Clinical Outcomes Associated With Diltiazem Use in Heart Failure With Reduced Ejection Fraction After Implementation of a Clinical Support System.

BACKGROUND: Despite atrial fibrillation guideline recommendations, many patients with heart failure with reduced ejection fraction (EF) continue to receive IV diltiazem for acute rate control. OBJECTIVE: Our institution recently implemented a clinical decision support system (CDSS)-based tool that recommends against the use of diltiazem in patients with an EF ≤ 40%. The objective of this study was to evaluate outcomes of adherence to the aforementioned CDSS-based tool. METHODS: This multi-hospital, retrospective study assessed patients who triggered the CDSS alert and compared those who did and did not discontinue diltiazem. The primary outcome was the occurrence of clinical deterioration. The primary endpoint was compared utilizing a Fisher's Exact Test, and a multivariate logistic regression model was developed to confirm the results of the primary analysis. RESULTS: A total of 246 patients were included in this study with 146 patients in the nonadherent group (received diltiazem) and 100 patients in the adherent group (did not receive diltiazem). There was a higher proportion of patients experiencing clinical deterioration in the alert nonadherence group (33% vs 21%, P = 0.044), including increased utilization of inotropes and vasopressors, and higher rate of transfer to ICU. CONCLUSION AND RELEVANCE: In patients with heart failure with reduced EF, diltiazem use after nonadherence to a CDSS alert resulted in an increased risk of clinical deterioration. This study highlights the need for improved provider adherence to diltiazem clinical decision support systems.

Validation of a Simulation-Based Resuscitation Curriculum for Maternal Cardiac Arrest.

OBJECTIVE: To assess the knowledge, skills, and self-efficacy of health care participants completing a simulation-based blended learning training curriculum on managing maternal medical emergencies and maternal cardiac arrest (Obstetric Life Support). METHODS: A formative assessment of the Obstetric Life Support curriculum was performed with a prehospital cohort comprising emergency medical services professionals and a hospital-based cohort comprising health care professionals who work primarily in hospital or urgent care settings and respond to maternal medical emergencies. The training consisted of self-guided precourse work and an instructor-led simulation course using a customized low-fidelity simulator. Baseline and postcourse assessments included multiple-choice cognitive test, self-efficacy questionnaire, and graded Megacode assessment of the team leader. Megacode scores and pass rates were analyzed descriptively. Pre- and post-self-confidence assessments were compared with an exact binomial test, and cognitive scores were compared with generalized linear mixed models. RESULTS: The training was offered to 88 participants between December 2019 and November 2021. Eighty-five participants consented to participation; 77 participants completed the training over eight sessions. At baseline, fewer than half of participants were able to achieve a passing score on the cognitive assessment as determined by the expert panel. After the course, mean cognitive assessment scores improved by 13 points, from 69.4% at baseline to 82.4% after the course (95% CI 10.9-15.1, P <.001). Megacode scores averaged 90.7±6.4%. The Megacode pass rate was 96.1%. There were significant improvements in participant self-efficacy, and the majority of participants (92.6%) agreed or strongly agreed that the course met its educational objectives. CONCLUSION: After completing a simulation-based blended learning program focused on managing maternal cardiac arrest using a customized low-fidelity simulator, most participants achieved a defensible passing Megacode score and significantly improved their knowledge, skills, and self-efficacy.

