An evidence-based evaluation of EMS protocols.

OBJECTIVE: To determine the extent to which prehospital patient care protocols incorporate the findings of the peer-reviewed scientific EMS literature. METHODS: Using a computerized literature search, articles published from eight institutions known to be active in prehospital care research were identified and obtained from the local health sciences library. Animal or bench research, analysis of administrative practices, evaluation of educational or quality assurance techniques, collective reviews, and air medical articles were excluded. We compared the findings of each article with the guidelines contained in 12 sets of prehospital care protocols, ranking them as: 1) consistent; 2) partially consistent; 3) not discussed; or 4) not consistent. The rankings for the article-protocol comparisons for each EMS system were compared using the Kruskal-Wallis test. RESULTS: Forty-nine papers were compared with 12 sets of protocols, resulting in 588 comparisons. More than half (53.1%, n = 312) of the comparisons were ranked as "consistent." Only 28 (4.8%) of the comparisons were found to be "not consistent." There was no significant difference in the rankings assigned to the comparisons for protocols from each individual system, nor in the rankings for protocols from the EMS system associated with the source of the article, from other systems with academic affiliations, and from systems without academic affiliations. CONCLUSION: Most EMS protocols are consistent with the published peer-reviewed research. There is no difference in the level of consistency when comparing protocols from EMS systems associated with the source of the articles, those associated with other academic institutions, and those without strong academic affiliations.

Influence of demographic variables in prehospital treatment of patients with chest pain.

OBJECTIVE: To determine whether the number of interventions requested by EMS personnel for patients with acute, nontraumatic chest pain varied with the patient's gender or race. METHODS: The authors conducted a retrospective chart review of the care requested for patients 17 years old or older complaining of acute, nontraumatic chest pain by one EMS squad in a city of 50,000 people over a six-month period. Interventions recorded for each patient included oxygen administration, artificial airway placement, intravenous fluid administration, defibrillation, and use of lidocaine and nitroglycerin. RESULTS: Of the 169 patients in this study, 54% (n = 92) were white and 56% (n = 95) were female. Age was missing for two patients; of the remainder, 75% (n = 127) were 40 years old or older. The numbers of interventions requested ranged from 0 to 4. EMS personnel requested supplemental oxygen for 163 patients. 81% of the females had i.v. lines placed or attempted, compared with 70% of the males; EMS personnel requested orders for nitroglycerin for 43% of the females and 29% of the males. Whites were more likely than nonwhites to have requests for i.v. lines or nitroglycerin. Overall, the numbers of interventions were similar among young females and among older patients, regardless of race or gender. The pattern for young males was different, with significantly more requests for interventions for young white males than for young non-white males (1.89 vs 1.34). CONCLUSIONS: Among older patients and among young females, EMS personnel requested similar numbers of interventions for patient complaining of acute, nontraumatic chest pain regardless of patients race. Patterns of care appeared to differ for young males, a finding that warrants further study.

Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress?

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Accuracy of fingerstick glucose values in shock patients.

BACKGROUND: Fingerstick blood glucose measurement has become widespread in both hospital and prehospital settings. OBJECTIVE: To determine the accuracy of fingerstick blood glucose measurement in patients with poor peripheral perfusion (shock). METHOD: Results obtained during three methods of glucose analysis (fingerstick blood glucose measurement; bedside and laboratory glucose analysis) were examined prospectively on 38 patients from inpatient medical and surgical critical care units or the emergency department of a large tertiary care referral center. RESULTS: The means of the three glucose measurements were significantly different. Univariate analysis of the mean laboratory glucose value versus the mean fingerstick glucose value was significantly different. The mean venipuncture glucose measured by the bedside glucose meter versus the mean venous laboratory glucose was not significantly different. CONCLUSION: These results suggest that fingerstick blood samples should not be used for bedside glucose analysis in patients who may have inadequate tissue perfusion.

Guidelines for the prehospital use of thrombolytic agents.

Recognizing that prehospital thrombolytic therapy may provide benefit to certain subsets of patients, the routine prehospital use of thrombolytic agents should be discouraged pending further scientific delineation and documentation of those subgroups. ACEP encourages further investigation to document feasibility, efficacy, cost-effectiveness, and safety of use of these agents in this environment. Detailed education is needed in such areas as contraindications and the mechanics of drug administration. Online medical direction is paramount to the successful use of these agents in the prehospital setting.

