- Email: [email protected]
Safety of managed care organization directed interfacility transfer of cardiac patients
RESEARCH FORUM ABSTRACTS
the National Association of EMS Physicians (NAEMSP) has declared it a standard that EMS systems provide support for medical directors in its recently published position paper, Physician Direction of EMS. To date, few data have been published about the degree of emphasis these systems provide to the medical director positions, and ant" impact of such. Study objectives: This study was conducted to quantify the degree of support for jurisdictional EMS directors (JMDs) by Maryland jurisdictions, and correlate this with their level of involvement using the posinon paper as a template, as well as the actual output, or features, of each system Methods: Twenty-two (96%) of 23 JMDs underwent a structured sur,'ey, repornng their frequency of involvement in various activities, the parameters in place to support their positions, and features of their systems. An analog scale used the answers to quantify these 3 items wath a score, namely the JMD Score, the Emphasis Score, and the Feature Score Results: Although most (81%) have a dimcal supervisor to assist the JMD, only 5 (22%) of the jurisdictions provide a stipend for the JMD. Jurisdictions pro~ading other parameters number from 2 to 9 (9% to 41%). When JMD Scores are plotted in rank order, the other two increase concurrently. Analysis using Pearson's coefficient shows correlation between the Emphasis and the JMD Scores (P=.001), and between Feature and Emphasis Scores (P=.017). Conclusion: Greater support for JMD positions correlates vath enhanced EMS system output. These data show that greater emphasis on JMD positions is more likely to allow the degree of involvement outlined by the position paper, and thus enhance EMS systems.
16
ParamedicIdentificationofAcateStroke
Eckstein M, Kidwell C, Starkrnan S. Weems K/University of Southern California School of Medicine, The Los Angeles Prehospital Stroke Study (LAPSS)Study Group, UCLA Medical Center, Los Angeles, CA Eligibility for thrombolytic therapy for acute stroke is time-critical. Paramedics nmst play a vital role in accurately identifying acute stroke patients to expedite their care. Study objective: To determine the accuracy of paramedic identification of acute stroke before implementation of a training program on stroke recognition and tmatmem. Methods: Emergency medical services (EMS) and hospital records were reviewed for all patients presumptively identified with acute stroke by Los Angeles City Fire Department (LAFD) paramedics from January 1, 1996, through December 31, 1996. The LRFD provides a 2-tiered EMS system serving a population of 3.7 million. The major data elements included emergency department diagnosis, computed tomography (CT) findings, and discharge diagnosis. Results: Dunng the study period, 778 patients met the inclusion criteria, and 338 (43%) of the hospital records were available for review. A discharge diagnosis of stroke or transient ischemic attack (TIA) was made for 296 (88%) patients Of the actual strokes, 156 (75%) were ischemic and 52 (25%) were hemorrhagic Among the remaining 42 patients, sepsis, syncope, seizures, metabolic abnormalities, and hypertension were the most frequent alternate diagnoses. Eight (1%) patients required paramedic-level interventions, including 7 who received intravenous glucose and 1 who was intubated. Conclusion: Paramedics accurately identified most patients with stroke or TIA. Additional training should emphasize differentiation from common stroke mimics to better discern those patients who may be eligible to receive thrombolytic therapy.
