Prone Dispatch-Directed CPR in Out-of-Hospital Cardiac Arrest: Two Successful Cases.

Historically, dispatch-directed cardiopulmonary resuscitation (CPR) protocols only allow chest compression instructions to be delivered for patients able to be placed in the traditional supine position. For patients who are unable to be positioned supine, the telecommunicator and caller have no option except to continue attempts to position supine, which may result in delayed or no chest compressions being delivered prior to emergency medical services arrival. Any delay or lack of bystander chest compressions may result in worsening clinical outcomes of out-of-hospital cardiac arrest (OHCA) victims. We present the first two cases, to the best of our knowledge, of successfully delivered, bystander-administered, prone CPR instructions by a trained telecommunicator for two OHCA victims unable to be positioned supine.

9-1-1 Caller-Described Heart Attack Symptoms.

INTRODUCTION: Heart attacks (HAs) present clinically with varying symptoms, which are not always described by patients as chest pain (CP) or chest discomfort (CD). Emergency Medical Dispatchers (EMDs) select the CP/CD dispatch protocol for non-chest pain HA symptoms or classic HA complaint of CP/CD. Nevertheless, it is still unknown how often callers report HA symptoms other than CP/CD. OBJECTIVES: The objective of this study was to characterize the caller's descriptions of the primary HA symptoms, descriptions of the other HA symptoms, and the use of a case entry (CE) question clarifier. METHODS: A retrospective descriptive study analyzed randomly selected EMD audios (where CD/CD protocol was used) from five accredited emergency communication centers in the United States. Several Quality Performance Review (QPR) experts reviewed the audios and recorded callers' initial problem descriptions, the use of and responses to the CE question clarifier, including the EMD-assigned final determinant code. RESULTS: A total of 1,261 audios were reviewed. The clarifier was used only 8.5% of the time. The CP/CD symptoms were mentioned alone or with other problems 87.0% of the time. Overall, CP symptom was mentioned alone 70.8%, HA alone 4.0%, and CD symptom alone 1.4% of the time. CONCLUSION: 9-1-1 callers report potential HA cases using a variety of terms and descriptions-most commonly CP. Other less-common symptoms associated with a HA may be mentioned. Therefore, EMDs must be well-trained to be prepared to probe the caller with a clarifying query to elicit more specific information when "having a heart attack" is the only complaint initially mentioned.

The effect of blood transfusion on outcomes among African children admitted to hospital with Plasmodium falciparum malaria: a prospective, multicentre observational study.

BACKGROUND: Infection with Plasmodium falciparum leads to severe malaria and death in approximately 400 000 children each year in sub-Saharan Africa. Blood transfusion might benefit some patients with malaria but could potentially harm others. The aim of this study was to estimate the association between transfusion and death among children admitted to hospital with P falciparum malaria. METHODS: In this prospective, multicentre observational study, we analysed admissions to six tertiary care hospitals in The Gambia, Malawi, Gabon, Kenya, and Ghana that participated in the Severe Malaria in African Children network. Patients were enrolled if they were younger than 180 months and had a Giemsa-stained thick blood smear that was positive for P falciparum. Blood transfusion (whole blood at a target volume of 20 mL per kg) was administered at the discretion of the responsible physicians who were aware of local and international transfusion guidelines. The primary endpoint was death associated with transfusion, which was estimated using models adjusted for site and disease severity. We also aimed to identify factors associated with the decision to transfuse. The exploratory objective was to estimate optimal haemoglobin transfusion thresholds using generalised additive models. FINDINGS: Between Dec 19, 2000, and March 8, 2005, 26 106 patients were enrolled in the study, 25 893 of whom had their transfusion status recorded and were included in the primary analysis. 8513 (32·8%) patients received a blood transfusion. Patients were followed-up until discharge from hospital for a median of 2 days (IQR 1-4). 405 (4·8%) of 8513 patients who received a transfusion died compared with 689 (4·0%) of 17 380 patients who did not receive a transfusion. Transfusion was associated with decreased odds of death in site-adjusted analysis (odds ratio [OR] 0·82 [95% CI 0·71-0·94]) and after adjusting for the increased disease severity of patients who received a transfusion (0·50 [0·42-0·60]). Severe anaemia, elevated lactate concentration, respiratory distress, and parasite density were associated with greater odds of receiving a transfusion. Among all study participants, transfusion was associated with improved survival when the admission haemoglobin concentration was up to 77 g/L (95% CI 65-110). Among those with impaired consciousness (Blantyre Coma Score ≤4), transfusion was associated with improved survival at haemoglobin concentrations up to 105 g/L (95% CI 71-115). Among those with hyperlactataemia (blood lactate ≥5·0 mmol/L), transfusion was not significantly associated with harm at any haemoglobin concentration-ie, the OR of death comparing transfused versus not transfused was less than 1 at all haemoglobin concentrations (lower bound of the 95% CI for the haemoglobin concentration at which the OR of death equals 1: 90 g/L; no upper bound). INTERPRETATION: Our findings suggest that whole blood transfusion was associated with improved survival among children hospitalised with P falciparum malaria. Among those with impaired consciousness or hyperlactataemia, transfusion was associated with improved survival at haemoglobin concentrations above the currently recommended transfusion threshold. These findings highlight the need to do randomised controlled trials to test higher transfusion thresholds among African children with severe malaria complicated by these factors. FUNDING: US National Institute of Allergy and Infectious Diseases.

