On-line Medical Direction: A Prospective Study

AbstractObjectives:To determine the frequency with which physician, on-line medical direction (OLMD) [direct medical control] of prehospital care results in orders, to describe the nature of these orders, and to measure OLMD time intervals.Methods:Blinded, prospective study.Setting:A university hospital base-station resource center.Participants:Ten emergency physicians, 50 advanced life support providers.Interventions:Prehospital treatment was directed by both standing orders and OLMD physician orders. Independent observers recorded event times and the characteristics of OLMD.Results:Physician orders were given in 47 (19%) of the 245 study cases, and covered a variety of interventions, including many already authorized by standing orders. Mean OLMD radio time was four minutes (245 ± 216 seconds [sec]), and time from beginning of OLMD to hospital arrival averaged 12 minutes (718 ± 439 sec). Mean transport time in this system was 13 minutes.Conclusion:Despite detailed standing orders, OLMD results in orders for clinical interventions in 19% of cases. On-line medical direction requires about four minutes of physician time per call. This constituted about one-third of the potential field treatment time interval in this system. Thus, OLMD appears to play an important role in providing quality prehospital care.

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Patient-Initiated Refusals of Prehospital Care: Ambulance Call Report Documentation, Patient Outcome, and On-line Medical Command

Prehospital and Disaster Medicine ◽

10.1017/s1049023x0004156x ◽

1995 ◽

Vol 10 (1) ◽

pp. 3-9 ◽

Cited By ~ 41

Author(s):

David C. Cone ◽

David T. Kim ◽

Steven J. Davidson

Keyword(s):

Patient Outcome ◽

Emergency Department ◽

Life Support ◽

Prehospital Care ◽

Advanced Life Support ◽

Support Service ◽

Exact Test ◽

On Line ◽

Potential Impact

AbstractIntroduction:There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR.Methods:The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up.Results:Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p <0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths.Conclusions:Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances.

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Medical Control of Mass Gatherings: Can Paramedics Perform Without Physicians On-site?

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00040590 ◽

1993 ◽

Vol 8 (4) ◽

pp. 327-331 ◽

Cited By ~ 18

Author(s):

Cary C. McDonald ◽

Max D. Koenigsberg ◽

Sharon Ward

Keyword(s):

Rock Music ◽

Life Support ◽

Prehospital Care ◽

Vital Signs ◽

Advanced Life Support ◽

First Aid ◽

Adverse Outcomes ◽

Mass Gatherings ◽

Medical Control ◽

On Line

AbstractObjective:Evaluate the experience of paramedic personnel at mass gatherings in the absence of on-site physicians.Design:Retrospective review of patients evaluated by paramedics with emergency medical services (EMS) medical control.Setting:First-aid facility operated by paramedics at an outdoor amphitheater involving 32 (predominantly rock music) concerts in accordance with the Chicago EMS System, June through September 1990.Participants:A total of 438 patients (≤0.1% on-site population) were evaluated.Interventions:Presentations to the first-aid facility were viewed as if the patient was presenting to an ambulance. Transportation to an emergency department was strongly recommended for all encounters. Time from presentation to the first-aid facility until disposition was limited to 30 minutes in the absence of on-line [direct] medical control. Refusal of care was accepted. On-line [direct] medical control with the EMS resource hospital was initiated as needed. Off-line [indirect] medical control consisted of weekly reviews of all patient records and periodic site visits.Results:Of the 438 patients, 366 (84%) refused further care, including 31 patients (7%) who refused advanced life support (ALS) level care. Seventy-two patients (16%) were transported; 37 by ALS and 35 by basic life support (BLS) units. On-line [direct] medical control was initiated in all ALS patients that were transported as well as for those who refused care. No known deaths or adverse outcomes occurred, based on lack of inquiries or complaints from the local EMS system, emergency departments receiving transported patients, law enforcement agencies, 9-1-1 emergency response providers, venue management, or security. No request for medical records from law firms have occurred. Problems noted initially were poor documentation and a tendency not to document all encounters (e.g., dispensing band-aids, tampons, earplugs, etc.). Concerns noted included: initial and subsequent vital signs, times of arrival, interventions, dispositions, and patient conditions of refusal. Specific problems with documentation of refusals at disposition included: appropriate mental status, speech, and gait; release with an accompanying family member or friend; and parental notification and approval of care for minors. There also was an initial tendency not to establish on-line [direct] medical control for ALS refusal or BLS medicolegal issues.Conclusions:The medical system configuration modeled after practices of prehospital care, demonstrates physicians did not need to be onsite when adequate EMS medical control existed with less than 30 minutes on-scene time.