317 ProvidersPreh~176176 Marco CA. Scfiears RM/St. Vincent Merc'~Medical Center. Toledo. OH; Hospitals of tt~e University of Pennsylvania.Philadelphia. PA Study objectives: Although prehospital resuscitation practices are often dictated by local protocol, numerous factors affect the application of such protocols to decisions regarding initiation, continuation, and termination of resusettative effons. This stud)" was undertaken to determine resuscitation practices, compliance with protocols, and factors affecting decisionmaking in the prehospital setting. Methods: This study is a cross-sectional survey Participants include prehospital providers attending a national meeting. The SUl-,'eyincluded questions regarding termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols, and compliance with advance directives. Results: Of 217 respondents, with a mean 9.0 years of expenence, most (79.7%) indicated that they would withhold resuscitative efforts in the presence of an official
OCTOBER1999, PART 2 34:4 ANNALSOF EMER6ENCYMEDICINE
state-approved advance directive Although most (76%) have established local protocols, only 54% considered these protocols adequate. If only an unofficial document or a verbal report of an advance directive were available, most (91.7%) w told proceed with resuscitative efforts. However, most (97.5%) would like to see ch;,nges in current practices in 3 particular areas: increased autonomy of prehospital providers in the field termination o[ resuscitative efforts, improved patient education, and improved physician-patient communication regarding advance directives. Conclusion: Although most prehospital providers honor only official stateapproved advance directives currentl),', a majority would like more autonomy in decisionmaking. This study supports the institution of improved clinical guidelines regarding the prehospiial termination of resuscitative efforts
1 0
Oat-of-HospitalProviderBeliefs RegardingUse of Red Lightsand 0 Sirens
Funk DL, Triner W, Green S/Albany Medical College, Albany, NY Stud)" objectives: Emergency medical services (EMS) often use red lights and sirens iRkS) when responding to calls, befieO.ng that their use saves time. Accident data demonstrate increased risk of collision and injury when RLS are used. Our objective is to descnbe EMS providers" perception of the nsks and benefits associated with RLS use Methods: This was a prospective, cross-sectional survey of EMS pro~4ders in area urban, suburban, and rural EMS agencies. A convenience sample of emergency vehicle dnvers attending regional traimng events compnsed the study group. Subjects reported level of EMS training. )'ears of experience, driver safety training, type of vehicle driven, and usual temtory. In addition, they indicated perceived effect of RtS on response nme and risk o[ collision. Data are described in terms of percentages with Z2 used where appropriate Results: A total of 99 surveys were returned. Most respondents were EMTParamedics ~41%) or EMT-Basics (35%). Seventy-one percent of respondents had more than 5 )'ears of expenence; 66% had completed a dnver safety course. Most (78%) drove an ambulance or first-response vehicle primarily, whereas 21% drove a fire truck most often. Fifty eight percent drove in a suburban area, 23% urban, and 19% rural. Sixty percent believed that RLS saved "significant time" Urban drivers and drivers of fire trucks were more likely to believe that RLS saved time (P<.05) No other demographic factors were associated with answers to this question. "Significant time" saved was defined as less than 1 minute by 15% of respondents, 1 to 2 minutes by 27%, 2 to 3 minutes by 16%, and more than 3 minutes by 41%. Thirty-three percent of drivers thought RLS saved less than 1 minute, 37% 1 to 2 minutes, 16% 2 to 3 minutes, and 14% more than 3 minutes Twenty percent of dnvers sup'eyed beheved RLS had no effect on cofiision dsk. No demographic variables were associated with this response Conclusion: Most drivers surveyed believed RLS save significant time. This belief did not correlate with level of training, years of experience, or driver safety training, hut was more common among dnvers of fire trucks and urban drivers. A significant number of emergency vehicle operators did nor believe RLS increased collision risk.
319 TransferSefatY oflManaged acCdiar t e Care Patients d aOrganization c i l i lDreicetdY o f Maravelli A, O'Angelo J. Kupas O, Dula D/Geisinger Medical Center. Danville. PA Stud)" objectives: Managed care organizations (MCOs) routinely attempt to retrieve their patients from out-of-system facilities to participating facilities. This study evaluates the safety of managed care repamation of cardiac patients wath respect to the incidence of predetermined complications. Methods: The study site ',,,'asa rural tertiary care medical center associated with a managed care organization with more than 200,000 members in more than 40 counties The MCO repamation process includes out-of-system physician consultation with a MCO emergency physician and a transfer network capable of air and ground interfacilit.v transports. Patients were included if the)' were transferred to the MCO's tertiary care hospital over a 14-month period with a transfer diagnosis of chest pain, stable or unstable angma, or myocardial infarction. Records were retrospectively re~aewed for objective, predefined transfer complications including hypotension, bradycardia, specific dysrhythmias, chest pain. and the need for various interventions, either during transport or ~sathin 3 hours of amval. Results: The 40 study patients had the following discharge diagnoses: angina (12), acute myocardial infarction (14), non-Q-wave myocardial infarction (5), and noncardiac etiologies of chest pain (9). Seventeen patients were transported by ground advanced life support ambulance, and 23 patients were transported by helicopter with
S81
RESEARCH FORUM ABSTRACTS
an average 62-minnte transport time. Complications included recurrence of chest pain (11 patients), hypotension (3 patients), and bradycardia (1 patient). Only one of the patients had persitent chest pain after appropriate treatment, and this patient required emergency angioplasty. This patient was transferred from a facility that could not provide cardiac catheterization. Within 3 hours of arrival at the tertiary care facility, 4 patients had cardiac catheterization and 2 of these had angioplasty. All patients requiring emergency catheterization were repatriated from facilities that did not have the ability to perform cardiac catheterization. Three patients who were hypotensive at the original facility had additional hypotension during transfer. Two of these patients were at community hospitals and would have clinically required transfer to tertiary care. During transfer, 1 patient experienced bradycardia that was not hemodynamically significant. Conclusion: From this limited number of managed care patients repatriated for presumed cardiac disease, the most common complication of transfer was recurrence of chest pain. The transport crew adequately treated all complications, and all of the patients requiring emergency catheterization were received from hospitals that lacked the ability to perfornl catheterizations.