Ability of Layperson Callers to Apply a Tourniquet Following Protocol-Based Instructions From an Emergency Medical Dispatcher.

Introduction: One of the greatest casualty-care improvements resulting from US military operations in Iraq and Afghanistan has been the reduction of preventable death from massive extremity hemorrhage - largely due to the widespread use of limb tourniquets. More recently, tourniquet use in civilian, prehospital settings has shown promise in reducing deaths in cases of catastrophic arterial limb hemorrhage. Telephone instructions by trained emergency medical dispatchers (EMDs) on applying an available tourniquet may help achieve such a benefit.Objectives: The objective of the study was to determine whether layperson callers can effectively stop simulated bleeding using an improvised or a commercial tourniquet, when provided with scripted instructions via phone from a trained protocol-aided EMD.Methods: This was a prospective, randomized trial involving layperson volunteers, done at four locations in Salt Lake City, Utah, USA. Volunteers were assigned randomly to three groups: one for each of two commonly available commercial tourniquets and one for an improvised tourniquet.Results: A total of 246 subjects participated in the study at the four locations between February 11, 2019 and June 22, 2019. The overall median time for all trials (i.e., elapsed time from the start to the end of the simulation) was 3 minutes and 19 seconds. Median time to stop the bleeding (i.e., elapsed time from the start of the simulation to the time the participant was able to successfully stop the bleeding) was 2 minutes and 57 seconds. Median tourniquet pressure was 256 mmHg and median-end blood loss was 1,365 mL. A total of 198 participants (80.49%) were able to completely stop the bleeding while 16 participants (6.5%) had the tourniquet applied with some bleeding still occurring, and 32 participants (13.01%) exceeded the threshold of 2,500 mL of blood loss, resulting in the "patient" not surviving.Conclusions: The study findings demonstrated that untrained bystanders provided with instructions via phone from a trained Emergency Medical Dispatcher applied a tourniquet and successfully stopped the bleeding completely in most cases.

Availability and Use of an Automated External Defibrillator at Emergency Medical Dispatch.

