Barry J. Knapp

Prospective Evaluation of an Emergency Medical Services-Administered Alternative Transport Protocol

Background. The ability of emergency medical services (EMS) providers to offer an alternative means of nonemergent transport for patients with minor medical complaints is a rarely sanctioned concept in U.S. EMS systems. Objective. To prospectively determine if paramedics using transport guidelines can identify patients with minor medical problems who can be safely transported by a nonmedical alternative transport mechanism (taxi). Methods. Paramedics in the city of Norfolk, Virginia, who had more than one year of experience and who had completed the study orientation course were eligible to enroll subjects in the study. Predetermined alternative transport exclusion criteria as well as inclusion guidelines were provided to paramedics. After on-scene evaluation, paramedics identified subjects who met the enrollment criteria and were deemed safe for emergent ambulance transport. Enrolled subjects were provided a prepaid taxi voucher, which allowed for transport to the closest emergency department (ED). Patients who refused study participation were transported to the ED by ambulance. Results. Ninety-three subjects were enrolled and transported to the ED via taxi. Eleven patients identified by EMS as meeting enrollment criteria refused study participation. The average time from taxi dispatch to ED triage was 43 minutes (95% confidence interval [CI] = 38 to 48). Nine (10%) subjects transported by taxi were ultimately admitted to the hospital. None of the study participants required ED blood transfusions or emergent procedures or suffered an adverse event that could be directly attributed to the delay in ED arrival by taxi. Conclusions. The ability of EMS to safely triage patients who activate the 9-1-1 system to an alternative transport mechanism remains an unproven concept. Our study adds to the concerns of other published literature that EMS providers underestimate the potential severity of illness.

The prehospital administration of intravenous methylprednisolone lowers hospital admission rates for moderate to severe asthma.

Objective. To compare hospital admission rates for patients with moderate to severe asthma who receive intravenous methylprednisolone given in the prehospital setting versus in the emergency department. Methods. A retrospective chart review was used to identify emergency medical services (EMS) transports of patients with moderate to severe asthma when 125 mg methylprednisolone was given intravenously in the prehospital setting under existing regional protocols. Data were collected on EMS runs in an urban/suburban system from May 1, 2000, through April 30, 2001. Only patients 18 to 50 years old with a history of asthma were included in the study. Patients were excluded if they left against medical advice, were long-term smokers, used home oxygen, or had a history of chronic obstructive pulmonary disease. A parallel search was performed from February 1, 1999, to April 30, 2000, to identify moderate–severe asthmatics who were transported by EMS and later given intravenous methylprednisolone in the emergency department. During this period, methylprednisolone was not available for use in this EMS system. Results. A total of 31 moderate to severe asthmatics were identified as receiving prehospital methylprednisolone. A total of 33 asthmatics were identified who were transported by EMS and later received intravenous methylprednisolone in the emergency department. Average patient age in the prehospital methylprednisolone group was 34 ± 10 years (mean ± standard deviation; 95% confidence interval [CI] = 31−37). Average age in the hospital group was 34 ± 10 years (95% CI = 31−37). Average time to administration of methylprednisolone in the prehospital setting was 15 ± 7 minutes (95% CI = 7−22). The average time elapsed in the emergency department before methylprednisolone was 40 ± 22 minutes (95% CI = 23−57). Only 12.9% (4) of the patients receiving prehospital solumedrol were admitted versus 33.3% (11) of those receiving the medication in the emergency department (p = 0.025). Patients were 3.375 times more likely to be admitted if they received methylprednisolone in the emergency department versus in the prehospital setting. Conclusion. Patients with moderate to severe asthma who receive intravenous methylprednisolone in the prehospital setting have significantly fewer hospital admissions.

A Survey of Handoff Practices in Emergency Medicine

This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.