320 Sildenafil Citrate:Changes in Paramedic Practice? ReedD, He aD, GoughJE, Brown kH/State University of New York, Health Science Center at Syracuse, Syracuse, NY; Hennepin County Medical Center, Minneapolis, MN; East Carolina University School of Medicine, Greenville, NC Study objective: Sildenafil citrate (SC), a new medication for erectile dysfunction, has been associated with hypotension and death in patients who use nitrates. Use of nitrates for chest pain (CP) patients who have had SC within 24 hours is contraindicated. A prior study revealed that on-line physicians do not routinely screen for SC use when ordering prehospital nitrates. We surveyed emergency medical technician-paramedics (EMT-Ps) to determine whether SC use influences their management of CP patients. Methods: An anonymous survey was distributed to all full-time EMT-Ps in 3 EMS systems. Results: Ninety-four (45%) of 210 paramedics responded. Fifty-five (59%) reported they had received specific guidelines for CP patients on SC. SC-related changes m cP protocols were reported by E6 (17%). Forty-seven (50%) reported that they specifically screen for SC use. Seventy-six (81%) had never identified a CP patient on SC; 17 (18%) estimated that 10% of their CP patients had used SC. Sixty-eight (72%) reported that SC use would influence the medications they would use For CP patients. Conclusion: In these 3 EMS systems, EMT-P management of CP patients on SC varies. Half of the EMT-Ps in this survey do not screen CP patients for SC use, and more than a quarter reported that SC use would not influence the medications they administer to CP patients.
21 In-flight Defibrillation by Cabin Attendants: Varig's Experience Timerman S, Alves PM, Stapleton E/FundacaoRuben Berta, Comite Nacional De Resussuscitacao,Rio de Jane#o, Sao Paule, Brazil Varig is the largest airline company in Latin America and one of the oldest in operation, being founded m 1926. With 17,000 employees and 117 aircrafts, Varig is a little smaller than the well-known SAS. Varig flies to 87 domestic and 35 international destinations. Brazil is a very large country and some domestic distances are very long; it also has some poor regions, like the Amazon, with very limited medical and aeronautical resources. There is no doubt the number of m-flight medical emergencies has increased in the last few years. This is particularly due to the fact that elderly people are traveling more, because they are stimulated to do so, they have time to do so, and they are actually living longer. Sudden cardiac events are the most frequent serious conditions that occur on board. Varig's experience has been an increasing number of events: a means of 15 medical emergencies on board a month, defined as the need to call a doctor during the flight. Unfortunately, there were 5 deaths on board last year, and already 2 deaths in 1999 (and 1 used automated external defibrillator). Methods: Varig trained 20 instructors (15 physicians and 5 first-aid lay instructors) m the American Heart Association (AHA) Heart Saver plus AED course with the goal of training 400 pursers. Results: A total of 356 persons were actually trained with a 1:3 instructor/student
S 82
ratio; 53% did not read the course material; 17% read the entire book; 100% recommend the course; and 13% want to be Basic Life Support instructors. On the written test, the average raw score was 75%_+9.7% correct. After the elimination of 4 problematic questions, the average score was 88%_+9.1% and only 3 participants scored below 80%. Future steps include tests for retention, skills, and theory (quality assurance); retraining problematic cases; continue training for 300 flight attendants on an emergency basis; continue training for cabin supervisors; and simulation studies on real aircraft. Conclusion: In-flight cardiac arrests present one of the most challenging issues in resuscitation. The chain of survival concept clearly has some weak links in aircraft. Saving lives on board requires commitment of the whole aviation community and the supporting msntutlons.