Objective: The aim of this study was to determine the frequency of automatic external defibrillator (AED) retrieval and placement by bystander callers when prompted by an Emergency Medical Dispatcher (EMD). Methods: This retrospective descriptive study utilized a convenience sample of emergency dispatch data collected from 23 Emergency Communication Centers (ECCs) spanning 14 states across the United States (U.S.) from July 11, 2014 to August 13, 2018, including all cases in which the EMD recorded any response to the AED availability prompt. Data were collected using ProQA, the software version of the Medical Priority Dispatch System. Primary outcome measures were (a) distribution of responses to the AED prompt; (b) percentage of cases in which an AED was retrieved; and (c) percentage of cases in which AED pads were placed by the bystander-caller. Results: A total of 2,200,285 cases were collected during the study period, in 18,904 (0.86%) of which the AED prompt was displayed (indicating suspected out of hospital cardiac arrest, or OHCA). Overall, an AED was reported as available 5.8% (n = 1,091) of the time the EMD recorded an answer to the AED prompt. In multiple-rescuer situations, a rescuer was sent to get the AED 2.8% (n = 523) of the time, as opposed to only 0.30% (n = 56) for single-rescuer calls. The AED was reported to be already on scene, by the patient, in 2.7% (n = 512) of the cases. A majority (72.0%; n = 417) of the time, rescuers who were sent to get an AED were unable to retrieve it, with single rescuers being successful more often (57.1% unable to retrieve, vs 73.6% for multiple rescuers). Conclusions: AEDs are reported as available by only a small percentage of callers to 911, and in the majority of cases in which a bystander rescuer is sent to retrieve an AED, one is never located or used. Sending someone to retrieve the AED may be more appropriate in multiple-rescuer situations than when a single bystander rescuer is alone on scene.

Can a Software-Based Metronome Tool Enhance Compression Rate in a Realistic 911 Call Scenario Without Adversely Impacting Compression Depth for Dispatcher-Assisted CPR?

IntroductionImplementation of high-quality, dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is critical to improving survival from out-of-hospital cardiac arrest (OHCA). However, despite some studies demonstrating the use of a metronome in a stand-alone setting, no research has yet demonstrated the effectiveness of a metronome tool in improving DA-CPR in the context of a realistic 911 call or using instructions that have been tested in real-world emergency calls.HypothesisUse of the metronome tool will increase the proportion of callers able to perform CPR within the target rate without affecting depth. METHODS: The prospective, randomized, controlled study involved simulated 911 cardiac arrest calls made by layperson-callers and handled by certified emergency medical dispatchers (EMDs) at four locations in Salt Lake City, Utah USA. Participants were randomized into two groups. In the experimental group, layperson-callers received CPR pre-arrival instructions with metronome assistance. In the control group, layperson-callers received only pre-arrival instructions. The primary outcome measures were correct compression rate (counts per minute [cpm]) and depth (mm). RESULTS: A total of 148 layperson-callers (57.4% assigned to experimental group) participated in the study. There was a statistically significant association between the number of participants who achieved the target compression rate and experimental study group (P=.003), and the experimental group had a significantly higher median compression rate than the control group (100 cpm and 89 cpm, respectively; P=.013). Overall, there was no significant correlation between compression rate and depth. CONCLUSION: An automated software metronome tool is effective in getting layperson-callers to achieve the target compression rate and compression depth in a realistic DA-CPR scenario.Scott G, Barron T, Gardett I, Broadbent M, Downs H, Devey L, Hinterman EJ, Clawson J, Olola C. Can a software-based metronome tool enhance compression rate in a realistic 911 call scenario without adversely impacting compression depth for dispatcher-assisted CPR? Prehosp Disaster Med. 2018;33(4):399-405.

Hospital-Confirmed Acute Myocardial Infarction: Prehospital Identification Using the Medical Priority Dispatch System.

