David C. Cone

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology

Clinical case: A 58-year-old woman called 9-1-1 with acute onset of chest pain that had persisted for 30 minutes. She had a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus but no previous history of myocardial infarction or heart failure. Her medications included aspirin, atorvastatin, lisinopril, and metoprolol. Paramedics were dispatched, and a prehospital ECG demonstrated 3- to 4-mm ST-segment elevation in leads I, aVL, and V2 through V6 (Figure 1). Her examination revealed a regular pulse of 90 bpm, a blood pressure of 100/60 mm Hg, clear lungs, and normal heart sounds with no murmurs. Paramedics interpreted the prehospital ECG and activated the catheterization laboratory en route to the hospital. On hospital arrival, the patient was transported directly to the catheterization laboratory. Coronary angiography demonstrated an occluded proximal left anterior descending artery, which was successfully treated with balloon angioplasty and a stent. The pertinent time intervals were as follows: paramedic dispatch to balloon time, 56 minutes; paramedic arrival at the scene to balloon time, 46 minutes; hospital door to balloon time, 23 minutes. Her biomarkers revealed a peak troponin T of 2.42 ng/mL and a peak creatine kinase muscle-brain isoenzyme of 26.8 ng/mL. An echocardiogram demonstrated normal left ventricular ejection fraction of 55%, with mild anterior hypokinesis, and the patient was discharged on hospital day 3. Figure 1. Prehospital ECG. American Heart Association national guidelines,1–3 as well as other consensus and scientific statements,4–11 recommend that emergency medical services (EMS) acquire and use prehospital ECGs to evaluate patients with suspected acute coronary syndrome. Despite these recommendations, prehospital ECGs are used in fewer than 10% of patients with ST-segment–elevation myocardial infarction (STEMI),12,13 and this rate has not substantially changed since the mid-1990s. Furthermore, even when a prehospital ECG is acquired, the information is often not …

Mass casualty triage: an evaluation of the data and development of a proposed national guideline.

Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States.

Emergency Medical Service Dispatch Cardiopulmonary Resuscitation Prearrival Instructions to Improve Survival From Out-of-Hospital Cardiac Arrest A Scientific Statement From the American Heart Association

Each year, millions of people around the world experience out-of-hospital cardiac arrest (OHCA), a condition characterized by unexpected cardiovascular collapse.1,2 OHCA is a leading cause of death. The incidence of treated OHCA is ≈50 to 60 per 100 000 person-years and is comparable throughout many parts of the world. Resuscitation of these patients is challenging and requires a coordinated set of rescuer actions termed the “Chain of Survival.” The links in the Chain of Survival are immediate recognition of cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), rapid defibrillation, effective advanced life support, and integrated post–cardiac arrest care.3 These actions involve the participation of a spectrum of rescuers, including family members, bystanders, emergency medical service (EMS) dispatchers, pre–hospital care providers, and hospital-based personnel; each group of rescuers has specific motivations, responsibilities, and skills. Unfortunately, in most communities in the United States and Canada, only 5% to 10% of all OHCA patients in whom resuscitation is attempted survive to discharge from the hospital. In contrast, survival rates can approach 20% (50% for witnessed ventricular fibrillation) in communities where the Chain of Survival is strong.4 Efforts to improve survival from OHCA should be aimed at strengthening each link in the Chain of Survival. An important underpinning of successful resuscitation is the interdependence of each of these links. Specifically, the early links, those involving bystanders (immediate emergency activation and early bystander CPR), are essential for the effectiveness of subsequent links. Thus, efforts that can improve early recognition of OHCA and increase bystander CPR are likely to improve survival from OHCA. When a bystander calls the community emergency response number (eg, 911 in the United States) to request medical aid, the call creates an opportunity to improve both identification of OHCA and provision of …

T ERMINATION OF R ESUSCITATION IN THE P REHOSPITAL S ETTING FOR A DULT P ATIENTS S UFFERING N ONTRAUMATIC C ARDIAC A RREST

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.