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The Prehospital Use of Nitroglycerin According to Standing Medical Orders in an Urban EMS System

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00039972 ◽

1993 ◽

Vol 8 (1) ◽

pp. 29-33 ◽

Cited By ~ 6

Author(s):

Linda L. Herman ◽

Max Koenigsberg ◽

Sharon Ward ◽

Edward P. Sloan

Keyword(s):

Blood Pressure ◽

Chest Pain ◽

Adverse Reactions ◽

Life Support ◽

Prehospital Care ◽

Advanced Life Support ◽

Subjective Symptom ◽

Base Station ◽

Base Stations ◽

Clinically Significant

AbstractPurpose:The purposes of this study are to quantify the use of nitroglycerin (NTG) in prehospital care, to detect deviations from the Standing Medical Orders (SMO), to determin the effectiveness of its administration, and the incidence of clinically significant adverse reactions (hypotension, bradycardia).Method:Retrospective review of 7683 Advanced Life Support (ALS) telemetry, base-station contacts over a three month period (June, July, Auguest 1990) to identify all prehospital patient contacts in which NTG was utilized.Setting:The Resource Hospital/Telemetry Base-Station a two community hospitals/Telemetry Base-Stations for the Chicago North EMS System.Results:There were 445 runs in which NTG was indicated as per SMO. Two hundred eighty-eight patients (64.7%) received NTG for appropriate indications as per SMO, 203 for ischemic chest pain (45.6%), 79 for pulmonary edema (17.7%), and six for both (1.3%). There were 157 (35.5%) runs in which NTG was indicated, but not administered. There were 22 patients who received NTG for indications that deviated from the SMO. Reassessment data concerning the subjective symptom was completed on 118 patients (40.9%), 92 (45.3%) patients with chest pain and 26 with dyspnea (32.9%). Following the administration of NTG, 21 patients (10.1%) with chest pain were unchanged, while 13 with dyspnea (15.3%) improved, 13 patients (15.3%) were unchanged, and none worsened. In 121 patients, the systolic blood pressure (SBP) decreased, while 24 were unchanged (5.4%), and 28 had an increase (6.3%). The mean initial value SBP was 176±44 mmHg and the repeat mean SBP was 164±41 mmHg with a mean decrease of 12±22 mmHg. The diastolic blood pressure (DBP) decreased in 87 patients, was unchanged in 53 (11.9%), and increased in 33 (7.4%). The initial mean DBP was 97±24 mmHg, the repeat mean DBP was 92±23 mmHg, a mean decrease of 5±15 mmHg. Only one patient became hypotensive with the administration of NTG and was successfully resusticated with a fluid bolus of 300 ml normal saline.Conclusions:In this EMS system, NTG is under-utilized based on the indications delineated by this system's SMOs. Reassessment is documented infrequently, but when completed, clinically significant adverse reactions are rare. Since the incidence of hypotension and bradycardia are rare, the inability to establish an IV line should not preclude the administration of NTG.

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Abstract TP245: Variance in Ems Run Times by Receiving Hospital for Stroke Patients in San Diego County

Stroke ◽

10.1161/str.51.suppl_1.tp245 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Amelia Kenner-brininger ◽

Lindsay Olson-Mack ◽

Lorraine Calzone ◽

Kristi L Koenig ◽

Thomas M Hemmen

Keyword(s):