Introduction Early recognition of an acute myocardial infarction (AMI) can increase the patient's likelihood of survival. As the first point of contact for patients accessing medical care through emergency services, emergency medical dispatchers (EMDs) represent the earliest potential identification point for AMIs. The objective of the study was to determine how AMI cases were coded and prioritized at the dispatch point, and also to describe the distribution of these cases by patient age and gender. Hypothesis/Problem No studies currently exist that describe the EMD's ability to correctly triage AMIs into Advanced Life Support (ALS) response tiers. METHODS: The retrospective descriptive study utilized data from three sources: emergency medical dispatch, Emergency Medical Services (EMS), and emergency departments (EDs)/hospitals. The primary outcome measure was the distributions of AMI cases, as categorized by Chief Complaint Protocol, dispatch priority code and level, and patient age and gender. The EMS and ED/hospital data came from the Utah Department of Health (UDoH), Salt Lake City, Utah. Dispatch data came from two emergency communication centers covering the entirety of Salt Lake City and Salt Lake County, Utah. RESULTS: Overall, 89.9% of all the AMIs (n=606) were coded in one of the three highest dispatch priority levels, all of which call for ALS response (called CHARLIE, DELTA, and ECHO in the studied system). The percentage of AMIs significantly increased for patients aged 35 years and older, and varied significantly by gender, dispatch level, and chief complaint. A total of 85.7% of all deaths occurred among patients aged 55 years and older, and 88.9% of the deaths were handled in the ALS-recommended priority levels. CONCLUSION: Acute myocardial infarctions may present as a variety of clinical symptoms, and the study findings demonstrated that more than one-half were identified as having chief complaints of Chest Pain or Breathing Problems at the dispatch point, followed by Sick Person and Unconscious/Fainting. The 35-year age cutoff for assignment to higher priority levels is strongly supported. The Falls and Sick Person Protocols offer opportunities to capture atypical AMI presentations. Clawson JJ , Gardett I , Scott G , Fivaz C , Barron T , Broadbent M , Olola C . Hospital-confirmed acute myocardial infarction: prehospital identification using the Medical Priority Dispatch System. Prehosp Disaster Med. 2018;33(1):29-35.

9-1-1 Triage of Non-Traumatic Chest Pain: Association with Hospital Diagnosis.

OBJECTIVE: Chest pain is one of the most common reasons people seek emergency care-and one of the most critical. In the United States, chest pain is the second most common reason for emergency department (ED) visits. A patient's primary complaint of "chest pain" may reflect a broad range of underlying causes; therefore, it is important that emergency medical service (EMS) agencies gain a thorough understanding of these cases, beginning with the initial management of chest pain in the 9-1-1 center. The primary objective of this study was to compare hospital-confirmed patient discharge diagnoses to all calls handled by emergency medical dispatchers (EMDs) using the Chest Pain/Chest Discomfort (Non-Traumatic) Chief Complaint Protocol. METHODS: The retrospective descriptive study utilized emergency medical dispatch, EMS, and hospital datasets, collected at two emergency communication centers in North America, from January 1, 2013 to December 31, 2014. Patients who were dispatched using the Chest Pain/Chest Discomfort Chief Complaint Protocol and matched to hospital datasets were included. The primary outcome was the number and percentage of cases classified as ischemic heart disease (IHD), other cardiac-related conditions, or non-cardiac-related conditions associated with chest pain. We also evaluated the distribution of causes of chest pain across demographic indicators and dispatch determinants. RESULTS: 3,007 cases were identified as "chest pain" at dispatch for which corresponding hospital records were identified. Cases in the study were obtained by linking EMS/Hospital and Emergency Medical Dispatch datasets. Of these cases, 47.1% (n = 1,417) were due to cardiac-related causes of chest pain, 61.5% of which were Ischemic Heart Disease (IHD), while the rest had other cardiac-related causes. Of the IHDs, 32.1% were Acute Myocardial Infarction (AMI). CONCLUSIONS: Underlying causes of non-traumatic chest pain reported to 9-1-1 demonstrate a wide range of etiologies, with a mix similar to that of chest pain patients in several other healthcare settings, including hospital emergency departments. Most IHD events are triaged by EMDs to the (highest) DELTA priority level, while the CHARLIE level captures nearly all of the remaining IHD cases.

Predictive Ability of an Emergency Medical Dispatch Stroke Diagnostic Tool in Identifying Hospital-Confirmed Strokes.

