Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a “hub and spoke” model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate.

The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA).

This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events.

Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P = .91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events.

In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.

Stroke is a major emergency that can cause a significant morbidity and mortality. Advancement in stroke management in recent years has allowed more patients to be diagnosed and treated by stroke teams; however, stroke is a time-sensitive emergency that requires a high level of coordination, particularly within the prehospital phase. This research is to determine whether patients received by Emergency Medical Services (EMS) at a tertiary health care facility had shorter stroke team activation, time to computed tomography (CT), or time to receive intravenous thrombolytics.

This research is a prospective cohort study of adults with stroke symptoms who required stroke team activation at a tertiary medical facility. The study included all patients received from September 1, 2017 through August 31, 2018. The primary outcome was the time difference to stroke team activation between patients received by EMS compared to patients that arrived by a private method of transportation. The secondary outcomes were the difference in time to CT scan and the time to receive intravenous recombinant tissue plasminogen activator (rtPA).

There were 75 (34.1%) patients who had been received by EMS, while 145 (65.9%) patients arrived via private transportation method (private car or by a friend/family member). The mean time to stroke team activation, time to CT, and time to receive thrombolytic therapy for the EMS group were: 8.19 (95% CI, 6.97 - 9.41) minutes; 18 (95% CI, 15.9 - 20.1) minutes; and 13.1 (95% CI, 6.95 - 19.3) minutes, respectively. Those for the private car group, on the other hand, were: 16 (95% CI, 12.4 - 19.6) minutes; 23.39 (95% CI, 19.6 - 27.2) minutes; and nine (95% CI, 4.54 -13.5) minutes, respectively. There was a significantly shorter time to stroke team activation for patients arriving via EMS compared to private car (P ≤ .00), but no significant difference was found on time to CT (P = .259) or time to receive rtPA (P = .100).

Emergency Medical Service transportation of stroke patients can significantly shorten the time to stroke team activation, leading to shorter triage and accelerated patient management. However, there was no statistical difference in time to CT or time to receive rtPA. Patients with stroke symptoms may benefit more from EMS transportation compared to private methods of transportation.

In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.

The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.

This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.

The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.

State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.

Hospital evacuations of patients with special needs are extremely challenging, and it is difficult to train hospital workers for this rare event.

Researchers developed an in-situ simulation study investigating the effect of standardized checklists on the evacuation of a patient under general anesthesia from the operating room (OR) and hypothesized that checklists would improve the completion rate of critical actions and decrease evacuation time.

A vertical evacuation of the high-fidelity manikin (SimMan3G; Laerdal Inc.; Norway) was performed and participants were asked to lead the team and evacuate the manikin to the ground floor after a mock fire alarm. Participants were randomized to two groups: one was given an evacuation checklist (checklist group [CG]) and the other was not (non-checklist group [NCG]). A total of 19 scenarios were run with 28 participants.

Mean scenario time, preparation phase of evacuation, and time to transport the manikin down the stairs did not differ significantly between groups (P = .369, .462, and .935, respectively). The CG group showed significantly better performance of critical actions, including securing the airway, taking additional drug supplies, and taking additional equipment supplies (P = .047, .001, and .001, respectively). In the post-evacuation surveys, 27 out of 28 participants agreed that checklists would improve the evacuation process in a real event.

Standardized checklists increase the completion rate of pre-defined critical actions in evacuations out of the OR, which likely improves patient safety. Checklist use did not have a significant effect on total evacuation time.

The goal of this search was to review the current literature regarding paramedic triage of primary care patients and the safety of paramedic-initiated non-transport of non-urgent patients.

A narrative literature review was conducted using the Medline (Medline Industries, Inc.; Mundelein, Illinois USA) database and a manual search of Google Scholar (Google; Mountain View, California USA).

Only 11 studies were found investigating paramedic triage and safety of non-transport of non-urgent patients. It was found that triage agreement between paramedic and emergency department staff generally is poor and that paramedics are limited in their abilities to predict the ultimate admission location of their patients. However, these triage decisions and admission predictions are much more accurate when the patient’s condition is the result of trauma and when the patient requires critical care services. Furthermore, the literature provides very limited support for the safety of paramedic triage in the refusal of non-urgent patient transport, especially without physician oversight. Though many non-transported patients are satisfied with the quality of non-urgent treatment that they receive from paramedics, the rates of under-triage and subsequent hospitalization reported in the literature are too high to suggest that this practice can be adopted widely.

