Antonio R. Fernandez

Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This Part describes the process of creating the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), informed by the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) publication.1,2 The process for the 2015 International Liaison Committee on Resuscitation (ILCOR) systematic review is quite different when compared with the process used in 2010.1–3 For the 2015 systematic review process, ILCOR used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) (www.gradeworkinggroup.org) approach to systematic reviews and guideline development. For the development of this 2015 Guidelines Update, the AHA used the ILCOR reviews as well as the AHA definition of Classes of Recommendation (COR) and Levels of Evidence (LOE) (Table 1). This Part summarizes the application of the ILCOR GRADE process to inform the creation of 2015 Guidelines Update, and the process of assigning the AHA COR and LOE. View this table: Table 1. Applying Class of Recommendations and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* ### Grading of Recommendations Assessment, Development, and Evaluation The 2015 CoSTR summarizes the published scientific evidence that was identified to answer specific resuscitation questions. ILCOR uses the GRADE system to summarize evidence and determine confidence in estimates of effect as well as to formulate treatment recommendations. GRADE is a consensus-crafted tool in wide use by many professional societies and reference organizations, including the American College of Physicians, the American Thoracic Society, and the Cochrane Collaboration, as well as the Centers for Disease Control and the World Health Organization. The choice of the GRADE approach was based on its increasingly ubiquitous use, practicality, and unique features. To our knowledge, the ILCOR evidence review process represents the largest application of the GRADE system in a healthcare-related review. GRADE is a system to review evidence to determine …

The Association Between Emergency Medical Services Field Performance Assessed by High‐fidelity Simulation and the Cognitive Knowledge of Practicing Paramedics

OBJECTIVES The objective of this study was to assess the association between the performance of practicing paramedics on a validated cognitive exam and their field performance, assessed on a simulated emergency medical services (EMS) response. METHODS This was an observational study of paramedics from a single-tiered, urban, advanced life support EMS agency. A high-fidelity simulated response to a medical emergency on environmentally realistic sound stages, and the cognitive portion of the national paramedic certification exam, were each assessed as pass or fail. Participants were randomly assigned to one of six simulations designed by the agencys educational staff, medical director, and representatives from the National Registry of EMTs to be equivalently difficult. Simulations were pilot tested to assess content and face validity. Each participant was classified as failing a simulation scenario if his or her score was one standard deviation (SD) below the population mean. RESULTS There were 107 paramedics who participated in the study. Participants reported a median of 7.7 years of service (interquartile range [IQR] = 4.1 to 12.8 years). Simulation scores were normally distributed. Ninety-two (86.0%) participants received a passing score for the simulation and 77 (72.0%) passed the cognitive exam. There were 70 (65.4%) individuals who passed both the simulation and the cognitive exam, eight (7.5%) who failed both the simulation and the cognitive exam, 22 (20.6%) who passed the simulation but failed the cognitive exam, and seven (6.5%) who failed the simulation but passed the cognitive exam. There was a significant association between passing the cognitive exam and passing the simulation (chi-square p-value = 0.02). CONCLUSIONS This study simultaneously assessed cognitive knowledge and simulated field performance. Utilization of these measurement techniques allowed for the assessment and comparison of field performance and cognitive knowledge. Results demonstrated an association between a practicing paramedics performance on a cognitive examination and field performance, assessed by a simulated EMS response.

Evaluation of occupational injuries in an urban emergency medical services system before and after implementation of electrically powered stretchers.

Musculoskeletal injuries are frequently reported among Emergency Medical Services (EMS) professionals. The objective of this study was to evaluate occupational injuries in an urban EMS system before and after implementation of hydraulic stretchers. Data for this analysis were obtained from Austin Travis County EMS (A/TCEMS). In December 2006, A/TCEMS placed into service electrically powered patient stretchers. The pre-intervention period was between 01/01/1999 and 12/31/2006, and the post-intervention period was between 01/01/2007 and 4/30/2008. Incidence rate calculations were performed for four injury sub-groups and rate ratios (RRs) and corresponding 95% confidence interval (CI) were presented. There were 2087 and 706 person-years of observation pre- and post-intervention, respectively. The incidence rates for overall injury pre-intervention and post-intervention were 61.1 and 28.8 per 100 FTE, with a corresponding RR of 0.47 (95% CI 0.41-0.55) indicating a significant decrease in the rate of injury. The subcategory of stretcher-related injuries had the lowest RR (0.30; 95% CI 0.17-0.52) when comparing pre- and post-intervention time periods.