EMS responses and non-transports during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic may affect both use of 9-1-1 systems and prehospital treatment and transport practices. We evaluated EMS responses in an EMS region when it experienced low to moderate burden of COVID-19 disease to assess overall trends, response and management characteristics, and non-transport rates. Our goal is to inform current and future pandemic response in similar regions. METHODS: We performed a retrospective review of prehospital EMS responses from 22 urban, suburban, and rural EMS agencies in Western Pennsylvania. To account for seasonal variation, we compared demographic, response, and management characteristics for the 2-month period of March 15 to May 15, 2020 with the corresponding 2-month periods in 2016-2019. We then tested for an association between study period (pandemic vs historical control) and incidence of non-transport in unadjusted and adjusted regression. Finally, we described the continuous trends in responses and non-transports that occurred during the year before and initial phase of the COVID-19 pandemic from January 1, 2019 to May 31, 2020. RESULTS: Among 103,607 EMS responses in the 2-month comparative periods of March 15 to May 15, 2016-2020, we found a 26.5% [95% CI 26.9%, 27.1%] decrease in responses in 2020 compared to the same months from the four prior years. There was a small increase in respiratory cases (0.6% [95%CI 0.1%, 1.1%]) and greater frequency of abnormal vital signs suggesting a sicker patient cohort. There was a relative increase (46.6%) in non-transports between periods. The pandemic period was independently associated with an increase in non-transport (adjusted OR 1.68; 95%CI 1.59, 1.78). Among 177,194 EMS responses occurring in the year before and during the early period of the pandemic, between January 1, 2019, and May 31, 2020, we identified a 31% decrease in responses and a 48% relative increase in non-transports for April 2020 compared to the previous year's monthly averages. CONCLUSION: Despite a low to moderate burden of infection during the initial period of the COVID-19 pandemic, we found a decline in overall EMS response volumes and an increase in the rate of non-transports independent of patient demographics and other response characteristics.

The 2019 Core Content of Emergency Medical Services Medicine.

On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.

Compound risk: History of traumatic stress predicts posttraumatic stress disorder symptoms and severity in sudden cardiac arrest survivors.

BACKGROUND: Sudden cardiac arrest (SCA) survivors can develop posttraumatic stress disorder (PTSD) which is associated with worse clinical outcomes. The purpose of this study was to evaluate the prevalence and predictors of PTSD in a large sample of SCA survivors. Prior history of psychological trauma and the effects of repeated trauma exposure on subsequent PTSD and symptom severity after SCA were also explored. METHODS: A retrospective, cross-sectional study of 188 SCA survivors from the Sudden Cardiac Arrest Association patient registry completed an online questionnaire that included measures of PTSD, trauma history, sociodemographics, general health, and cardiac history. RESULTS: Sixty-three (36.2%) SCA survivors in this sample scored above the clinical cutoff for PTSD. Female gender, worse general health, and younger age predicted PTSD symptoms after SCA. Additionally, 50.2% of SCA survivors (n = 95) reported a history of trauma exposure and 25.4% (n = 48) of the total sample endorsed a traumatic stress response to a historic trauma. Results indicated that a traumatic stress response to a historic trauma was a stronger predictor of PTSD after SCA (odds ratio = 4.77) than all other variables in the model. CONCLUSIONS: PTSD symptoms are present in over one-third of SCA survivors. While demographic or health history variables predicted PTSD after SCA, a history of traumatic stress response to a previous trauma emerged as the strongest predictor of these symptoms. Routine assessment and interdisciplinary management are discussed as potential ways to expedite survivors' recovery and return to daily living.

Cardiac anxiety after sudden cardiac arrest: Severity, predictors and clinical implications.

BACKGROUND: Survival from cardiac arrest is a medical success but simultaneously produces psychological challenges related to perception of safety and threat. The current study evaluated symptoms of cardiac-specific anxiety in sudden cardiac arrest (SCA) survivors and examined predictors of cardiac anxiety secondary to cardiac arrest. METHODS: A retrospective, cross-sectional study of 188 SCA survivors from the Sudden Cardiac Arrest Association patient registry completed an online questionnaire that included a measure of cardiac anxiety (CAQ) and sociodemographic, cardiac history, and psychosocial adjustment data. CAQ scores were compared to published means from implantable cardioverter defibrillator (ICD), inherited long QT syndrome (LQTS), and hypertrophic cardiomyopathy (HCM) samples and a hierarchical regression was performed. RESULTS: Clinically relevant cardiac anxiety and cardioprotective behaviors were frequently endorsed and 18% of survivors reported persistent worry about their heart even when presented with normal test results. Compared to all other samples, SCA survivors reported significantly higher levels of heart-focused attention (d=0.3-1.1) and greater cardiac fear and avoidance behaviors than LQTS patients. SCA patients endorsed less severe fear and avoidance symptoms than the HCM sample. Hierarchical regression analyses revealed that younger age (p=0.02), heart murmur (p=0.02), history of ICD shock≥1 (p=0.01), and generalized anxiety (p=0.008) significantly predicted cardiac anxiety. The overall model explained 29.2% of the total variance. CONCLUSIONS: SCA survivors endorse high levels of cardiac-specific fear, avoidance and preoccupation with cardiac symptoms. Successful management of SCA patients requires attention to anxiety about cardiac functioning and security.

