Expert verification of the knowledge base of FEED--a feedback expert system for EMS documentation.

Feedback Expert System for Emergency Medical Services (EMS) Documentation (FEED) has a rule-based knowledge base (KB) that was verified against specifications in a focus group consisting of six experts. The focus group suggested changes in almost all rules discussed, indicating that the KB did not meet specifications at that stage of development. However, enough information was gathered to address these issues in the next iteration of development.

Instructions to "push as hard as you can" improve average chest compression depth in dispatcher-assisted cardiopulmonary resuscitation.

BACKGROUND AND OBJECTIVE: Cardiopulmonary resuscitation (CPR) with adequate chest compression depth appears to improve first shock success in cardiac arrest. We evaluate the effect of simplification of chest compression instructions on compression depth in dispatcher-assisted CPR protocol. METHODS: Data from two randomized, double-blinded, controlled trials with identical methodology were combined to obtain 332 records for this analysis. Subjects were randomized to either modified Medical Priority Dispatch System (MPDS) v11.2 protocol or a new simplified protocol. The main difference between the protocols was the instruction to "push as hard as you can" in the simplified protocol, compared to "push down firmly 2in. (5cm)" in MPDS. Data were recorded via a Laerdal ResusciAnne SkillReporter manikin. Primary outcome measures included: chest compression depth, proportion of compressions without error, with adequate depth and with total release. RESULTS: Instructions to "push as hard as you can", compared to "push down firmly 2in. (5cm)", resulted in improved chest compression depth (36.4 mm vs. 29.7 mm, p<0.0001), and improved median proportion of chest compressions done to the correct depth (32% vs. <1%, p<0.0001). No significant difference in median proportion of compressions with total release (100% for both) and average compression rate (99.7 min(-1) vs. 97.5 min(-1), p<0.56) was found. CONCLUSIONS: Modifying dispatcher-assisted CPR instructions by changing "push down firmly 2in. (5cm)" to "push as hard as you can" achieved improvement in chest compression depth at no cost to total release or average chest compression rate.

Instructions to "put the phone down" do not improve the quality of bystander initiated dispatcher-assisted cardiopulmonary resuscitation.

OBJECTIVE: The quality of early bystander CPR appears important in maximizing survival. This trial tests whether explicit instructions to "put the phone down" improve the quality of bystander initiated dispatch-assisted CPR. METHODS: In a randomized, double-blinded, controlled trial, subjects were randomized to a modified version of the Medical Priority Dispatch System (MPDS) version 11.2 protocol or a simplified protocol, each with or without instruction to "put the phone down" during CPR. Data were recorded from a Laerdal Resusci Anne Skillreporter manikin. A simulated emergency medical dispatcher, contacted by cell phone, delivered standardized instructions. Primary outcome measures included chest compression rate, depth, and the proportion of compressions without error, with correct hand position, adequate depth, and total release. Time was measured in two distinct ways: time required for initiation of CPR and total amount of time hands were off the chest during CPR. Proportions were analyzed by Wilcoxon rank sum tests and time variables with ANOVA. All tests used a two-sided alpha-level of 0.05. RESULTS: Two hundred and fifteen subjects were randomized-107 in the "put the phone down" instruction group and 108 in the group without "put the phone down" instructions. The groups were comparable across demographic and experiential variables. The additional instruction to "put the phone down" had no effect on the proportion of compressions administered without error, with the correct depth, and with the correct hand position. Likewise, "put the phone down" did not affect the average compression depth, the average compression rate, the total hands-off-chest time, or the time to initiate chest compressions. A statistically significant, yet trivial, effect was found in the proportion of compressions with total release of the chest wall. CONCLUSIONS: Instructions to "put the phone down" had no effect on the quality of bystander initiated dispatcher-assisted CPR in this trial.

Expert validation of the knowledge base for E-CAD - a pre-hospital dispatch triage decision support system.