Estimating the Probability of Passing the National Paramedic Certification Examination

OBJECTIVES It is hypothesized that student and program characteristics will influence the probability of passing the national paramedic certification exam. The objective of this study was to utilize student and program characteristics to build a statistical model to determine the probability of success on the cognitive portion of the national paramedic certification exam. METHODS The study population for this analysis consisted of graduates attempting the National Registry of Emergency Medical Technicians (NREMT) paramedic written examination from January 1, 2002, through December 31, 2002. To be included in this analysis, graduates must have been first-time testers and have completed a survey attached to the exam. Independent variables analyzed reflected program and student characteristics derived from the survey questions and the NREMT application. A multivariable logistic regression model was fit to the outcome (pass/fail) of the examination. RESULTS Complete demographic and survey data were available for 5,208 (86.8%) individuals. The final multivariable logistic regression model included nine independent variables. There were two programmatic characteristics (national accreditation and instructor qualification), six student characteristics (high school class rank, years of education, required for employment, age, race, and gender), and one graduate characteristic (elapsed time since course completion) that had a significant effect on the probability of passing the examination. CONCLUSIONS National program accreditation, lead instructor qualifications, student educational background, and student demographics are all significantly associated with the probability of success on the national paramedic certification examination. This model can be used by program directors, paramedic program instructors, and prospective paramedic students to maximize the probability of attaining national paramedic certification.

The Association between Patients’ Perception of Their Overall Quality of Care and Their Perception of Pain Management in the Prehospital Setting

Abstract Objective. Our objective was to determine whether there is an association between a patients impression of his or her overall quality of care and his or her satisfaction with the pain management provided. We hypothesized that satisfaction with pain management would show a significant positive association with a patients impression of overall quality of care. Methods. This was a retrospective review of patient satisfaction data initially collected by a third-party company from January 1, 2007, to September 1, 2010. Participants were randomly selected from all transported patients, proportional to their paramedic-defined acuity level, with a goal of 100 interviews per month. The proportions of patients sampled from each acuity level were 25% priority 1 (high), 50% priority 2 (medium), and 25% priority 3 (low). Patients were excluded if there was no telephone number recorded in the prehospital patient record, no transportation was recorded, or the call was labeled as a psychiatric complaint. All satisfaction questions used a five-point Likert scale with ratings from excellent to poor, which were dichotomized for analysis. The outcome variable was the patients perception of his or her overall quality of care. The main independent variable was the patients rating of his or her pain management by emergency medical services (EMS) staff at the scene. Demographic variables were assessed for potential confounding. Results. There were 2,741 patients with complete data for the outcome and main independent variables; 41.7% of the respondents were male and the average age was 54.1 years (standard deviation = 22.6). The overall quality of care was rated as excellent by 65.9% of the patients, whereas 59.2% rated their pain management as excellent. Of the patients who rated their pain management as excellent, 79.0% rated the overall quality of care as excellent, whereas only 21.0% of the patients rated the overall quality of care as excellent if pain management was not excellent. When the patients rated EMS staff as excellent for both helping to control or reduce pain and explaining the medications given, they were 2.7 (95% confidence interval 1.4–5.4) times more likely to rate their overall quality of care as excellent. Conclusion. Our model indicated that pain management was associated with increased perception of overall quality of care only when EMS providers explained the medications provided and their potential side effects.

Strategies of High-Performing Paramedic Educational Programs

Objective. To identify the specific educational strategies used by paramedic educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination. Methods. NREMT data from 2003–2007 were analyzed to identify consistently high-performing paramedic educational programs. Representatives from 12 programs that have maintained a 75% first-attempt pass rate for at least four of five years and had more than 20 graduates per year were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: “What are specific strategies that lead to a successful paramedic educational program?” Results. All 12 emergency medical services (EMS) educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful paramedic educational program: 1) achieve and maintain national accreditation; 2) maintain high-level entry requirements and prerequisites; 3) provide students with a clear idea of expectations for student success; 4) establish a philosophy and foster a culture that values continuous review and improvement; 5) create your own examinations, lesson plans, presentations, and course materials using multiple current references; 6) emphasize emergency medical technician (EMT)-Basic concepts throughout the class; 7) use frequent case-based classroom scenarios; 8) expose students to as many prehospital advanced life support (ALS) patient contacts as possible, preferably where they are in charge; 9) create and administer valid examinations that have been through a review process (such as qualitative analysis); 10) provide students with frequent detailed feedback regarding their performance (such as formal examination reviews); 11) incorporate critical thinking and problem solving into all testing; and 12) deploy predictive testing with analysis prior to certification. Conclusion. Twelve specific strategies were identified by representatives from high-performing paramedic education programs. Further study should be conducted to determine whether implementation of these recommendations would improve program pass rates on the NREMT credentialing examination and improve entry-level paramedic field performance.

