Ed Cain

The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics

STUDY OBJECTIVE We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting. METHODS We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury. RESULTS The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The kappa value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule. CONCLUSION This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.

Cost effectiveness and outcomes of a nurse practitioner–paramedic–family physician model of care: the Long and Brier Islands study

Aim This longitudinal study was designed to address four research questions and the hypothesis; that adults living in a rural community receiving primary health care and emergency services from a team that included an on-site nurse practitioner (NP) and paramedics and an off-site family physician would, over time, demonstrate evidence of improved psychosocial adjustment and less expenditure of health care resources. Background In Canada, there is a growing awareness and commitment to addressing the challenges of providing primary health care services in rural areas. A literature review supported the role of NPs in primary health care and a potential role for paramedics. No studies were found that evaluated the combination of NPs, paramedics and physicians as providers of primary health care. Methods Structured questionnaires, individual and group interviews with patients, health and social service care providers and administrators and community members were used to describe and evaluate the impact of the model of care over the three years of the study. Findings The innovative model of care resulted in decreased cost, increased access, a high level of acceptance and satisfaction and effective collaboration among care providers. Organizational structures to support the innovative model of primary health care were identified.

Prehospital hypoglycemia: the safety of not transporting treated patients

OBJECTIVES Emergency medical services (EMS) personnel frequently encounter patients who refuse transport after being treated for a hypoglycemic episode. The outcomes of most of these patients are unknown. The purpose of this study was to determine the outcomes of patients treated and not transported for hypoglycemia and identify criteria that could be used to identify patients who did not require transport to hospital. METHODS This was a prospective, observational study involving all adult (>15 years) hypoglycemic patients (blood glucose less than 4 mmol/L by glucometer) attended to by the EMS system in the Halifax Metropolitan area in the province of Nova Scotia during a ten-month interval. RESULTS There were 220 calls for adult patients with hypoglycemia. Of the 75 calls that resulted in transport, there were 17 further hypoglycemic episodes requiring a repeat call for an ambulance (22.7%) and three recurrences (4%). Of the 145 calls that did not result in transport, 40 further episodes of hypoglycemia (27.6%) and three recurrences (2%) were reported. These differences were not statistically significant (p=0.43 and 0.33, respectively). There was also no statistically significant difference in the intervals between hypoglycemic episodes for patients transported (51.1 days +/-65) compared with patients not transported for their previous hypogylcemic episode (40.7 days +/-53.5) (p=0.6). Of the 47 calls entered in the study, there were seven repeat calls for hypoglycemia (15%) and one recurrence (2.1%). The majority of patients did not follow up with their physician. CONCLUSIONS Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. Admission to hospital is rarely required. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and nontransported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.

P REHOSPITAL H YPOGLYCEMIA : T HE S AFETY OF N OT T RANSPORTING T REATED P ATIENTS

Objectives. Emergency medical services (EMS) personnel frequently encounter patients who refuse transport after being treated for a hypoglycemic episode. The outcomes of most of these patients are unknown. The purpose of this study was to determine the outcomes of patients treated and not transported for hypoglycemia and identify criteria that could be used to identify patients who did not require transport to hospital. Methods. This was a prospective, observational study involving all adult (>15 years) hypoglycemic patients (blood glucose less than 4 mmol/L by glucometer) attended to by the EMS system in the Halifax Metropolitan area in the province of Nova Scotia during a ten-month interval. Results. There were 220 calls for adult patients with hypoglycemia. Of the 75 calls that resulted in transport, there were 17 further hypoglycemic episodes requiring a repeat call for an ambulance (22.7%) and three recurrences (4%). Of the 145 calls that did not result in transport, 40 further episodes of hypoglycemia (27.6%) and three recurrences (2%) were reported. These differences were not statistically significant (p = 0.43 and 0.33, respectively). There was also no statistically significant difference in the intervals between hypoglycemic episodes for patients transported (51.1 days ± 65) compared with patients not transported for their previous hypogylcemic episode (40.7 days ± 53.5) (p = 0.6). Of the 47 calls entered in the study, there were seven repeat calls for hypoglycemia (15%) and one recurrence (2.1%). The majority of patients did not follow up with their physician. Conclusions. Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. Admission to hospital is rarely required. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and nontransported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.