322
EndocrineMarkers as Predictors of Outcomein ElderlyPatients Admitted Through the Emergency Department With Febrile Illnesses
Hlibczuk V, Silber S/New York Methodist Hospital, Brooklyn, NY Study objective: The objective of this pilot project is to determine whether endocrine markers (thyroid, adrenal, and gonadotropin) drawn on initial presentation to the emergency department can predict length of hospital stay and mortality in elderly patients admitted with febrile illnesses. The importance of this study is to determine if endocrine ffmction can be used to predict which elderly febrile patients might require more intensive clinical management. Methods: We performed a prospective observational study of all patients 60 years of age or older admitted to the hospital through the ED with temperature 38.3~ (101~ or higher. Serum levels of thyroid function (total triiodothyronine [T3], free thyroxine [T4], thyroid-stimulating hormone/TSH]), adrenal function (serum cortisol), and gonadotropins (follicle-stimulating hormone [FSH], luteinizing hormone [LH]) were drawn in the ED. Patients with prior history of endocrine disease or previous enrollment in the study were excluded. Outcomes measured were length of stay in the hospital and mortality. Multiple linear regression analysis was used to determine the effect of all combined variables on length of stay in smwivors. Each variable was analyzed separately comparing survivors with nonsurvivors using Student's independent t test. Differences were considered significant when P<.05. Results: SLxty-five patients were entered into the study. Fifty-three survived and were discharged from the hospital. The mean serum cortisol levels were elevated in both smwivors and nonsurvivors (upper limit of normal 29 btg/dL). The mean cortisol value was significantly higher in nonsurvivors (40.6 ~tg/dL) than in survivors (29.5 ~tg/dL; P=.036). Female survivors showed a trend (P=. 129) of higher mean FSH (37.99 mlU/mL) compared with nonsurvivors (16.43 MIU/mL) with normal values ranging 27 to 133 mlU/mL. A significant inverse relationship was found between length of stay and T3 levels in survivors (P=.008). However, when comparing laboratory normal T3 values with abnormal T3 values, no significant difference was found. Conclusion: Our study suggests that hormonal levels had a significant correlation on length of stay and survival in elderly patients admitted through the ED with a febrile illness. Further studies need to be performed to determine the clinical application of these findings.
323
Emergency Department Revisit-Admissions for Ectopic Pregnancy: A Case Series and New, Evidence-Based, Diagnostic Protocol
Kohn MA, I
ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 2
the National Association of EMS Physicians (NAEMSP) has declared it a standard that EMS systems provide support for medical directors in its recently published position paper, Physician Direction of EMS. To date, few data have been published about the degree of emphasis these systems provide to the medical director positions, and ant" impact of such. Study objectives: This study was conducted to quantify the degree of support for jurisdictional EMS directors (JMDs) by Maryland jurisdictions, and correlate this with their level of involvement using the posinon paper as a template, as well as the actual output, or features, of each system Methods: Twenty-two (96%) of 23 JMDs underwent a structured sur,'ey, repornng their frequency of involvement in various activities, the parameters in place to support their positions, and features of their systems. An analog scale used the answers to quantify these 3 items wath a score, namely the JMD Score, the Emphasis Score, and the Feature Score Results: Although most (81%) have a dimcal supervisor to assist the JMD, only 5 (22%) of the jurisdictions provide a stipend for the JMD. Jurisdictions pro~ading other parameters number from 2 to 9 (9% to 41%). When JMD Scores are plotted in rank order, the other two increase concurrently. Analysis using Pearson's coefficient shows correlation between the Emphasis and the JMD Scores (P=.001), and between Feature and Emphasis Scores (P=.017). Conclusion: Greater support for JMD positions correlates vath enhanced EMS system output. These data show that greater emphasis on JMD positions is more likely to allow the degree of involvement outlined by the position paper, and thus enhance EMS systems.