Improved flight following through continuous quality improvement.

INTRODUCTION: Flight following is a key component of an air medical transport service's safety program. National standards require conscientious adherence to flight following. EastCare monitored its compliance with internal flight-following requirements for three years. SETTING: EastCare is a single-helicopter, hospital-based air medical transport service located in a rural region of the southeastern United States. It has a full-time staff of flight nurses, pilots and communications specialists. METHODS: A continuous quality improvement (CQI) process was initiated to delineate specific areas requiring improvement. These areas were discussed at the air medical service's monthly CQI meetings. RESULTS: In 1989, the communications specialists achieved flight following intervals of < or = 15 minutes in 98% of attempts. In 1990 and 1991, the frequency of flight-following intervals of < or = 15 minutes were 98.8% and 99.6%, respectively. The CQI process pointed out educational requirements, technological problems and other areas for improvement. CONCLUSION: The use of a structured CQI process for this service directly contributed to consistently strong compliance in the frequency of flight following.

Air medical transport utilization review in North Carolina.

OBJECTIVE: To perform a review of the collective experience of all hospital-based helicopter ambulances in the state of North Carolina for compliance with utilization review criteria. DESIGN: Flight records of the six members of the North Carolina Aeromedical Affiliation for the months of November and December 1989 were compared with utilization review criteria by an independent reviewer. A secondary review was performed by a staff member for each service. Scene responses and patients flown to a hospital other than the sponsor were evaluated. SETTING: All six hospital-based helicopter services in North Carolina. TYPE OF PARTICIPANTS: All available flight records for November and December 1989. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 756 transports, 747 flight records were available for review. Initial review demonstrated compliance with the criteria for 713 (95.4%) patients; secondary review showed compliance for 18 of 34 flights not meeting initial review, for an overall compliance rate of 97.9%. Compliance rates for scene responses and transports taken to a hospital other than the sponsoring facility were 96.6% and 94.1%, respectively. CONCLUSIONS: Review of all flights over a period of two-months by all six hospital-based helicopter services in North Carolina using utilization review criteria demonstrated a very high rate of compliance with the established criteria.

Civilian field surgery in the rural trauma setting: a proposal for providing optimal care.

Rural trauma presents unique problems for surgical care. While military surgeons are prepared to provide care at or near the scene of battle, civilian literature is devoid of reports for care provided by surgeons at sites of injury occurrences. Although these injuries are infrequent, they are more likely to occur in rural trauma settings. This article describes two cases of extremity injury that required amputation at the scene and presents a proposal for swift mobilization of appropriately trained surgeons to the scene with adequate instrumentation and lighting, which can significantly reduce the morbidity and mortality of these victims.

Inability to assess breath sounds during air medical transport by helicopter.

This study assessed the capabilities of a traditional and an amplified stethoscope used by flight nurses to assess breath sound during air medical transport in an MBB BO-105 helicopter. We developed a normal breath sound model using a prerecorded tape of breath sounds interspersed with segments without breath sounds; the recorder had been placed in the chest wall of a resuscitation training manikin. Flight nurses completed control listening sessions in a quiet environment and experimental sessions during flight using a traditional stethoscope for half of the sessions and an amplified stethoscope for the remaining half. In the quiet environment, flight nurses accurately reported the presence or absence of breath sounds in 110 (92%) of 120 trials. During helicopter flight, none of the flight nurses heard breath sounds during any of the recorded segments with either the traditional stethoscope or the amplified stethoscope. We conclude that flight nurses are unable to hear normal breath sounds using a traditional or amplified stethoscope during flight in a medically configured MBB BO-105 helicopter. Improved stethoscopes, innovative methods of listening, and reduction of aircraft noise are potential solutions to the problems of breath sound assessment during air medical transport.

Utilization review. Keeping air medical services in the air.

Are air medical services taking patients for a ride? Establishing a utilization review process can help justify the necessity of services rendered to patients and assist in reimbursement.

Predictors of flight nurse job satisfaction.