Part 4: Systems of Care and Continuous Quality Improvement 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The science and recommendations discussed in the other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) form the backbone of resuscitation. They answer the “why”, “what,” and “when” of performing resuscitation steps. In a perfectly controlled and predictable environment, such as a laboratory setting, those answers often suffice, but the “how” of actual implementation depends on knowing the “who” and “where” as well. The ideal work flow to accomplish resuscitation successfully is highly dependent on the system of care as a whole. Healthcare delivery requires structure (eg, people, equipment, education, prospective registry data collection) and process (eg, policies, protocols, procedures), which, when integrated, produce a system (eg, programs, organizations, cultures) leading to outcomes (eg, patient safety, quality, satisfaction). An effective system of care (Figure 1) comprises all of these elements—structure, process, system, and patient outcomes—in a framework of continuous quality improvement (CQI). Figure 1. Taxonomy of systems of care. In this Part, we will focus on 2 distinct systems of care: the system for patients who arrest inside the hospital and the one for those who arrest outside it. We will set into context the building blocks for a system of care for cardiac arrest, with consideration of the setting, team, and available resources, as well as CQI from the moment the patient becomes unstable until after the patient is discharged. The chain of survival metaphor, first used almost 25 years ago,1 is still very relevant. However, it may be helpful to create 2 separate chains (Figure 2) to reflect the differences in the steps needed for response to cardiac arrest in the hospital (in-hospital cardiac arrest [IHCA]) and out of the hospital (out of hospital cardiac arrest [OHCA]). Regardless of where an arrest occurs, the care following resuscitation converges …

Comparison of Emergency Medical Services Systems Across Pan-Asian Countries: A Web-based Survey

Abstract Background. There are great variations in out-of-hospital cardiac arrest (OHCA) survival outcomes among different countries and different emergency medical services (EMS) systems. The impact of different systems and their contribution to enhanced survival are poorly understood. This paper compares the EMS systems of several Asian sites making up the Pan-Asian Resuscitation Outcomes Study (PAROS) network. Some preliminary cardiac arrest outcomes are also reported. Methods. This is a cross-sectional descriptive survey study addressing population demographics, service levels, provider characteristics, system operations, budget and finance, medical direction (leadership), and oversight. Results. Most of the systems are single-tiered. Fire-based EMS systems are predominant. Bangkok and Kuala Lumpur have hospital-based systems. Service level is relatively low, from basic to intermediate in most of the communities. Korea, Japan, Singapore, and Bangkok have intermediate emergency medical technician (EMT) service levels, while Taiwan and Dubai have paramedic service levels. Medical direction and oversight have not been systemically established, except in some communities. Systems are mostly dependent on public funding. We found variations in available resources in terms of ambulances and providers. The number of ambulances is 0.3 to 3.2 per 100,000 population, and most ambulances are basic life support (BLS) vehicles. The number of human resources ranges from 4.0 per 100,000 population in Singapore to 55.7 per 100,000 population in Taipei. Average response times vary between 5.1 minutes (Tainan) and 22.5 minutes (Kuala Lumpur). Conclusion. We found substantial variation in 11 communities across the PAROS EMS systems. This study will provide the foundation for understanding subsequent studies arising from the PAROS effort.

Using publication metrics to highlight academic productivity and research impact.

This article provides a broad overview of widely available measures of academic productivity and impact using publication data and highlights uses of these metrics for various purposes. Metrics based on publication data include measures such as number of publications, number of citations, the journal impact factor score, and the h-index, as well as emerging metrics based on document-level metrics. Publication metrics can be used for a variety of purposes for tenure and promotion, grant applications and renewal reports, benchmarking, recruiting efforts, and administrative purposes for departmental or university performance reports. The authors also highlight practical applications of measuring and reporting academic productivity and impact to emphasize and promote individual investigators, grant applications, or department output.