BACKGROUND: Early hospital notification of a possible stroke arriving via emergency medical services (EMS) can prepare stroke center personnel for timely treatment, especially timely administration of tissue plasminogen activator. Stroke center notification from the emergency dispatch center-before responders reach the scene-may promote even earlier and faster system activation, meaning that stroke center teams may be ready to receive patients as soon as the ambulance arrives. This study evaluates the use of a Medical Priority Dispatch System (MPDS; Priority Dispatch Corp., Salt Lake City, UT) Stroke Diagnostic Tool (SDxT) to identify possible strokes early by comparing the tools' results to on-scene and hospital findings. METHODS: The retrospective descriptive study utilized stroke data from 3 sources: emergency medical dispatch, EMS, and emergency department/hospital. RESULTS: A total of 830 cases were collected between June 2012 and December 2013, of which 603 (72.7%) had matching dispatch records. Of the 603 cases, 304 (50.4%) were handled using MPDS Stroke Protocol 28. The SDxT had an 86.4% ability (OR [95% CI]: 2.3 [1.5, 3.5]) to effectively identify strokes among all the hospital-confirmed stroke cases (sensitivity), and a 26.6% ability to effectively identify nonstrokes among all the hospital-confirmed nonstroke cases (specificity). CONCLUSIONS: The SDxT demonstrated a very high sensitivity, compared to similar tools used in the field and at dispatch. The specificity was somewhat low, but this was expected-and is intended in the creation of protocols to be used over the phone in emergency situations. The tool is a valuable method for identifying strokes early and may allow early hospital notification.

Using On-scene EMS Responders' Assessment and Electronic Patient Care Records to Evaluate the Suitability of EMD-triaged, Low-acuity Calls for Secondary Nurse Triage in 911 Centers.

INTRODUCTION: Using the Medical Priority Dispatch System (MPDS) - a systematic 911 triage process - to identify a large subset of low-acuity patients for secondary nurse triage in the 911 center is a largely unstudied practice in North America. This study examines the ALPHA-level subset of low-acuity patients in the MPDS to determine the suitability of these patients for secondary triage by evaluating vital signs and necessity of lights-and-siren transport, as determined by attending Emergency Medical Services (EMS) ambulance crews. OBJECTIVES: The primary objective of this study was to determine the clinical status of MPDS ALPHA-level (low-acuity) patients, as determined by on-scene EMS crews' patient care records, in two US agencies. A secondary objective was to determine which ALPHA-level codes are suitable candidates for secondary triage by a trained Emergency Communication Nurse (ECN). METHODS: In this retrospective study, one full year (2013) of both dispatch data and EMS patient records data, associated with all calls coded at the ALPHA-level (low-acuity) in the dispatch protocol, were collected. The primary outcome measure was the number and percentage of ALPHA-level codes categorized as low-acuity, moderate-acuity, high-acuity, and critical using four common vital signs to assign these categories: systolic blood pressure (SBP), pulse rate (PR), oxygen saturation (SpO2), and Glasgow Coma Score (GCS). Vital sign data were obtained from ambulance crew electronic patient care records (ePCRs). The secondary endpoint was the number and percentage of ALPHA-level codes that received a "hot" (lights-and-siren) transport. RESULTS: Out of 19,300 cases, 16,763 (86.9%) were included in the final analysis, after excluding cases from health care providers and those with missing data. Of those, 89% of all cases did not have even one vital sign indicator of unstable patient status (high or critical vital sign). Of all cases, only 1.1% were transported lights-and-siren. CONCLUSION: With the exception of the low-acuity, ALPHA-level seizure cases, the ALPHA-level patients are suitable to transfer for secondary triage in a best-practices, accredited, emergency medical dispatch center that utilizes the MPDS at very high compliance rates. The secondary nurse triage process should identify the few at-risk patients that exist in the low-acuity calls.

Outcome accuracy of the Emergency Medical Dispatcher's initial selection of a diabetic problems protocol.