The knowledge base (KB) for E-CAD (Enhanced Computer-Aided Dispatch), a triage decision support system for Emergency Medical Dispatch (EMD) of medical resources in trauma cases, is being evaluated. We aim to achieve expert consensus for validation and refinement of the E-CAD KB using the modified Delphi technique. Evidence-based, expert-validated and refined KB will provide improved EMD practice guidelines and may facilitate acceptance of the E-CAD by state-wide professionals.

Information needs of pre-hospital care providers - a requirements analysis.

To assess information needs of Emergency Medical Services (EMS) personnel and the potential of electronic decision support tools, we surveyed 39 paramedic students and practicing EMS personnel. We found frequent use of paper-based tools, with imperfect accessibility and ease of use. Potential electronic decision support tools were rated as helpful, but some alerts were rated low. The results may be helpful in design, implementation and research of electronic decision support tools for EMS.

Relationship between knowledge of cardiopulmonary resuscitation guidelines and performance.

OBJECTIVE: Despite widespread training with CPR guidelines, CPR is often poorly performed. We explore relationships between knowledge of CPR guidelines and performance (compression rate, compression depth, compression to ventilation ratio, and ventilation volume). METHODS: Sixty professional EMTs were sampled at 26 randomly ordered EMS response stations from an urban system of 31 stations. A recording manikin and video model were used to assess performance in a standardized scenario, and a survey was used to assess guideline knowledge. Survey and performance outcomes were categorized prospectively as correct or incorrect based on the International CPR Guidelines from 2000. Relationships were modeled with logistic regression. Covariates included years of work experience, frequency of CPR performance, and ALS versus BLS EMT level. RESULTS: Compression rate was between 80 and 120 min(-1) in 56% (33/59) of trials. Compression depth was 1.5-2 in. in 39% (23/59), compression to ventilation ratio approximated to 15:2 in 42% (25/59), and ventilation volume was 800-1,200 cm(3) in 13% (8/60). Accurate knowledge of the CPR guidelines was associated with better performance of chest compression rate and compression to ventilation ratio. Adjusted OR (95% CI) were 4.6 (1.2-18.1) for compression rate, 1.7 (0.4-6.5) for compression depth, 4.5 (1.1-18.5) for compression to ventilation ratio, and 9.0 (0.2-351) for ventilation volume. CONCLUSIONS: Although accurate knowledge of guidelines is associated with increased odds of correct performance of some aspects of CPR, overall performance remains poor.

A regional database of antidote availability.

Timely pre-hospital management of snake bite and poisoning cases is hindered by the lack of information about availability of antidotes in hospitals. We aim to build a regional antidote database by collecting real-time antidote stock information from hospital pharmacy inventory systems and make this information available to the emergency medical technicians (EMTs). This would save valuable time, leading to improved outcomes for the patients.

Development and testing of an algorithm for efficient resource positioning in pre-hospital emergency care.

Response times for pre-hospital emergency care may be improved with the use of algorithms that analyzes historical patterns in incident location and suggests optimal places for pre-positioning of emergency response units. We will develop such an algorithm based on cluster analysis and test whether it leads to significant improvement in mileage when compared to actual historical data of dispatching based on fixed stations.

A study design for comparing electronic patient care report (ePCR) with paper PCR in pre-hospital care.

Data gathering processes in pre-hospital care have been poorly studied. This study aims to compare an electronic PCR with the current paper standard. EMTs will hear a case narrative and enter this information in paper PCR, ePCR or ePCR pre-filled with historical patient data pulled from a database. Time taken, accuracy and completeness will be measured for each encounter. This study will provide better insight into data entry at the point of care.

Erythema annulare centrifugum with autoimmune hepatitis.

Erythema annulare centrifugum (EAC) is a rare disease entity characterized by dense perivascular lymphocytic infiltrates in dermis. It has been associated with a few conditions, though its etiology is largely unknown. To our knowledge there has been no reported association with autoimmune hepatitis described earlier. This child also was positive for hepatitis C virus antibodies, though HCV RNA was negative. We should keep in mind the false positivity of hepatitis C antibodies before deciding on its therapy.