Learner Improvement From a Simulation-Enhanced Ultrasonography Curriculum for First-Year Medical Students: Simulation-Enhanced Ultrasonography Curriculum for First-Year Medical Students

We describe a simulation‐enhanced ultrasonography (US) curriculum for first‐year medical students as part of a comprehensive curricular integration of US skills. Our goal was to assess student knowledge and performance of US and determine their satisfaction with the integrated curriculum.

Emergency Physician-performed Transesophageal Echocardiography in Simulated Cardiac Arrest

Introduction Transesophageal echocardiography (TEE) is a well-established method of evaluating cardiac pathology. It has many advantages over transthoracic echocardiography (TTE), including the ability to image the heart during active cardiopulmonary resuscitation. This prospective simulation study aims to evaluate the ability of emergency medicine (EM) residents to learn TEE image acquisition techniques and demonstrate those techniques to identify common pathologic causes of cardiac arrest. Methods This was a prospective educational cohort study with 40 EM residents from two participating academic medical centers who underwent an educational model and testing protocol. All participants were tested across six cases, including two normals, pericardial tamponade, acute myocardial infarction (MI), ventricular fibrillation (VF), and asystole presented in random order. Primary endpoints were correct identification of the cardiac pathology, if any, and time to sonographic diagnosis. Calculated endpoints included sensitivity, specificity, and positive and negative predictive values for emergency physician (EP)-performed TEE. We calculated a kappa statistic to determine the degree of inter-rater reliability. Results Forty EM residents completed both the educational module and testing protocol. This resulted in a total of 80 normal TEE studies and 160 pathologic TEE studies. Our calculations for the ability to diagnose life-threatening cardiac pathology by EPs in a high-fidelity TEE simulation resulted in a sensitivity of 98%, specificity of 99%, positive likelihood ratio of 78.0, and negative likelihood ratio of 0.025. The average time to diagnose each objective structured clinical examination case was as follows: normal A in 35 seconds, normal B in 31 seconds, asystole in 13 seconds, tamponade in 14 seconds, acute MI in 22 seconds, and VF in 12 seconds. Inter-rater reliability between participants was extremely high, resulting in a kappa coefficient across all cases of 0.95. Conclusion EM residents can rapidly perform TEE studies in a simulated cardiac arrest environment with a high degree of precision and accuracy. Performance of TEE studies on human patients in cardiac arrest is the next logical step to determine if our simulation data hold true in clinical practice.

Framework for classifying compliance and medical immediacy among low-acuity presentations at an urban trauma center

BackgroundThis research offers two exploratory frameworks, one for medical regimen compliance and one for medical immediacy. The first classifies compliance awareness, compliance mitigation, and financial limitation for those patients that exhibit nonadherence with a medical regimen. The second classifies medical immediacy and characterizes avoidable utilization.MethodsRepresentative sampling of adult patients presenting at an emergency department (62,000/ppy) triaged as low acuity; emergency department physician assessment of noncompliance with medical regimen for those patients with a complaint related to a chronic condition; and emergency department physician assessment of medical immediacy and avoidable utilization.ResultsPhysicians report 48.3% (95% confidence interval (CI) 43.5% to 53.1%) of patients with at least a single chronic condition are presenting with symptoms or complaint related to a chronic condition, and 39.6% (CI 31.7% to 47.4%) of these exhibit noncompliance with the medical regimen associated with that chronic condition. 16.4% (CI 6.6% to 26.1%) of the patients exhibit pseudo compliance, a belief that the medical regimen is in compliance when in fact it is not. If the patient had been in compliance, 85.9% (CI 77.0% to 94.8%) of the presenting conditions may have been mitigated. Noncompliance cases (34.5% (CI 22.0% to 47.1%)) are partly attributable to financial constraints. Further, 19.1% (CI 15.7% to 22.5%) are assessed as requiring no medical intervention and 3.4% (CI 1.8% to 4.9%) require immediate stabilization.ConclusionsA large portion of low-acuity presentations are related to a chronic condition and noncompliance with the associated medical regimen contributes to the need to seek medical services. Interventions addressing literacy and financial constraints may increase compliance and decrease utilization.