INTRODUCTION: Diabetes mellitus, although a chronic disease, also can cause acute, sudden symptoms requiring emergency intervention. In these cases, Emergency Medical Dispatchers (EMDs) must identify true diabetic complaints in order to determine the correct care. In 911 systems utilizing the Medical Priority Dispatch System (MPDS), International Academies of Emergency Dispatch-certified EMDs determine a patient's chief complaint by matching the caller's response to an initial pre-scripted question to one of 37 possible chief complaints protocols. The ability of EMDs to identify true diabetic-triggered events reported through 911 has not been studied. OBJECTIVE: The primary objective of this study was to determine the percentage of EMD-recorded patient cases (using the Diabetic Problems protocol in the MPDS) that were confirmed by either attending paramedics or the hospital as experiencing a diabetic-triggered event. METHODS: This was a retrospective study involving six hospitals, one fire department, and one ambulance service in Salt Lake City, Utah USA. Dispatch data for one year recorded under the Diabetic Problems protocol, along with the associated paramedic and hospital outcome data, were reviewed/analyzed. The outcome measures were: the percentage of cases that had diabetic history, percentage of EMD-identified diabetic problems cases that were confirmed by Emergency Medical Services (EMS) and/or hospital records as true diabetic-triggered events, and percentage of EMD-identified diabetic patients who also had other medical conditions. A diabetic-triggered event was defined as one in which the patient's emergency was directly caused by diabetes or its medical management. Descriptive statistics were used for categorical measures and parametric statistical methods assessed the differences between study groups, for continuous measures. RESULTS: Three-hundred ninety-three patient cases were assigned to the Diabetic Problems Chief Complaint protocol. Of the 367 (93.4%) patients who had a documented history of diabetes, 279 (76%) were determined to have had a diabetic-triggered event. However, only 12 (3.6%) initially assigned to this protocol did not have a confirmed history of diabetes. CONCLUSIONS: Using the MPDS to select the Diabetic Problems Chief Complaint protocol, the EMDs correctly identified a true diabetic-triggered event the majority of the time. However, many patients had other medical conditions, which complicated the initial classification of true diabetic-triggered events. Future studies should examine the associations between the five specific Diabetic Problems Chief Complaint protocol determinant codes (triage priority levels) and severity measures, eg, blood sugar level and Glasgow Coma Score.

Aspirin administration by emergency medical dispatchers using a protocol-driven aspirin diagnostic and instruction tool.

BACKGROUND: The American College of Cardiology and the American Heart Association recommend early aspirin administration to patients with symptoms of acute coronary syndrome (ACS)/acute myocardial infarction (AMI). The primary objective of this study was to determine if Emergency Medical Dispatchers (EMD) can provide chest pain/heart attack patients with standardised instructions effectively, using an aspirin diagnostic and instruction tool (ADxT) within the Medical Priority Dispatch System (MPDS) before arrival of an emergency response crew. METHODS: This retrospective study involved three dispatch centres in the UK and USA. We analysed 6 months of data involving chest pain/heart attack symptoms taken using the MPDS chest pain and heart problems/automated internal cardiac defibrillator protocols. RESULTS: The EMDs successfully completed the ADxT on 69.8% of the 44141 cases analysed. The patient's mean age was higher when the ADxT was completed, than when it was not (mean ± SD: 53.9 ± 19.9 and 49.9 ± 20.2; p<0.001, respectively). The ADxT completion rate was higher for second-party than first-party calls (70.3% and 69.0%; p=0.024, respectively). A higher percentage of male than female patients took aspirin (91.3% and 88.9%; p=0.001, respectively). Patients who took aspirin were significantly younger than those who did not (mean ± SD: 61.8 ± 17.5 and 64.7 ± 17.9, respectively). Unavailability of aspirin was the major reason (44.4%) why eligible patients did not take aspirin when advised. CONCLUSIONS: EMDs, using a standardised protocol, can enable early aspirin therapy to treat potential ACS/AMI prior to responders' arrival. Further research is required to assess reasons for not using the protocol, and the significance of the various associations discovered.

The accuracy of emergency medical dispatcher-assisted layperson-caller pulse check using the medical priority dispatch system protocol.