There is insufficient evidence to suggest that non-urgent patients can safely be refused transport based on paramedic triage alone. Further attempts to implement paramedic-initiated non-transport of non-urgent patients should be approached with careful triage protocol development, paramedic training, and pilot studies. Future primary research and systematic reviews also are required to build on the currently limited literature.

Fraess-PhillipsAJ. Can Paramedics Safely Refuse Transport of Non-Urgent Patients?Prehosp Disaster Med. 2016;31(6):667–674.

Data on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities.

We conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations.

Sixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment considered most helpful included flashlights (24%), transport sleds (21%), and oxygen tanks and respiratory therapy supplies (19%). An evacuation wish list included walkie-talkies/phones (26%), lighting/electricity (18%), flashlights (10%), and portable ventilators and suction (16%).

ICU providers who evacuated critically ill patients during Hurricane Sandy had little prior knowledge of evacuation processes or vertical evacuation experience. The weakest links in the patient evacuation process were communication and the availability of practical tools. Incorporating ICU providers into hospital evacuation planning and training, developing standard evacuation communication processes and tools, and collecting a uniform dataset among all evacuating hospitals could better inform critical care evacuation in the future. (Disaster Med Public Health Preparedness. 2016;10:20–27)

Critical care transport (CCT) teams must manage a wide array of medications before and during transport. Appreciating the medications required for transport impacts formulary development as well as staff education and training.

As there are few data describing the patterns of medication administration, this study quantifies medication administrations and patterns in a series of adult CCTs.

This was a retrospective review of medication administration during CCTs of patients with severe hypoxemic respiratory failure from October 2009 through December 2012 from referring hospitals to three tertiary care hospitals.

Two hundred thirty-nine charts were identified for review. Medications were administered by the CCT team to 98.7% of these patients, with only three patients not receiving any medications from the team. Fifty-nine medications were administered in total with 996 instances of administration. Fifteen drugs were each administered to only one patient. The mean number of medications per patient was 4.2 (SD=1.8) with a mean of 1.9 (SD=1.1) drug infusions per patient.

These results demonstrate that, even within a relatively homogeneous population of patients transferred with hypoxemic respiratory failure, a wide range of medications were administered. The CCT teams frequently initiated, titrated, and discontinued continuous infusions, in addition to providing numerous doses of bolused medications.

WilcoxSR , SaiaMS , WadenH , McGahnSJ , FrakesM , WedelSK , RichardsJB . Medication Administration in Critical Care Transport of Adult Patients with Hypoxemic Respiratory Failure. Prehosp Disaster Med. 2015;30(4):1-5.

While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics.

The objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system.

A retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospital's immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed.

Diversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate.

Hospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.

KahnC , StrattonS , AndersonC . Characteristics of Hospitals Diverting Ambulances in a California EMS System. Prehosp Disaster Med. 2014;29(1):1-5.

The objectives of this study were to develop a novel training model for using mass-casualty incident (MCI) scenarios that trained hospital and prehospital staff together using Microsoft Visio, images from Google Earth and icons representing first responders, equipment resources, local hospital emergency department bed capacity, and trauma victims. The authors also tested participants’ knowledge in the areas of communications, incident command systems (ICS), and triage.

Participants attended Managing Multiple-Casualty Incidents (MCIs), a one-day training which offered pre- and post-tests, two one-hour functional exercises, and four distinct, one-hour didactic instructional periods. Two MCI functional exercises were conducted. The one-hour trainings focused on communications, National Incident Management Systems/Incident Command Systems (NIMS/ICS) and professional roles and responsibilities in NIMS and triage. The trainings were offered throughout communities in western Montana. First response resource inventories and general manpower statistics for fire, police, Emergency Medical Services (EMS), and emergency department hospital bed capacity were determined prior to MCI scenario construction. A test was given prior to and after the training activities.

