Andrew C. Stevens

Effect of introducing the mucosal atomization device for fentanyl use in out-of-hospital pediatric trauma patients.

BACKGROUND Pain associated with pediatric trauma is often under-assessed and under-treated in the out-of-hospital setting. Administering an opioid such as fentanyl via the intranasal route is a safe and efficacious alternative to traditional routes of analgesic delivery and could potentially improve pain management in pediatric trauma patients. OBJECTIVE The study sought to examine the effect of introducing the mucosal atomization device (MAD) on analgesia administration as an alternative to intravenous fentanyl delivery in pediatric trauma patients. The hypothesis for the study is that the introduction of the MAD would increase the administration of fentanyl in pediatric trauma patients. METHODS The research utilized a 2-group design (pre-MAD and post-MAD) to study 946 pediatric trauma patients (age <16) transported by a large, urban EMS agency to one of eight hospitals in Marion County, which is located in Indianapolis Indiana. Two emergency medicine physicians independently determined whether the patient met criteria for pain medication receipt and a third reviewer resolved any disagreements. A comparison of the rates of fentanyl administration in both groups was then conducted. RESULTS There was no statistically significant difference in the rate of fentanyl administration between the pre-MAD (30.4%) and post-MAD groups (37.8%) (P = .238). A subgroup analysis showed that age and mechanism of injury were stronger predictors of fentanyl administration. CONCLUSION Contrary to the hypothesis, the addition of the MAD device did not increase fentanyl administration rates in pediatric trauma patients. Future research is needed to address the barriers to analgesia administration in pediatric trauma patients.

Pharmacist Involvement in a Community Paramedicine Team

Background: Hospital readmissions have recently gained scrutiny by health systems as a result of their high costs of care and potential for financial penalty in hospital reimbursement. Mobile-integrated health and community paramedicine (MIH-CP) programs have expanded to serve patients at high risk of hospital readmission. Pharmacists have also improved clinical outcomes for patients during in-home visits. However, pharmacists working with a MIH-CP program have not been previously described. This project utilized a novel multidisciplinary Community Paramedicine Team (CPT) consisting of a pharmacist, paramedic, and social worker to target patients with heart failure at high risk of readmission to assist with coordination of care and education. Objectives: This article describes the development of the CPT, delineation of CPT member responsibilities, and outcomes from pilot visits. Methods: The CPT visited eligible patients in their homes to provide services. Patients with heart failure who were readmitted within 30 days were eligible for a home visit. Results: A total of 6 patients were seen during the pilot, and 2 additional patients were seen after the pilot. Conclusion: Imbedding a pharmacist into a CPT provides a unique expansion of pharmacy services and a novel approach to address hospital readmissions.

Board 259 Program Innovations Abstract A Novel Simulation Program to Train Paramedic Students in Safe EMS Patient Handoff (Submission #411)

Introduction/Background Emergency medical services (EMS) patient handoffs are a critical step in patient care and safety. Approximately 28 million such handoffs occur every year in the United States.1 Despite the importance of safe handoff to patient care, very little exists in formally accredited EMS or paramedic science education regarding the appropriate information to convey to hospital based patient care teams. While the effective use of simulation in paramedic education has been previously described,2,3 the essential step of patient handoff has been largely ignored. We developed and successfully implemented an interprofessional simulation program focused on safe patient handoff. Methods A focus group of emergency medicine faculty, nursing faculty and paramedic science educators came together to develop a program for teaching paramedic science students safe and effective handoffs. The selected educational tool for patient handoff was previously validated and contains the following information: Identification, Mechanism/medical complaint, Injuries/information relative to complaint, Signs/vitals including GCS, Treatment and trends, Allergies, Medications, Background history, and Other (IMIST-AMBO).4 Paramedic students received a didactic session on IMIST-AMBO and were then brought to the simulation center to practice communication and other patient management skills. The simulation began in the center’s Transport Room, featuring a decommissioned ambulance with a manikin representing a patient who had been in a high speed motor vehicle collision. After receiving initial “on scene” information from a confederate first-responder, teams of two paramedic students assumed care of the manikin for a 10 minute transport period. Upon arrival at the hospital, the students had to successfully unload the patient and transport him down the hall to a simulated emergency department room. Emergency medicine residents and nursing students, who until that point were blind to the use of paramedic students, were waiting in the room. The paramedic students transferred care to the team, communicating what they believed was pertinent information. The remainder of the case was completed with paramedic students providing additional assistance to the emergency department team. Following each case a structured debrief session was conducted featuring all members of the patient care team. The debriefing focused on communication issues as part of the patient handoff. All participants completed pre-session and post-session surveys regarding attitudes toward interprofessional communication and overall satisfaction with the simulation. Results: Conclusion A total of 12 paramedic students, 19 emergency medicine residents and 16 nursing students participated in the simulation. In the post-session survey, 44/47 participants (93.6%) agreed or strongly agreed that the in room experience was valuable for preparing them to work with other healthcare providers and 43/47 participants (91.5%) agreed or strongly agreed that the debriefing was valuable. Importantly, 44/47 participants (93.6%) agreed or strongly agreed that the experience enhanced their understanding of the importance of “clear, concise, and respectful” communication during paramedic-physician handoffs. Amongst the primary target audience of paramedic students, 100% agreed or strongly agreed with that statement. In open-ended feedback, paramedic students described the experience as “very beneficial” and noted that it seemed realistic. This model demonstrates an effective educational method for teaching safe patient handoff. Further studies more accurately quantifying the educational benefit will likely follow and have the potential to impact paramedic science education at other institutions. With the clear importance of safe and effective handoff in overall patient care, this could benefit our patients. Furthermore, safe patient transitions are not limited to paramedic-physician handoff in the emergency department and this simulation-based educational model could be easily adapted to provide training for multiple healthcare providers. References 1. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment. U.S. Department of Transportation, National Highway Traffic Safety Administration, DOT HS ### ###, Washington, DC, 2012. Available at www.ems.go. 2. Boyle et al. “Contemporary simulation education for undergraduate paramedic students” Emerg Med J. 2007 Dec;24(12):854-7. 3. Leikin et al. “Simulation applications in emergency medical services” Dis Mon. 2011 Nov;57(11):723-33. 4. Ledema et al. “Design and trial of a new ambulance-to-emergency department handover protocol: ’IMIST-AMBO’.” BMJ Qual Saf. 2012 Aug;21(8):627-33. Disclosures None.