16
ParamedicIdentificationofAcateStroke
Eckstein M, Kidwell C, Starkrnan S. Weems K/University of Southern California School of Medicine, The Los Angeles Prehospital Stroke Study (LAPSS)Study Group, UCLA Medical Center, Los Angeles, CA Eligibility for thrombolytic therapy for acute stroke is time-critical. Paramedics nmst play a vital role in accurately identifying acute stroke patients to expedite their care. Study objective: To determine the accuracy of paramedic identification of acute stroke before implementation of a training program on stroke recognition and tmatmem. Methods: Emergency medical services (EMS) and hospital records were reviewed for all patients presumptively identified with acute stroke by Los Angeles City Fire Department (LAFD) paramedics from January 1, 1996, through December 31, 1996. The LRFD provides a 2-tiered EMS system serving a population of 3.7 million. The major data elements included emergency department diagnosis, computed tomography (CT) findings, and discharge diagnosis. Results: Dunng the study period, 778 patients met the inclusion criteria, and 338 (43%) of the hospital records were available for review. A discharge diagnosis of stroke or transient ischemic attack (TIA) was made for 296 (88%) patients Of the actual strokes, 156 (75%) were ischemic and 52 (25%) were hemorrhagic Among the remaining 42 patients, sepsis, syncope, seizures, metabolic abnormalities, and hypertension were the most frequent alternate diagnoses. Eight (1%) patients required paramedic-level interventions, including 7 who received intravenous glucose and 1 who was intubated. Conclusion: Paramedics accurately identified most patients with stroke or TIA. Additional training should emphasize differentiation from common stroke mimics to better discern those patients who may be eligible to receive thrombolytic therapy.
317 ProvidersPreh~176176 Marco CA. Scfiears RM/St. Vincent Merc'~Medical Center. Toledo. OH; Hospitals of tt~e University of Pennsylvania.Philadelphia. PA Study objectives: Although prehospital resuscitation practices are often dictated by local protocol, numerous factors affect the application of such protocols to decisions regarding initiation, continuation, and termination of resusettative effons. This stud)" was undertaken to determine resuscitation practices, compliance with protocols, and factors affecting decisionmaking in the prehospital setting. Methods: This study is a cross-sectional survey Participants include prehospital providers attending a national meeting. The SUl-,'eyincluded questions regarding termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols, and compliance with advance directives. Results: Of 217 respondents, with a mean 9.0 years of expenence, most (79.7%) indicated that they would withhold resuscitative efforts in the presence of an official
OCTOBER1999, PART 2 34:4 ANNALSOF EMER6ENCYMEDICINE
state-approved advance directive Although most (76%) have established local protocols, only 54% considered these protocols adequate. If only an unofficial document or a verbal report of an advance directive were available, most (91.7%) w told proceed with resuscitative efforts. However, most (97.5%) would like to see ch;,nges in current practices in 3 particular areas: increased autonomy of prehospital providers in the field termination o[ resuscitative efforts, improved patient education, and improved physician-patient communication regarding advance directives. Conclusion: Although most prehospital providers honor only official stateapproved advance directives currentl),', a majority would like more autonomy in decisionmaking. This study supports the institution of improved clinical guidelines regarding the prehospiial termination of resuscitative efforts
1 0
Oat-of-HospitalProviderBeliefs RegardingUse of Red Lightsand 0 Sirens
Funk DL, Triner W, Green S/Albany Medical College, Albany, NY Stud)" objectives: Emergency medical services (EMS) often use red lights and sirens iRkS) when responding to calls, befieO.ng that their use saves time. Accident data demonstrate increased risk of collision and injury when RLS are used. Our objective is to descnbe EMS providers" perception of the nsks and benefits associated with RLS use Methods: This was a prospective, cross-sectional survey of EMS pro~4ders in area urban, suburban, and rural EMS agencies. A convenience sample of emergency vehicle dnvers attending regional traimng events compnsed the study group. Subjects reported level of EMS training. )'ears of experience, driver safety training, type of vehicle driven, and usual temtory. In addition, they indicated perceived effect of RtS on response nme and risk o[ collision. Data are described in terms of percentages with Z2 used where appropriate Results: A total of 99 surveys were returned. Most respondents were EMTParamedics ~41%) or EMT-Basics (35%). Seventy-one percent of respondents had more than 5 )'ears of expenence; 66% had completed a dnver safety course. Most (78%) drove an ambulance or first-response vehicle primarily, whereas 21% drove a fire truck most often. Fifty eight percent drove in a suburban area, 23% urban, and 19% rural. Sixty percent believed that RLS saved "significant time" Urban drivers and drivers of fire trucks were more likely to believe that RLS saved time (P<.05) No other demographic factors were associated with answers to this question. "Significant time" saved was defined as less than 1 minute by 15% of respondents, 1 to 2 minutes by 27%, 2 to 3 minutes by 16%, and more than 3 minutes by 41%. Thirty-three percent of drivers thought RLS saved less than 1 minute, 37% 1 to 2 minutes, 16% 2 to 3 minutes, and 14% more than 3 minutes Twenty percent of dnvers sup'eyed beheved RLS had no effect on cofiision dsk. No demographic variables were associated with this response Conclusion: Most drivers surveyed believed RLS save significant time. This belief did not correlate with level of training, years of experience, or driver safety training, hut was more common among dnvers of fire trucks and urban drivers. A significant number of emergency vehicle operators did nor believe RLS increased collision risk.