A comparative assessment of adverse event classification in the out-of-hospital setting.

OBJECTIVES: We sought to test reliability of two approaches to classify adverse events (AEs) associated with helicopter EMS (HEMS) transport. METHODS: The first approach for AE classification involved flight nurses and paramedics (RN/Medics) and mid-career emergency physicians (MC-EMPs) independently reviewing 50 randomly selected HEMS medical records. The second approach involved RN/Medics and MC-EMPs meeting as a group to openly discuss 20 additional medical records and reach consensus-based AE decision. We compared all AE decisions to a reference criterion based on the decision of three senior emergency physicians (Sr-EMPs). We designed a study to detect an improvement in agreement (reliability) from fair (kappa = 0.2) to moderate (kappa = 0.5). We calculated sensitivity, specificity, percent agreement, and positive and negative predictive values (PPV/NPV). RESULTS: For the independent reviews, the Sr-EMP group identified 26 AEs while individual clinician reviewers identified between 19 and 50 AEs. Agreement on the presence/absence of an AE between Sr-EMPs and three MC-EMPs ranged from κ = 0.20 to κ = 0.25. Agreement between Sr-EMPs and three RN/Medics ranged from κ = 0.11 to κ = 0.19. For the consensus/open-discussion approach, the Sr-EMPs identified 13 AEs, the MC-EMP group identified 18 AEs, and RN/medic group identified 36 AEs. Agreement between Sr-EMPs and MC-EMP group was (κ = 0.30 95%CI -0.12, 0.72), whereas agreement between Sr-EMPs and RN/medic group was (κ = 0.40 95%CI 0.01, 0.79). Agreement between all three groups was fair (κ = 0.33, 95%CI 0.06, 0.66). Percent agreement (58-68%) and NPV (63-76%) was moderately dissimilar between clinicians, while sensitivity (25-80%), specificity (43-97%), and PPV (48-83%) varied. CONCLUSIONS: We identified a higher level of agreement/reliability in AE decisions utilizing a consensus-based approach for review rather than independent reviews.

Measuring adverse events in helicopter emergency medical services: establishing content validity.

INTRODUCTION: We sought to create a valid framework for detecting adverse events (AEs) in the high-risk setting of helicopter emergency medical services (HEMS). METHODS: We assembled a panel of 10 expert clinicians (n = 6 emergency medicine physicians and n = 4 prehospital nurses and flight paramedics) affiliated with a large multistate HEMS organization in the Northeast US. We used a modified Delphi technique to develop a framework for detecting AEs associated with the treatment of critically ill or injured patients. We used a widely applied measure, the content validity index (CVI), to quantify the validity of the framework's content. RESULTS: The expert panel of 10 clinicians reached consensus on a common AE definition and four-step protocol/process for AE detection in HEMS. The consensus-based framework is composed of three main components: (1) a trigger tool, (2) a method for rating proximal cause, and (3) a method for rating AE severity. The CVI findings isolate components of the framework considered content valid. CONCLUSIONS: We demonstrate a standardized process for the development of a content-valid framework for AE detection. The framework is a model for the development of a method for AE identification in other settings, including ground-based EMS.

Use of therapeutic hypothermia after in-hospital cardiac arrest.