A mail survey was conducted to investigate occupational stress, depression, and job satisfaction among flight nurses. Multivariate multiple regression was used to predict job satisfaction and depression simultaneously. Age, gender, marital status, years employed in air medical transport, employment in a hospital-based program, employment in a program which made scene responses, and stress were the independent variables. The multivariate equation (lambda = 0.54, F14,684 = 17.55, p less than 0.0001) and the univariate equations predicting depression (F7,343 = 24.04, p less than 0.0001) and job satisfaction (F7,343 = 24.09, p less than 0.0001) were significant. Stress was a highly significant predictor of both depression (t = 12.48, df = 1, p less than 0.0001) and job satisfaction (t = -12.13, df = 1, p less than 0.0001). Older respondents were more likely to be satisfied with their jobs (t = 1.99, df = 1, p less than 0.05), and respondents who made scene responses were less likely to be satisfied (t = -2.41, df = 1, p less than 0.05). Identification of flight nurses experiencing high levels of stress and interventions to alleviate this stress, utilizing the experience of older flight nurses, and adequate preparation for scene responses may enhance job satisfaction and perhaps reduce attrition.

Helicopter use by rural emergency departments to transfer trauma victims: a study of time-to-request intervals.

To assess how soon rural emergency departments (EDs) call for helicopters to transport seriously injured patients, the records of all trauma victims (excluding isolated CNS trauma) transported by an emergency helicopter service from referring hospitals to a trauma center over an 18-month period were studied. Admission time to the referring ED was compared with the exact time a call for the helicopter was received and a time-to-request interval (TTR) was calculated. A total of 64 cases were studied. Fifty (78%) of the patients had blunt trauma; 14 (22%) had penetrating trauma. The average TTR for the helicopter was 69.8 minutes, with a range from 17 minutes before arrival at the referring ED to 337 minutes after arrival. Children (aged less than or equal to 16 years) had an average TTR of 34.1 minutes compared with 76.4 minutes for adults (aged greater than 16 years). Of the variables examined, patient age was the only factor significantly associated with TTR. These observations suggest that, except in children, there frequently is a lengthy time interval between the time trauma patients arrive at EDs in rural eastern North Carolina and the time an emergency helicopter service is called to transport them to a trauma center.

Occupational stress and job satisfaction among flight nurses. A survey of National Flight Nurses Association members.

A mail survey of members of the National Flight Nurses Association was conducted to assess occupational stress and job satisfaction. In addition to scales measuring stress and job satisfaction, the questionnaire requested demographic information and included a depression scale. The anticipated direct relationship between stress and depression was observed (r = .56, p .0001), as were the expected inverse relationships between stress and job satisfaction (r = .54, p less than .0001), and between depression and job satisfaction (r = -.45, p .0001). Responses to statements on the stress scale indicated that work interference with family life and failure to receive recognition were important sources of stress, while avoidance behaviors such as tardiness and daydreaming were used infrequently to cope with stress. Inadequate recognition, particularly by administrators and supervisors, and lack of involvement in decision-making processes surfaced as sources of dissatisfaction, as did inadequate feedback about job performance. The tasks performed by flight nurses and being members of cohesive work groups were important sources of job satisfaction. The results indicate that although flight nurses basically are satisfied with their jobs and enjoy working in air medical transport, they want to know that they are performing well. They also want to be involved in decision-making processes and to be recognized for the stressful jobs they perform.

A comparison of four methods of testing emergency medical technician triage skills.

Triage skills are requisite for all providers of prehospital care. Methods of assessing the acquisition of triage skills vary in complexity and expense. In this study, 61 prehospital care providers classified 20 cases, divided into four groups of five cases each: moulaged live trauma victims, nonmoulaged live trauma victims, nonmoulaged manikin trauma victims, and written scenarios. The providers were asked to classify the cases in each group by assigning triage tags to indicate injury severity and to rank the trauma victims in each group according to the urgency of care required. Analysis of variance revealed statistically significant differences among the four methods in both mean tagging scores (F3,235 = 8.63, P less than .0001) and mean ranking scores (F3,232 = 6.09, P less than .001). Multiple comparisons using Scheffe's test revealed that the mean tagging and ranking scores for moulaged live victims and written scenario methods were comparable and that both were significantly superior to the scores of the two other methods. However, a qualitative evaluation revealed that the providers greatly preferred triage of moulaged live victims to the other three methods.