INTRODUCTION: Knowing the pulse rate of a patient in a medical emergency can help to determine patient acuity and the level of medical care required. Little evidence exists regarding the ability of a 911 layperson-caller to accurately determine a conscious patient's pulse rate. Hypothesis The hypothesis of this study was that, when instructed by a trained emergency medical dispatcher (EMD) using the scripted Medical Priority Dispatch System (MPDS) protocol Pulse Check Diagnostic Tool (PCDxT), a layperson-caller can detect a carotid pulse and accurately determine the pulse rate in a conscious person. METHODS: This non-randomized and non-controlled prospective study was conducted at three different public locations in the state of Utah (USA). A healthy, mock patient's pulse rate was obtained using an electrocardiogram (ECG) monitor. Layperson-callers, in turn, initiated a simulated 911 phone call to an EMD call-taker who provided instructions for determining the pulse rate of the patient. Layperson accuracy was assessed using correlations between the layperson-caller's finding and the ECG reading. RESULTS: Two hundred sixty-eight layperson-callers participated; 248 (92.5%) found the pulse of the mock patient. There was a high correlation between pulse rates obtained using the ECG monitor and those found by the layperson-callers, overall (94.6%, P < .001), and by site, gender, and age. CONCLUSIONS: Layperson-callers, when provided with expert, scripted instructions by a trained 911 dispatcher over the phone, can accurately determine the pulse rate of a conscious and healthy person. Improvements to the 911 instructions may further increase layperson accuracy.

Medical Priority Dispatch System breathing problems protocol key question combinations are associated with patient acuity.

INTRODUCTION: The Breathing Problems Chief Complaint (CC) protocol in the Medical Priority Dispatch System (MPDS) was the system's most frequently used protocol. While "severe breathing problems" is a significant predictor of cardiac arrest (CA), previous data have demonstrated that the DELTA-level determinant codes in this CC contain patients across a wide spectrum of acuity. HYPOTHESIS: The hypothesis in this study was that certain combinations of caller answers to the breathing problems protocol key questions (KQs) are correlated with different but specific patient acuities. METHODS: This was a retrospective study conducted at one International Academies of Emergency Dispatch (IAED) Accredited Center of Excellence. Key Question combinations were generated and analyzed from 11 months of dispatch data, and extracted from MPDS software and the computer assisted dispatch system. Descriptive statistics were used to evaluate measures between study groups. RESULTS: Forty-two thousand cases were recorded; 52% of patients were female and the median age was 61 years. Overall, based on the original MPDS Protocol (before generating KQ combinations), patients with abnormal breathing and clammy conditions were the youngest. The MPDS DELTA-level constituted the highest percentage of cases (74.0%) and the difficulty speaking between breaths (DSBB) condition was the most prevalent (50.3%). Ineffective breathing and not alert conditions had the highest cardiac arrest quotient (CAQ). Based on the KQ combinations, the CA patients who also had the not alert condition were significantly older than other patients. The percentage of CA outcomes in asthmatic patients was significantly higher in DSBB plus not alert; DSBB plus not alert plus changing color; and DSBB plus not alert plus clammy conditions cases, compared to asthmatic abnormal breathing cases. CONCLUSIONS: The study findings demonstrated that MPDS KQ answer combinations relate to patient acuity. Cardiac arrest patients are significantly less likely to be asthmatic than those without CA, and vice versa. Using a prioritization scheme that accounts for the presence of either single or multiple signs and/or symptom combinations for the Breathing Problems CC protocol would be a more accurate method of assigning DELTA-level cases in the MPDS.

The perception of medical professionals and medical students on the usefulness of an emergency medical card and a continuity of care report in enhancing continuity of care.