Response Time ◽

San Diego ◽

Life Support ◽

Prehospital Care ◽

Advanced Life Support ◽

San Diego County ◽

Stroke Patients ◽

Transport Time ◽

Stroke Registry ◽

Few Data

Background: Emergency Medical Services (EMS) play an important role as initial providers after stroke. Few data are available that capture Stroke Receiving System and EMS response and transport data. We used a stroke registry from a community of 3.3 million residents, 18 stroke receiving centers, and 19 ground transporting advanced life support EMS agencies to evaluate EMS response time, scene time, and transport times. Our aim was to inform the stroke community about duration of EMS care and guide future prehospital interventions. Methods: We included all cases from the San Diego County Stroke Registry arriving by EMS with associated computer automated dispatch (CAD) record and base hospital record (BHR) from July 2017 through December 2018. Records were linked on the EMS incident number, reviewed for accuracy. We analyzed EMS response, scene, transport and total run times (enroute to arrival) by receiving hospital. Results: Between July 2017 and December 2018 2,376 EMS patients were transported to 18 hospitals. Volume per hospital ranged from 11 to 483 patients over the study period. Mean (±SD) response time was 7.0 (±3.7) minutes, range: 5.3 to 9.3 minutes between hospitals. Mean (±SD) scene time was 13.1 (±5.2) minutes, range: 10.5 to 15.0 minutes between hospitals. Transport time averaged 13.8 (±7.7) minutes, range: 8.3 to 23.8 minutes between hospitals (IQR=8.5-17.9). The mean (±SD) total EMS run time was 33.8 (±10.8) minutes, range: 26.4 to 44.9 minutes between hospitals (IQR=26.4-39.9). Conclusion: Only minor variations in EMS response and scene times were observed across the Stroke Receiving Centers. However, transport time showed greater variation and contributed to the differences in total EMS run times. Many systems had short transport times, limiting prehospital interventions. Next steps include studying factors contributing to transport time variation to inform prehospital care and triage decisions of possible stroke patients to optimize transport times.

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Eligibility for intravenous thrombolysis in acute stroke: A multicenter prospective study

Stroke ◽

10.1161/str.32.suppl_1.372-c ◽

2001 ◽

Vol 32 (suppl_1) ◽

pp. 372-372

Author(s):

Enrique Mostacero ◽

Sonia Santos ◽

Antonio Davalos ◽

Alberto Gil-Peralta ◽

Jose Castillo ◽

...

Keyword(s):

Risk Factors ◽

Prospective Study ◽

Acute Stroke ◽

Life Support ◽

Advanced Life Support ◽

Stroke Onset ◽

Stroke Severity ◽

Street Hospital ◽

Modifiable Factors ◽

Dispatch System

P182 Objective: To elucidate the proportion of patients who would have been eligible for alteplase treatment following the ECASS II criteria in a prospective study conducted in 20 Spanish general or university hospitals. Methods: The first 100 consecutive patients with an acute stroke admitted between 9/98 and 4/99 in each participating hospital were evaluated. Data concerning exclusion criteria for tPA, demographic variables, distance to hospital (<5km,5–20km,>20km), time (0–6am,6–12,12–6pm,6–12pm) and place (home, work/street, hospital) of symptoms onset, subject detecting the event (victim, family member, bystander), dispatch system (own initiative, EMS, primary physician, community hospital), delay and type of transport (own transport, basic, or advanced life support ambulance), cardiovascular risk factors, stroke severity (Canadian scale) and type of stroke were recorded. Results: Out of 1599 screened patients, 166 (10.4%) fulfilled all criteria for tPA treatment. Multiple reasons for exclusion were time from onset >6h in 23%, or unknown in 23%, delay in neurological attention >6h in 39%, TC not available within 6h from onset in 34%, hemorrhage in 14%, early signs of infarction involving >33% MCA in 8%, TIA or rapidly improving symptoms in 24%, coma or hemiplegia plus forced eye deviation in 5%, hypertension >185/110 in 2%, coagulation abnormalities in 1%, and other reasons in 6%. Univariate analyses showed that high eligibility for tPA was associated with type of the first medical intervention (emergency medical system)(p=0.006), type of transport (basic or advanced life support ambulance)(p<0.0001), stroke severity (p<0.001), and type of stroke (cardioembolic) (p=0.0027). Age, distance to hospital, time and place of stroke onset, subject detecting the event, and risk factors were not significantly related to eligibility. Conclusions: Candidates for intravenous tPA treatment within 6 hours from stroke onset are 10% of patients admitted in general hospitals of an EU country. Delay in neurologic attention and CT examination were the main reasons for exclusion. Dispatch system, and type of transport were modifiable factors related to eligibility.