OBJECTIVES: Formal guidelines recommend that therapeutic hypothermia be considered after in-hospital cardiac arrest. The rate of therapeutic hypothermia use after in-hospital cardiac arrest and details about its implementation are unknown. We aimed to determine the use of therapeutic hypothermia for adult in-hospital cardiac arrest, whether use has increased over time, and to identify factors associated with its use. DESIGN: Multicenter, prospective cohort study. SETTING: A total of 538 hospitals participating in the Get With the Guidelines-Resuscitation database (2003-2009). PATIENTS: A total of 67,498 patients who had return of spontaneous circulation after in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the initiation of therapeutic hypothermia. We measured the proportion of therapeutic hypothermia patients who achieved target temperature (32-34 °C) and were overcooled. Of 67,498 patients, therapeutic hypothermia was initiated in 1,367 patients (2.0%). The target temperature (32-34 °C) was not achieved in 44.3% of therapeutic hypothermia patients within 24 hours and 17.6% were overcooled. The use of therapeutic hypothermia increased from 0.7% in 2003 to 3.3% in 2009 (p < 0.001). We found that younger age (p < 0.001) and occurrence in a non-ICU location (p < 0.001), on a weekday (p = 0.005), and in a teaching hospital (p = 0.001) were associated with an increased likelihood of therapeutic hypothermia being initiated. CONCLUSIONS: After in-hospital cardiac arrest, therapeutic hypothermia was used rarely. Once initiated, the target temperature was commonly not achieved. The frequency of use increased over time but remained low. Factors associated with therapeutic hypothermia use included patient age, time and location of occurrence, and type of hospital.

Multivariate analysis of successful intravenous line placement in the prehospital setting.

BACKGROUND: Intravenous (IV) line placement is an important prehospital advanced life support skill, but IV success rates are variable among providers. Little is known about what factors are associated with successful IV placement, limiting the ability to develop benchmarks for skill maintenance, such as requiring a specific number of IV placements per year. OBJECTIVE: We aimed to identify whether first-pass IV success was associated with the number of attempted or successful previous IV attempts. We hypothesized that IV success is associated with the number of successful IV placements in the preceding year. METHODS: We retrospectively studied 800 consecutive charts with an IV attempt from 11 suburban and rural emergency medical services (EMS) agencies over a one-month period. Cases involving pediatric patients (age <18 years) and those with incomplete data were excluded. Success of the first IV attempt was identified. Potential predictor variables were collected and analyzed by univariate logistic regression, including patient age, systolic blood pressure, history of IV drug abuse or renal disease, traumatic event, catheter size, and location of IV attempt, as well as the individual provider's numbers of total and successful IV attempts in the preceding year. Variables significantly associated with IV success at the p < 0.10 level were included in a multivariate regression model using a p-value of 0.05. RESULTS: Of 602 cases meeting the study criteria, 469 (77.9%) had a successful first-pass IV placement. Significantly associated with IV success in the univariate regression were patient age (p = 0.054), trauma (p = 0.074), IV catheter size (p < 0.001), IV location (p = 0.056), and the number of previous successful IV attempts (p = 0.039), whereas the number of total previous IV attempts was not significantly associated (p = 0.871). In the multivariate logistic regression model, only IV catheter size had a significant association (p < 0.001), with a larger-bore IV catheter size associated with higher success. CONCLUSION: In this retrospective study, larger IV catheter size, but not the prehospital providers' previous year's experience, was associated with successful IV placement in adult patients. These data fail to support requirements for a minimum number of yearly IV placements by full-time paramedics to improve success rates.

The core content of emergency medical services medicine.

On September 23, 2010, the American Board of Medical Specialties (ABMS) approved emergency medical services (EMS) as a subspecialty of emergency medicine. As a result, the American Board of Emergency Medicine (ABEM) is planning to award the first certificates in EMS medicine in the fall of 2013. The purpose of subspecialty certification in EMS, as defined by ABEM, is to standardize physician training and qualifications for EMS practice, to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and to facilitate integration of prehospital patient treatment into the continuum of patient care. In February 2011, ABEM established the EMS Examination Task Force to develop the Core Content of EMS Medicine (Core Content) that would be used to define the subspecialty and from which questions would be written for the examinations, to develop a blueprint for the examinations, and to develop a bank of test questions for use on the examinations. The Core Content defines the training parameters, resources, and knowledge of the treatment of prehospital patients necessary to practice EMS medicine. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear on the examinations. This article describes the development of the Core Content and presents the Core Content in its entirety.