Strategies of High-Performing EMT-Basic Educational Programs

Introduction. The objective of this project was to identify the specific educational strategies used by emergency medical technician (EMT) educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination. Methods. NREMT data from 2001 to 2005 was analyzed in order to identify consistently high-performing EMT-Basic educational programs. Representatives from each program were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: “What are specific strategies that lead to a successful EMT-Basic educational program?” Results. Ten out of the 12 EMS educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful EMT-Basic educational program: 1) accept students who are highly motivated to succeed; 2) assure institutional support; 3) administer multiple assessments; 4) develop standardized lesson plans; 5) have a passing standard that is above the minimum competency level; 6) hire qualified/certified instructors; 7) maintain effective communication between didactic, practical, andfield instructors; 8) maintain instructional consistency; 9) provide clearly defined objectives; 10) provide immediate feedback for written, practical evaluations to students; 11) require prerequisites; and12) teach test-taking skills. Conclusions. Twelve specific strategies were identified by high-performing EMT-Basic programs. From these, seven recommendations to improve programmatic pass rates on the NREMT certification exam were derived. Further study should be conducted to determine if implementation of these recommendations improves programmatic pass rates on the NREMT certification exam.

Variation in the Use of 12‐Lead Electrocardiography for Patients With Chest Pain by Emergency Medical Services in North Carolina

Background Prehospital 12‐lead electrocardiography (ECG) is critical to timely STEMI care although its use remains inconsistent. Previous studies to identify reasons for failure to obtain a prehospital ECG have generally only focused on individual emergency medical service (EMS) systems in urban areas. Our study objective was to identify patient, geographic, and EMS agency‐related factors associated with failure to perform a prehospital ECG across a statewide geography. Methods and Results We analyzed data from the Prehospital Medical Information System (PreMIS) in North Carolina from January 2008 to November 2010 for patients >30 years of age who used EMS and had a prehospital chief complaint of chest pain. Among 3.1 million EMS encounters, 134 350 patients met study criteria. From 2008–2010, 82 311 (61%) persons with chest pain received a prehospital ECG; utilization increased from 55% in 2008 to 65% in 2010 (trend P<0.001). Utilization by health referral region ranged from 22.9% to 74.2% and was lowest in rural areas. Men were more likely than women to have an ECG performed (63.0% vs 61.3%, adjusted RR 1.02, 95% CI 1.01 to 1.04). The certification‐level of the EMS provider (paramedic vsbasic/intermediate) and system‐level ECG equipment availability were the strongest predictors of ECG utilization. Persons in an ambulance with a certified paramedic were significantly more likely to receive a prehospital ECG than nonparamedics (RR 2.15, 95% CI 1.55, 2.99). Conclusions Across a large geographic area prehospital ECG use increased significantly, although important quality improvement opportunities remain. Increasing ECG availability and improving EMS certification and training levels are needed to improve overall care and reduce rural‐urban treatment differences.

Evaluation of the Implementation of the Trauma Triage and Destination Plan on the Field Triage of Injured Patients in North Carolina

Abstract Objective: Timely triage and appropriate destination decision making for injured patients are central challenges faced by emergency medical services (EMS) systems. In 2010, North Carolina (NC) adopted a statewide Trauma Triage and Destination Plan (TTDP) based on the CDCs Field Triage Guidelines to better address these challenges. We sought to characterize the implementation of these guidelines by quantifying their effect on multiple metrics of patient care. Methods: We employed a retrospective pre-post study design utilizing a statewide EMS medical record database. We assessed several metrics of patient care—including changes in destination choice, appropriateness of EMS destination, transit time to first hospital, transit time to definitive care, and others—in a six-month period in the year before and after the implementation of the guidelines. Results: We evaluated a total of 190,307 EMS encounters pre- (n = 93,927) and post-implementation (n = 96,380). Among all patients, there was not a significant difference in the percentage transported to a community hospital or Level I, II, or III trauma center as their first destination. Among those patients meeting TTDP guidelines for transport to a trauma center, the number transported to a Level I or II trauma center decreased 1.0% from 30.6% (n = 2,911) to 29.6% (n = 2,954) (95% CI: −0.2%, 2.2%). Those transported to a Level I trauma center decreased 0.4% from 21.2% to 20.8% in the post-period (95% CI: −0.7%, 1.5%). There were also no significant changes in EMS scene times (14.0 pre-, 14.1 post-) and transport times (12.9 pre-, 13.0 post-). While scene distance from a Level I trauma center showed a decreased likelihood of transport to that center, there was an overall post-implementation increase of 2.5% from 18.0% to 20.5% (95% CI: −3.6%, −1.3%) in transport to a Level I trauma center among patients meeting anatomic criteria across all distance ranges. Conclusions: We found that implementation of region-specific destination plans based on the Field Triage Guidelines had little effect on selected hospital destination, scene times, transport times, and other metrics of EMS decision making and effectiveness. We suspect this is due to delays in information dissemination and adoption by field providers.

Management of Aortic Valve Dysfunction After Transapical Approach Using the Technique “Valve After Valve”

We report a case of a 77-year-old patient with severe aortic stenosis who underwent transapical aortic valve implantation with a 23-mm Edwards Sapien valve (Edwards Lifesciences Inc, Irvine CA). This procedure was complicated with the occurrence of an acute regurgitation due to entrapment of one of the leaflets that was successfully managed by valve after valve technique.