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Pediatric Prehospital Care in Urban and Rural Areas

PEDIATRICS ◽

10.1542/peds.88.4.681 ◽

1991 ◽

Vol 88 (4) ◽

pp. 681-690 ◽

Cited By ~ 1

Author(s):

James S. Seidel ◽

Deborah Parkman Henderson ◽

Patrick Ward ◽

Barbara Wray Wayland ◽

Beverly Ness

Keyword(s):

Emergency Medical Services ◽

Rural Areas ◽

Urban Areas ◽

Pediatric Patients ◽

Life Support ◽

Prehospital Care ◽

Advanced Life Support ◽

Medical Services ◽

Care Providers ◽

Emergency Medical

There are limited data concerning pediatric prehospital care, although pediatric prehospital calls constitute 10% of emergency medical services activity. Data from 10 493 prehospital care reports in 11 counties of California (four emergency medical services systems in rural and urban areas) were collected and analyzed. Comparison of urban and rural data found few significant differences in parameters analyzed. Use of the emergency medical services system by pediatric patients increased with age, but 12.5% of all calls were for children younger than 2 years. Calls for medical problems were most common for patients younger than 5 years of age; trauma was a more common complaint in rural areas (64%, P = .0001). Frequency of vital sign assessment differed by region, as did hospital contact (P < .0001). Complete assessment of young pediatric patients, with a full set of vital signs and neurologic assessment, was rarely performed. Advanced life support providers were often on the scene, but advanced life support treatments and procedures were infrequently used. This study suggests the need for additional data on which to base emergency medical services system design and some directions for education of prehospital care providers.

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65. The Evolution of the Prehospital Care of Pediatric Asthma

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00045751 ◽

1996 ◽

Vol 11 (S2) ◽

pp. S35-S35

Author(s):

Anthony Ciccone ◽

Carol Irving ◽

Robert F. Lavery ◽

Bartholomew J. Tortella

Keyword(s):

Discriminant Analysis ◽

Life Support ◽

Pediatric Population ◽

Prehospital Care ◽

Pediatric Asthma ◽

Case Series ◽

Treatment Decision ◽

Continuous Data ◽

Stepwise Discriminant Analysis ◽

Prehospital Treatment

Purpose: The prevalence of asthma in the pediatric population is approximately 9% and the incidence of acute exacerbation in this population has been increasing. The purpose of this study was to determine if there has been a change in the pre-hospital presentation and treatment of pediatric asthma.Methods: This observational study was a retrospective consecutive case series comparing pediatric (#18 yrs) asthmatics treated and transported by an inner city EMS system over two years. (1987, 1992). Data collected included patient demographics, prehospital treatment, and evaluated diagnostic criteria used by paramedics to initiate treatment. Students t test was performed for continuous data and contingency analysis (chisquare) for non-continuous data. A Wilks stepwise discriminant analysis was performed on 1987 and 1992 data to evaluate diagnostic factors.Results: There were 407 transports in 1987 and 652 in 1992, representing a 60% increase. 237(56%) of patients received advanced life support (ALS) in 1987 and 344(53%) in 1992. Mean age of ALS patients in 1987 was 10.25 (±5.3) and was 8.03 (±2.8) in 1992 (p <0.001). Albuterol inhalation supplanted epinephrine (1987-205, 1992-1) and aminophylline (1987-15, 1992-1) as the treatment for asthma in our service system. The discriminant analysis revealed that in 1987, paramedics treatment decision making was influenced by age, cough, cold, and/or fever, home medications, accessory muscles, absence of wheezing, and normal respiratory rate. This changed in 1992 where only the presence or absence of wheezing and accessory muscle-use to be highly correlated with treatment decisions.