A total of 175 firefighters, EMS, law enforcement, hospital personnel or other first-responders completed the pre- and post-test. Firefighters produced higher baseline scores than all other disciplines during pre-test analysis. At the end of the training all disciplines demonstrated significantly higher scores on the post-test when compared with their respective baseline averages. Improvements in post-test scores were noted for participants from all disciplines and in all didactic areas: communications, NIMS/ICS, and triage.

Mass-casualty incidents offer significant challenges for prehospital and emergency room workers. Fire, Police and EMS personnel must secure the scene, establish communications, define individuals’ roles and responsibilities, allocate resources, triage patients, and assign transport priorities. After emergency department notification and in advance of arrival, emergency department personnel must assess available physical resources and availability and type of manpower, all while managing patients already under their care. Mass-casualty incident trainings should strengthen the key, individual elements essential to well-coordinated response such as communications, incident management system and triage. The practice scenarios should be matched to the specific resources of the community. The authors also believe that these trainings should be provided with all disciplines represented to eliminate training “silos,” to allow for discussion of overlapping jurisdictional or organizational responsibilities, and to facilitate team building.

GlowSD, ColucciVJ, AllingtonDR, NoonanCW, HallEC. Managing Multiple-Casualty Incidents: A Rural Medical Preparedness Training Assessment. Prehosp Disaster Med. 2013;28(4):1-8.

Diversion of ambulances by hospital emergency departments has become a day-to-day occurrence in many jurisdictions within Canada. Yet, despite the increasing prevalence of this phenomenon, its impact on transported patients, on the EMS system, and on the health care system overall has not, to date, been well quantified. Despite the increasing sophistication and capabilities of North American EMS systems, it is difficult to argue with the principle that unstable or potentially unstable patients are best served by expeditious transport for definitive care to acute care facilities. T o this end, this study represents an effort to assess the systemic and patient care impacts of ambulance diversions.

Patient-care and corresponding ambulance trip records for all patients transported by this EMS system for a five week period were abstracted to identify those patients in which an ambulance was diverted from its initial destination. Adverse events include hypotensive episodes, airway compromise, changes in level of consciousness, and the onset of violent behavior. Response and transport times also were abstracted, comparisons utilized student's t-test and 95% Confidence Intervals. Results: Ambulance diversions increased EMS response times and prehospital transport times. Adverse medical events occurred during 4.3% of diverted ambulance runs. Patients, when faced with the prospect of transport to other than their hospital of choice, not infrequently cancelled EMS transport and sought other means of transport. Subsequent interfacility transport was required for 4.3% of the diverted patients.

Diversion of ambulances impacts the EMS system by increasing response and transport times; the region, by generating subsequent interfacility transports; and patients, as adverse medical events can occur during the diverted transport.

Aeromedical transport in northern areas may be associated with hypothermia. The objective of this study was to determine whether significant hypothermia (core temperature <35ºC) occurs in severely injured or ill intubated patients during transport by rotary wing aircraft.

In this prospective cohort study, all intubated patients over 16 years of age who were transported by rotary wing aircraft from rural hospitals or trauma scenes in northern Alberta to regional hospitals in Edmonton were eligible for study. Esophageal thermometers were used to measure core temperature at 10-minute intervals during transport.

Of 133 potentially eligible patients, 116 were enrolled; 69 (59%) had esophageal thermometers inserted, and 47 (41%) had other temperature measurements. Severe hypothermia occurred in only 1% to 2% of cases, but 28% to 39% of patients met criteria for mild hypothermia prior to transport. Core temperatures did not fall during transport, despite the fact that warming techniques were documented in only 38% of cases.

During brief (<225 km) rotary wing aeromedical transport of severely injured or ill patients, significant hypothermia is uncommon and body temperature is generally well maintained with the use of simple passive measures. These findings do not justify recommendations for more aggressive core temperature monitoring during this type of aeromedical transport.

The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress.

Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay.

Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays.

Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.

While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care.

Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews.

Data for the two most common advanced life support calls in this system—seizures and chest pains—were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calk. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls.

One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0±4.2 minutes for three-person crews and 19.4±8.3 minutes for two-person crews (p <0.001). Mean on-scene time for patients with chest pain was 13.6±4.9 minutes for three-person crews, and 15.4±3.2 minutes for two-person crews assisted by fire department personnel (p >0.05).

Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer onscene times than three-person EMS crews.

The resuscitation rate from out-of-hospital cardiac arrest is low. There are many factors to be considered as contributing to this phenomenon. One factor not previously considered is the impact of a moving ambulance environment on the ability to perform closed-chest compressions.

Proper closed-chest compressions can be performed in a moving ambulance.

A cardiopulmonary resuscitation (CPR) training mannequin with an attached skill meter (Skillmeter ResusciAnnie®, Laerdal, Armonk, N. Y., USA) that measures each chest compression for proper depth and hand placement was used. Ten emergency medical technician-basic (EMT-B) certified prehospital providers were assigned into one of five teams. Each team performed a total of four sessions of five minutes of continuous closed-chest compressions on the mannequin. Two sessions were done by each team: one in the control environment with the mannequin placed on the floor, and the other in the experimental environment with the mannequin placed in the back of a moving ambulance. The ambulance was operated without warning lights and siren, and all traffic rules were obeyed. The percentage of correct closed-chest compressions was recorded for each session, and the mean values were compared using Student's t-test with alpha set at 0.01 for statistical significance.

Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 ±15.6 for the control group and 45.6 ±18.3 for the ambulance group (p = 0.0005).

A moving ambulance environment appears to impair the ability to perform closed-chest compressions.

Nationwide data were collected concerning serious, disabling injuries requiring hospitalization (SDIH) or deaths among urban emergency medical services (EMS) providers.

A mail survey of EMS systems was conducted among the 200 most populated U.S. cities.

Participants were training and operations officers of urban EMS systems.

Ninety forms (45%) were returned with 88 evaluable (44%). There were 81 SDIHs for a rate of one in 31,616 dispatches. No deaths were reported. Body parts most frequently injured were the hand (22%), head (19%), foot (16%), and eye (14%). Although 90% of fire-based EMS systems (fire-EMS) provided helmets, eye protection, safety shoes, and gloves, less than half (45%) of nonfire-EMS did so. Three (4%) SDIHs resulted from acts of violence.

Occupational injuries of EMS personnel are at a serious level. Fire-based EMS systems experienced a higher rate of hand SDIHs despite the provision of protective equipment. Few nonfire-EMS staff are provided with safety equipment, which may have resulted in a relatively high number of head and hand SDIHs. Fire-EMS medical directors need to take an active role in verifying that protective equipment is adequate and appropriate to allow the performance of field EMS duties without being too cumbersome. Medical directors of nonfire-EMS must be advocates for the provision of basic protective equipment aimed at mitigating SDIHs of EMS staff.

The purpose of this study is to describe treatment of asthma in children by paramedics.

Retrospective review of an advanced life support (ALS) run reports over a one-year period.

Review of paramedic response to pediatric respiratory emergencies in an urban, primarily inner-city, prioritized, dual-response emergency medical services (EMS) system.

Patients < 19 years of age complaining of shortness of breath, paramedics, pediatric residents, and attending physicians.

The medical records of 383 patients were reviewed for demographic and medical information. The population was separated into an ALS treatment group (received ALS) and a NO-ALS group (evaluation and/or oxygen only). Sixty percent of the patients (n = 231) were classified into the ALS group; 89% received epinephrine. Sixty-six percent (n = 101) of the NO-ALS patients received evaluation only, and the remaining 34% (n = 51) were evaluated and received oxygen. The ALS patients were older and had significantly higher respiratory rates and accessory muscle use than did the NO-ALS patients. Relief was reported in 66 % of ALS patients. No adverse reactions were reported in the ALS group. Determining factors influencing ALS treatment included age, the use of medications at home, wheezing, accessory muscle use, respiratory rate, and presence or absence of upper respiratory infection (URI) symptoms.

This study demonstrates that asthma constitutes the majority of pediatric emergencies in the prehospital setting in this inner-city EMS system. The ALS treatment of pediatric asthma improves patient status. Factors which may influence paramedic judgment in treating asthma in children may be inappropriate. There is a critical need for further research in the prehospital treatment of pediatric asthma and in developing education interventions directed at the entire spectrum of prehospital care of pediatric emergencies.