The Canadian Prehospital Evidence-based Protocols Project: Knowledge Translation in Emergency Medical Services Care

OBJECTIVES The principles of evidence-based medicine are applicable to all areas and professionals in health care. The care provided by paramedics in the prehospital setting is no exception. The Prehospital Evidence-based Protocols Project Online (PEP) is a repository of appraised research evidence that is applicable to interventions performed in the prehospital setting and is openly available online. This article describes the history, current status, and potential future of the project. METHODS The primary objective of the PEP is to catalog and grade emergency medical services (EMS) studies with a level of evidence (LOE). Subsequently, each prehospital intervention is assigned a class of recommendation (COR) based on all the appraised articles on that intervention, in an effort to organize the evidence so it may be put into practice efficiently. An LOE is assigned to each article by the section editor, based on the study rigor and applicability to EMS. The section editor committee consists of EMS physicians and paramedics from across Canada, and two from Ireland and a paramedic coordinator. The evidence evaluation cycle is continuous; as the section editors send back appraisals, the coordinator updates the database and sends out another article for review. RESULTS The database currently has 182 individual interventions organized under 103 protocols, with 933 citations. CONCLUSIONS This project directly meets recent recommendations to improve EMS by using evidence to support interventions and incorporating it into protocols. Organizing and grading the evidence allows medical directors and paramedics to incorporate research findings into their daily practice. As such, this project demonstrates how knowledge translation can be conducted in EMS.

Methodology for the development of a Canadian national EMS research agenda

BackgroundMany health care disciplines use evidence-based decision making to improve patient care and system performance. While the amount and quality of emergency medical services (EMS) research in Canada has increased over the past two decades, there has not been a unified national plan to enable research, ensure efficient use of research resources, guide funding decisions and build capacity in EMS research. Other countries have used research agendas to identify barriers and opportunities in EMS research and define national research priorities. The objective of this project is to develop a national EMS research agenda for Canada that will: 1) explore what barriers to EMS research currently exist, 2) identify current strengths and opportunities that may be of benefit to advancing EMS research, 3) make recommendations to overcome barriers and capitalize on opportunities, and 4) identify national EMS research priorities.Methods/DesignParamedics, educators, EMS managers, medical directors, researchers and other key stakeholders from across Canada will be purposefully recruited to participate in this mixed methods study, which consists of three phases: 1) qualitative interviews with a selection of the study participants, who will be asked about their experience and opinions about the four study objectives, 2) a facilitated roundtable discussion, in which all participants will explore and discuss the study objectives, and 3) an online Delphi consensus survey, in which all participants will be asked to score the importance of each topic discovered during the interviews and roundtable as they relate to the study objectives. Results will be analyzed to determine the level of consensus achieved for each topic.DiscussionA mixed methods approach will be used to address the four study objectives. We anticipate that the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these a priori concerns.

Impaired driving charges in injured impaired drivers requiring treatment in an emergency department

OBJECTIVE To determine the percentage of injured impaired drivers brought to the only trauma centre in Nova Scotia who were charged with impaired driving. METHODS This retrospective observational study identified alcohol impaired drivers involved in a motor vehicle crash (MVC) brought to the emergency department (ED). Patients were selected based on blood alcohol concentrations (BACs) found to be above the legal limit. Medical records were examined to determine if the patient was the driver in an MVC. Patient records were then cross-referenced with a police database to determine the percentage of injured impaired drivers who were charged with impaired driving. RESULTS Between April 1, 2006, and April 1, 2008, 1,102 patients brought to the QEII Health Sciences Centre (QEII HSC) ED were found to have BACs over the legal limit. Of these patients, only 57 (5.2%) were found to have been the driver in an MVC. The majority of patients were male (49; 86%), with an average age of 32 years. Most injuries (51; 89.5%) were the result of a single-vehicle crash. The mean Glasgow Coma Scale score was 12.6, and the mean Injury Severity Score was 14.4. Cross-referencing with police records showed that only 22.8% (13 of 57) of injured drivers were charged with impaired driving. Those drivers not charged with impaired driving had a significantly lower median BAC and median age. CONCLUSION During the study, the majority of alcohol-impaired drivers injured in an MVC who were brought to the QEII HSC ED for assessment of their injuries were not charged with impaired driving.