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A Workplace-Based Observation Strategy to Assess Prehospital Care Delivery by Public Ambulances in Ukraine

Prehospital and Disaster Medicine ◽

10.1017/s1049023x19004138 ◽

2019 ◽

Vol 34 (s1) ◽

pp. s179-s180

Author(s):

Stanislav Gaievskyi ◽

Oleksandr Linchevskyy ◽

Colin Meghoo

Keyword(s):

Life Support ◽

Care Delivery ◽

Prehospital Care ◽

Advanced Life Support ◽

Cost Effective ◽

Financial Resources ◽

Successful Implementation ◽

Patient Privacy ◽

Patient Encounter ◽

Treatment Protocols

Introduction:Current methods to evaluate the delivery of urgent prehospital care often rely on inadequate surrogate measures or unreliable self-reported data. A workplace-based strategy may be feasible to assess the delivery of prehospital care by ambulances in selected populations.Aim:To perform a nationwide assessment of the psychomotor performance of public ambulance workers in Ukraine, we created a plan of workplace-based observation. We conducted a post-hoc analysis of this strategy to assess feasibility, strengths, and limitations for future use in assessing prehospital ambulance performance.Methods:With support from the Ministry of Health, we sent teams of trained observers to 30 ambulance substations across Ukraine. Using data collection tools on mobile devices, these observers accompanied Advanced Life Support ambulances on urgent calls for periods of 72 hours. We evaluated this program for collecting patient encounter data against the investment of time, personnel, and financial resources.Results:Over a two-month period, we directly observed 524 patient encounters by public ambulances responding to urgent calls at 30 ambulance substations across Ukraine. We employed 6 observers and 2 administrators over this time period. Collecting our observations required 2,160 person-hours at the ambulance substations. The total distance traveled to these sites was 11,375 kilometers. Project costs amounted to 37,000 USD, equating to 71 USD per observed patient encounter.Discussion:Workplace-based assessments are a cost-effective strategy to collect data on the delivery of prehospital care in select populations. This data can be useful for identifying the current state of EMS care delivered and evaluating compliance with established treatment protocols. Successful implementation depends on effective planning and coordination with a commitment of time, personnel, and financial resources. Issues of patient privacy, legal permission, and observer training must be considered.

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Architecture and Functionality of the Advanced Life Support On-Line Project Information System

10.4271/2004-01-2365 ◽

2004 ◽

Cited By ~ 5

Author(s):

John A. Hogan ◽

Julie A. Levri ◽

Rich Morrow ◽

Jim Cavazzoni ◽

Luis F. Rodriguez ◽

...

Keyword(s):

Information System ◽

Life Support ◽

Advanced Life Support ◽

On Line

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Investigation of health professionals’ knowledge retention in CPR after completing the Advance Life Support in Gynecology (ALSG) Course

10.21203/rs.3.rs-47957/v1 ◽

2020 ◽

Author(s):

Nikolaos Vrachnis ◽

Nikolaos Antonakopoulos ◽

Antigoni Tsigirlioti ◽

Vasilios Pergialiotis ◽

Nicoleta Iacovidou ◽

...

Keyword(s):

Health Professionals ◽

Life Support ◽

Cardiopulmonary Arrest ◽

Advanced Life Support ◽

Knowledge Retention ◽

Standards Of Care ◽

Time Interval ◽

Continuous Training ◽

Factors Affecting ◽

High Standards

Abstract Background Studies have shown that immediate and effective cardiopulmonary resuscitation plays a major role in the survival of victims of cardiac arrest. Numerous studies also demonstrate the need for continuous training of health professionals. In Greece life support courses are established in various fields including pediatrics, obstetrics and gynecology. The ALSG (Advanced Life Support in Gynecology) course was initiated in 2011 and covers gynecological emergencies that often lead to cardiopulmonary arrest, including ruptured ectopic pregnancy, toxic shock syndrome and postoperative collapse. The purpose of this study was to investigate knowledge retention in CPR after completion of the ALSG course and to define the factors affecting it. Methods A descriptive qualitative study was, designed and conducted through anonymous questionnaires sent electronically to past ALSG course participants. Results A total of 100 questionnaires were sent and 50 were completed and returned. Mean knowledge retention was 87.4 ± 18.2. The multivariate analysis revealed that the time interval since training in life support significantly correlated with the actual score. Additionally, more correct answers were given by course instructors than certified course graduates. Conclusion Instructors in life support courses achieve longer retention of their knowledge than trainees, while increased time interval between training and knowledge recall results in lower scores. In conclusion, continuing education of health professionals and adoption of algorithms, such as those taught in the ALSG course, are likely to help maintain knowledge and achieve high standards of care.

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