OBJECTIVES: To evaluate the medical professionals and medical students perceived usefulness of an emergency medical card (EMC) and a continuity of care (CoC) report, in enhancing CoC. METHODS: The study reviewers included medical professionals from outpatient clinics at Intermountain Healthcare and fourth-year medical students from the University of Utah. Three cases we randomly extracted from a database of patients who had added new care information at the time. EMCs and CoC reports were populated for the cases, and information then de-identified. Using patient information in the electronic medical record (EMR), reviewers evaluated if the EMR information was adequate to support medical decisions made on the patient's diagnosis, medications, laboratory tests, and disposition. The reviewer assessed if the EMC and CoC report information would influence the medical decisions made. An online survey was used to assess the reviewers' perception on the usefulness of the two documents. RESULTS: On average, 94% of the reviewers perceived the EMC to be useful in enhancing medical decision making at the point of care, and 74% found the CoC report to be useful. More specifically, the two documents were found to be useful in decreasing encounter time (100% each), increasing overall knowledge of healthcare providers (100% each), influencing decision on the treatment (94% each), and new laboratory test orders (87% and 90%, respectively). CONCLUSIONS: The EMC and CoC report were found to be useful methods for transporting patient healthcare information across the healthcare continuum. The documents were found more specifically to be useful for effective decision making, improving efficiency and quality of care, at the point of care.

Pentoxifylline as an adjunct therapy in children with cerebral malaria.

BACKGROUND: Pentoxifylline (PTX) affects many processes that may contribute to the pathogenesis of severe malaria and it has been shown to reduce the duration of coma in children with cerebral malaria. This pilot study was performed to assess pharmacokinetics, safety and efficacy of PTX in African children with cerebral malaria. METHODS: Ten children admitted to the high dependency unit of the Kilifi District Hospital in Kenya with cerebral malaria (Blantyre coma score of 2 or less) received quinine plus a continuous infusion of 10 mg/kg/24 hours PTX for 72 hours. Five children were recruited as controls and received normal saline instead of PTX. Plasma samples were taken for PTX and tumour necrosis factor (TNF) levels. Blantyre Coma Score, parasitemia, hematology and vital signs were assessed 4 hourly. RESULTS: One child (20%) in the control group died, compared to four children (40%) in the PTX group. This difference was not significant (p = 0.60). Laboratory parameters and clinical data were comparable between groups. TNF levels were lower in children receiving PTX. CONCLUSIONS: The small sample size does not permit definitive conclusions, but the mortality rate was unexpectedly high in the PTX group.

Association between patient unconscious or not alert conditions and cardiac arrest or high-acuity outcomes within the Medical Priority Dispatch System "Falls" protocol.

INTRODUCTION: Falls are one of the most common types of complaints received by 9-1-1 emergency medical dispatch centers. They can be accidental or may be caused by underlying medical problems. Though "not alert" falls patients with severe outcomes mostly are "hot" transported to the hospital, some of these cases may be due to other acute medical events (cardiac, respiratory, circulatory, or neurological), which may not always be apparent to the emergency medical dispatcher (EMD) during call processing. OBJECTIVES: The objective of this study was to characterize the risk of cardiac arrest and "hot-transport" outcomes in patients with "not alert" condition, within the Medical Priority Dispatch System (MPDS®) Falls protocol descriptors. METHODS: This retrospective study used 129 months of de-identified, aggregate, dispatch datasets from three US emergency communication centers. The communication centers used the Medical Priority Dispatch System version 11.3-OMEGA type (released in 2006) to interrogate Emergency Medical System callers, select dispatch codes assigned to various response configurations, and provide pre-arrival instructions. The distribution of cases and percentages of cardiac arrest and hot-transport outcomes, categorized by MPDS® code, was profiled. Assessment of the association between MPDS® Delta-level 3 (D-3) "not alert" condition and cardiac arrest and hot-transport outcomes then followed. RESULTS: Overall, patients within the D-3 and D-2 "long fall" conditions had the highest proportions (compared to the other determinants in the "falls" protocol) of cardiac arrest and hot-transport outcomes, respectively. "Not alert" condition was associated significantly with cardiac arrest and hot-transport outcomes (p<0.001). CONCLUSIONS: The "not alert" determinant within the MPDS® "fall" protocol was associated significantly with severe outcomes for short falls (<6 feet; 2 meters) and ground-level falls. As reported to 9-1-1, the complaint of a "fall" may include the presence of underlying conditions that go beyond the obvious traumatic injuries caused by the fall itself.