319 TransferSefatY oflManaged acCdiar t e Care Patients d aOrganization c i l i lDreicetdY o f Maravelli A, O'Angelo J. Kupas O, Dula D/Geisinger Medical Center. Danville. PA Stud)" objectives: Managed care organizations (MCOs) routinely attempt to retrieve their patients from out-of-system facilities to participating facilities. This study evaluates the safety of managed care repamation of cardiac patients wath respect to the incidence of predetermined complications. Methods: The study site ',,,'asa rural tertiary care medical center associated with a managed care organization with more than 200,000 members in more than 40 counties The MCO repamation process includes out-of-system physician consultation with a MCO emergency physician and a transfer network capable of air and ground interfacilit.v transports. Patients were included if the)' were transferred to the MCO's tertiary care hospital over a 14-month period with a transfer diagnosis of chest pain, stable or unstable angma, or myocardial infarction. Records were retrospectively re~aewed for objective, predefined transfer complications including hypotension, bradycardia, specific dysrhythmias, chest pain. and the need for various interventions, either during transport or ~sathin 3 hours of amval. Results: The 40 study patients had the following discharge diagnoses: angina (12), acute myocardial infarction (14), non-Q-wave myocardial infarction (5), and noncardiac etiologies of chest pain (9). Seventeen patients were transported by ground advanced life support ambulance, and 23 patients were transported by helicopter with
S81
RESEARCH FORUM ABSTRACTS
an average 62-minnte transport time. Complications included recurrence of chest pain (11 patients), hypotension (3 patients), and bradycardia (1 patient). Only one of the patients had persitent chest pain after appropriate treatment, and this patient required emergency angioplasty. This patient was transferred from a facility that could not provide cardiac catheterization. Within 3 hours of arrival at the tertiary care facility, 4 patients had cardiac catheterization and 2 of these had angioplasty. All patients requiring emergency catheterization were repatriated from facilities that did not have the ability to perform cardiac catheterization. Three patients who were hypotensive at the original facility had additional hypotension during transfer. Two of these patients were at community hospitals and would have clinically required transfer to tertiary care. During transfer, 1 patient experienced bradycardia that was not hemodynamically significant. Conclusion: From this limited number of managed care patients repatriated for presumed cardiac disease, the most common complication of transfer was recurrence of chest pain. The transport crew adequately treated all complications, and all of the patients requiring emergency catheterization were received from hospitals that lacked the ability to perfornl catheterizations.
320 Sildenafil Citrate:Changes in Paramedic Practice? ReedD, He aD, GoughJE, Brown kH/State University of New York, Health Science Center at Syracuse, Syracuse, NY; Hennepin County Medical Center, Minneapolis, MN; East Carolina University School of Medicine, Greenville, NC Study objective: Sildenafil citrate (SC), a new medication for erectile dysfunction, has been associated with hypotension and death in patients who use nitrates. Use of nitrates for chest pain (CP) patients who have had SC within 24 hours is contraindicated. A prior study revealed that on-line physicians do not routinely screen for SC use when ordering prehospital nitrates. We surveyed emergency medical technician-paramedics (EMT-Ps) to determine whether SC use influences their management of CP patients. Methods: An anonymous survey was distributed to all full-time EMT-Ps in 3 EMS systems. Results: Ninety-four (45%) of 210 paramedics responded. Fifty-five (59%) reported they had received specific guidelines for CP patients on SC. SC-related changes m cP protocols were reported by E6 (17%). Forty-seven (50%) reported that they specifically screen for SC use. Seventy-six (81%) had never identified a CP patient on SC; 17 (18%) estimated that 10% of their CP patients had used SC. Sixty-eight (72%) reported that SC use would influence the medications they would use For CP patients. Conclusion: In these 3 EMS systems, EMT-P management of CP patients on SC varies. Half of the EMT-Ps in this survey do not screen CP patients for SC use, and more than a quarter reported that SC use would not influence the medications they administer to CP patients.
