conducted a prospective observational cohort study in Atlantis. From August 1, 2014, to January 31, 2015, de-identified Atlantis EFAR, EMS, and hospital data (clinical and operational) were manually collected using customized paper-based instruments, and entered into a secure electronic study registry. All adults and children who received an ambulance response in the study period were included. Calls for inter-facility transfers were excluded. Response and clinical data were analyzed descriptively. The frequency of EMS and EFAR responses were classified by neighborhood and adjusted for population size. Ethical review was obtained in South Africa and the USA. Results: There were 1892 EMS primary responses in Atlantis during the study period, of which 8 (0.4%) had EFAR responses. Non-EFAR bystanders were on scene in 1273 (67.3%) of cases. 846 (44.7%) of the EMS calls were designated by dispatch as high priority (P-1), 1036 (54.7%) mid priority (P-2), and 1 (0.05%) low priority (P-3). EFARs were present on-scene in 4 P-1 responses, 4 P-2 responses, and 0 P-3. Mean EMS incident-to-scene response interval was 18.8 minutes (range 0-85) for P-1 calls and 76.4 minutes (range 0-968) for P-2 calls compared with 24.0 minutes (range 0-85) for EFAR responses. EFARs utilized first-aid skills during every response: guided EMS to scene (n¼5), communicated with EMS dispatch (n¼2), provided scene control (n¼2), emotional support (n¼4), basic airway management (n¼1), and placed the victim in recovery position (n¼3). Mean number of EMS incidents per 1000 population was 29.7 (range 5.90 - 136.8) (Table 1). EFARs responded in 5 of 11 (45.5%) Atlantis neighborhoods. There were no EFAR responses in the neighborhood with the highest density of EMS responses. Conclusions: There were few EFAR responses (8) relative to the large volume of medical emergencies and EMS responses (1892). This marked discrepancy precludes a robust comparative analysis between EFAR and non-EFAR responses. For P-1 calls, EMS units arrived on scene faster than EFARs which may be one reason few EFARs were noted. EFARs responded in less than half of Atlantis neighborhoods, mostly skewed towards lower EMS response density areas, implying a geographic mismatch or insufficient EFARs. Recommendations to increase EFAR responses include: training EFARs in rural areas with long EMS responses, recruiting EFARs from high incident neighborhoods, and community engagement to sustain
S80 Annals of Emergency Medicine
217 EMF
Assessing the Need for Protocolized Observation Care for Stroke and Asthma in Rural Haiti
Rouhani S, Marsh RH, Baugh C, Cheridor JE, Schuur J/Brigham and Women’s Hospital, Boston, MA; Hopital Universitaire de Mirebalais, Mirebalais, Haiti
Study Objectives: Emergency departments (EDs) in low-resource settings face high patient volumes with limited ED space, inpatient space, and staffing. In high-resource settings, observation medicine (OBS) has been shown to decrease patient length of stay while preserving quality of care. It is unknown if the same benefits would be seen in low-resource settings. Methods: This is the first portion of a quality improvement study on the implementation of OBS protocols at L’Hôpital Universitaire de Mirebalais, an academic hospital in rural Haiti with a 15-bed ED and 6-bed ED OBS unit. This is a descriptive study of patients who would be potentially eligible for two OBS protocols (stroke and asthma), to evaluate baseline quality and efficiency of care prior to protocol implementation. Patient visits from January-December 2014 were identified by diagnoses from electronic ED consult notes. No OBS protocols were in use during this time. Charts were manually reviewed to verify the patient’s length of stay (LOS) was at least 4 hours and that the patient would have met ED OBS protocol criteria, had the protocols existed at the time. Stroke inclusion criteria were absence of a hemorrhagic stroke, oxygen saturation >90%, BP < 240/120, conscious, and no evidence of atrial fibrillation. Asthma inclusion criteria were wheezing and dyspnea, age over 1 year, room air oxygen saturation >88%, respiratory rate <45, and blood pressure >90/50. Charts were reviewed using an explicit tool and entered into a RedCAP database. LOS was the time from ED check-in to hospital departure (from ED or inpatient service). Quality metrics for stroke were aspirin administration, a documented swallow study, and physical therapy consult, and for asthma were recording and monitoring of peak flow and receipt of systemic steroids. Results: Of 149 ED stroke patients reviewed, 71 were eligible for inclusion. Of these patients, 9 were admitted with the remainder managed in the ED. Average LOS among stroke patients was 24 hours (range 5-94 hours) for those managed exclusively in the ED, and 16.5 days or 395 hours (range 139-904 hours) for those on the inpatient service. A minority, 15%, of stroke patients received aspirin in the ED and 15% received physical therapy consults. Only 7% had a swallow study documented. Of 93 asthma visits reviewed, only 21 were eligible, as most did not meet the minimum LOS. Most were managed in the ED; only 1 was admitted. For asthma patients, average LOS was 16 hours (range 4-61 hours). No asthma patients had a peak flow recorded, and only 11/21 (52%) received systemic steroids. Conclusion: This baseline data shows significant variability in length of stay among asthma and stroke patients potentially eligible for ED OBS protocols. Notably, few patients achieved target quality of care markers. This indicates a need to focus on quality improvement and standardization of practice when implementing ED observation protocols.
Volume 66, no. 4s : October 2015