Mass casualty triage in the chemical, biological, radiological, or nuclear environment

Field trauma triage systems currently used by emergency responders at mass casualty incidents and disasters do not adequately account for the possibility of contamination of patients with chemical, biological, radiological, or nuclear material. Following a discussion of background issues regarding mass casualty triage schemes, this paper proposes chemical, biological, radiological, or nuclear-compatible trauma triage algorithms, based on a review of the literature and the input of recognized content experts. A basic trauma triage template is first proposed, with patient assessment limited to ability to walk, presence of breathing, and ability to follow commands. This template is then modified for use in chemical, biological, and radiation/nuclear situations in which the exposed or contaminated victims have also sustained conventional trauma. The proposed algorithms will need further refinement and testing.

Information Loss in Emergency Medical Services Handover of Trauma Patients

Abstrast Introduction. Little is known about how effectively information is transferred from emergency medical services (EMS) personnel to clinicians in the emergency department receiving the patient. Information about prehospital events and findings can help ensure expedient and appropriate care. The trauma literature describes 16 prehospital data points that affect outcome and therefore should be included in the EMS report when applicable. Objective. To determine the degree to which information presented in the EMS trauma patient handover is degraded. Methods. At a level I trauma center, patients meeting criteria for the highest level of trauma team activation (“full trauma”) were enrolled. As part of routine performance improvement, the physician leadership of the trauma program watched all available video-recorded full trauma responses, checking off whether the data points appropriate to the case were verbally “transmitted” by the EMS provider. Two EMS physicians then each independently reviewed the trauma teams chart notes for 50% of the sample (and a randomly selected 15% of the charts to assess agreement) and checked off whether the same elements were documented (“received”) by the trauma team. The focus was on data elements that were “transmitted” but not “received.” Results. In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). On the average chart, 72.9% of the transmitted items were received (95% confidence interval 69.0%–76.8%). The most commonly transmitted data elements were mechanism of injury (94 times), anatomic location of injury (81), and age (67). Prehospital hypotension was received in only 10 of the 28 times it was transmitted; prehospital Glasgow Coma Scale [GCS] score 10 of 22 times; and pulse rate 13 of 49 times. Conclusions. Even in the controlled setting of a single-patient handover with direct verbal contact between EMS providers and in-hospital clinicians, only 72.9% of the key prehospital data points that were transmitted by the EMS personnel were documented by the receiving hospital staff. Elements such as prehospital hypotension, GCS score, and other prehospital vital signs were often not recorded. Methods of “transmitting” and “receiving” data in trauma as well as all other patients need further scrutiny.

Emergency medical services and cultural determinants of an emergency in Karachi, Pakistan

Objectives. The study was conducted to understand the prehospital system in Karachi, the mode of transport that adult inpatients use to reach the emergency departments (EDs), and the barriers to the use of ambulances. Methods. The study consisted of two parts. The first part involved interviewing the administrators of major ambulance services in Karachi. The second part consisted of a structured interview of randomly selected adult inpatients admitted to one government and one private hospital. Results. Seven ambulance service administrators were interviewed. The interviews revealed that ambulances in Karachi are mainly involved in transporting patients from hospital to hospital or to home. A large number of calls are for transporting dead bodies. A total of 92 patients were interviewed (58 male, 34 female). Admission complaints included abdominal pain (22), blunt trauma (11), penetrating trauma (3), chest pain (6), shortness of breath (4), hematemesis (3), acute focal weakness (4), high fever (4), and other (32). The most common mode of transport to the ED was taxi (53, 58%), followed by private car (21, 23%). Specific reasons for not using ambulances included a perception that the patient was not sick enough (34, 45%), slow response of the ambulance services (17, 23%), not knowing how to find one (8, 11%), and the high cost (6, 8%). Conclusion. In case of a medical emergency, most people in Karachi do not use ambulances. The reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.