21 In-flight Defibrillation by Cabin Attendants: Varig's Experience Timerman S, Alves PM, Stapleton E/FundacaoRuben Berta, Comite Nacional De Resussuscitacao,Rio de Jane#o, Sao Paule, Brazil Varig is the largest airline company in Latin America and one of the oldest in operation, being founded m 1926. With 17,000 employees and 117 aircrafts, Varig is a little smaller than the well-known SAS. Varig flies to 87 domestic and 35 international destinations. Brazil is a very large country and some domestic distances are very long; it also has some poor regions, like the Amazon, with very limited medical and aeronautical resources. There is no doubt the number of m-flight medical emergencies has increased in the last few years. This is particularly due to the fact that elderly people are traveling more, because they are stimulated to do so, they have time to do so, and they are actually living longer. Sudden cardiac events are the most frequent serious conditions that occur on board. Varig's experience has been an increasing number of events: a means of 15 medical emergencies on board a month, defined as the need to call a doctor during the flight. Unfortunately, there were 5 deaths on board last year, and already 2 deaths in 1999 (and 1 used automated external defibrillator). Methods: Varig trained 20 instructors (15 physicians and 5 first-aid lay instructors) m the American Heart Association (AHA) Heart Saver plus AED course with the goal of training 400 pursers. Results: A total of 356 persons were actually trained with a 1:3 instructor/student
S 82
ratio; 53% did not read the course material; 17% read the entire book; 100% recommend the course; and 13% want to be Basic Life Support instructors. On the written test, the average raw score was 75%_+9.7% correct. After the elimination of 4 problematic questions, the average score was 88%_+9.1% and only 3 participants scored below 80%. Future steps include tests for retention, skills, and theory (quality assurance); retraining problematic cases; continue training for 300 flight attendants on an emergency basis; continue training for cabin supervisors; and simulation studies on real aircraft. Conclusion: In-flight cardiac arrests present one of the most challenging issues in resuscitation. The chain of survival concept clearly has some weak links in aircraft. Saving lives on board requires commitment of the whole aviation community and the supporting msntutlons.
322
EndocrineMarkers as Predictors of Outcomein ElderlyPatients Admitted Through the Emergency Department With Febrile Illnesses
Hlibczuk V, Silber S/New York Methodist Hospital, Brooklyn, NY Study objective: The objective of this pilot project is to determine whether endocrine markers (thyroid, adrenal, and gonadotropin) drawn on initial presentation to the emergency department can predict length of hospital stay and mortality in elderly patients admitted with febrile illnesses. The importance of this study is to determine if endocrine ffmction can be used to predict which elderly febrile patients might require more intensive clinical management. Methods: We performed a prospective observational study of all patients 60 years of age or older admitted to the hospital through the ED with temperature 38.3~ (101~ or higher. Serum levels of thyroid function (total triiodothyronine [T3], free thyroxine [T4], thyroid-stimulating hormone/TSH]), adrenal function (serum cortisol), and gonadotropins (follicle-stimulating hormone [FSH], luteinizing hormone [LH]) were drawn in the ED. Patients with prior history of endocrine disease or previous enrollment in the study were excluded. Outcomes measured were length of stay in the hospital and mortality. Multiple linear regression analysis was used to determine the effect of all combined variables on length of stay in smwivors. Each variable was analyzed separately comparing survivors with nonsurvivors using Student's independent t test. Differences were considered significant when P<.05. Results: SLxty-five patients were entered into the study. Fifty-three survived and were discharged from the hospital. The mean serum cortisol levels were elevated in both smwivors and nonsurvivors (upper limit of normal 29 btg/dL). The mean cortisol value was significantly higher in nonsurvivors (40.6 ~tg/dL) than in survivors (29.5 ~tg/dL; P=.036). Female survivors showed a trend (P=. 129) of higher mean FSH (37.99 mlU/mL) compared with nonsurvivors (16.43 MIU/mL) with normal values ranging 27 to 133 mlU/mL. A significant inverse relationship was found between length of stay and T3 levels in survivors (P=.008). However, when comparing laboratory normal T3 values with abnormal T3 values, no significant difference was found. Conclusion: Our study suggests that hormonal levels had a significant correlation on length of stay and survival in elderly patients admitted through the ED with a febrile illness. Further studies need to be performed to determine the clinical application of these findings.
323
Emergency Department Revisit-Admissions for Ectopic Pregnancy: A Case Series and New, Evidence-Based, Diagnostic Protocol
Kohn MA, I
ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 2