The Development of a National Emergency Medical Services Curriculum Framework for Physicians in Canada

Background. As the role of emergency medical services (EMS) continues to expand, EMS physicians andmedical directors require special skills andtraining to keep pace with the rapidly evolving subspecialty of EMS. In Canada, subspecialty training in EMS is still relatively new, anda standard national curriculum for physician EMS training does not exist. Objective. To develop a national EMS curriculum for emergency medicine (EM) residents andfellows andan abbreviated curriculum for non-EM trainees andcommunity physicians. Methods. The authors obtained EMS curricula andopportunities from Canadian EM andEMS training programs anda sample of U.S. programs to determine existing curricula, anddeveloped a framework for a national EMS curriculum using an expert working group of EMS medical directors andEMS leaders in Canada. Results. Canadian EM residency training programs included an EMS rotation, but their content anddepth of training were not uniform. The expert working group proposed a comprehensive set of training objectives, grouped into 16 categories, stratified by level of training. Conclusion. The proposed framework andobjectives are suitable for training medical students, family medicine trainees, community physicians, EM residents, andEMS fellows in Canada. The authors hope this article will serve as a guideline for residency andfellowship directors to develop their EMS training programs in a consistent manner, promote formal training for physicians involved in EMS, andhelp define the specific knowledge andexpertise required of physicians who provide EMS medical direction in Canada.

State of the Evidence for Emergency Medical Services (EMS) Care: The Evolution and Current Methodology of the Prehospital Evidence-Based Practice (PEP) Program

Background: Emergency medical services (EMS) leaders and clinicians need to incorporate evidence into safe and effective clinical practice. Access to high-quality evidence, and the time to synthesize it, can be barriers to evidence-based practice. The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, repository of critically appraised evidence specific to EMS. This paper describes the evolution and current methodology of the PEP program. Methods/design: The purpose of PEP is to identify, catalog and critically appraise relevant studies. Following regular systematic searches, two trained appraisers critically appraise included studies and assign a score on three-point level of evidence (LOE) and direction of evidence (DOE) scales. Each clinical intervention is plotted on a 3 × 3 (LOE × DOE) evidence matrix, which provides a summary recommendation. Discussion: The PEP program is a unique knowledge translation tool, specific to EMS. End-users can easily identify which clinical interventions are, or are not, supported by evidence.

CAN PREHOSPITAL CRITERIA BE USED TO TRIAGE PATIENTS WHO CALL 911 TO ALTERNATIVE HEALTH CARE FACILITIES

Objective: To prospectively validate the ability of EMS dispatch codes to identify patients with low-acuity illnesses, using patient need for only basic life support (BLS) care as a proxy for low illness acuity. Methods: This prospective cohort study was conducted in an urban city with a single advanced life support (ALS) level EMS provider. The 911 center was certified in using EMS dispatch protocols from Priority Medical Dispatch. Patients were included if they requested emergency assistance between July 2002 and June 2003 and they were assigned one of 28 previously derived low acuity EMS dispatch codes. Dispatch data, level of care actually provided, and disposition were obtained for each patient. For each low-acuity dispatch code, we used descriptive statistics to calculate the fraction of patients who received only BLS level care and the 95% confidence interval. We prospectively defined a low-acuity patient as an individual who received only BLS level care. Results: EMS cared for 30,806 patients during the study period. 11,334 (36.5%) met inclusion criteria and 10,782 (95.1%) received BLS care. 22 of the 28 codes resulted in low-acuity care at least 90% of the time. The performance of selected low-acuity diagnoses include: abdominal pain (EMS dispatch code: 1A) 97.5% BLS, 95% CI: 96.3%–98.4%; assault (4A) 98.4% BLS, 95% CI: 95.5%– 99.7%; back pain (5A) 97.6% BLS, 95% CI: 95.7%–98.8%, falls (17A) 92.6% BLS, 95% CI: 90.6%–94.4%, eye problems (16A) 100% BLS, 95% CI: 97.6%–100%; headache (18A) 95% BLS, 95% CI: 90%–98%; traumatic injuries (21A, 30A, 30B1) 95.7% BLS, 95% CI: 94.3%–96.8%, abnormal behavior/suicide attempt (25A, 25B) 97.7% BLS, 95% CI: 97.1%–98.2%, pregnancy/miscarriage (24A, B, D) 92.7% BLS, 95% CI: 90.8%–92.3%; and general illness (26A) 94.4% BLS, 95% CI: 93.4%–95.3%. Conclusions: This validation study confirms that most of the previously derived EMS dispatch codes do accurately identify patients who primarily require BLS level prehospital care, a proxy for low-acuity patients. These lowacuity codes can be used to triage EMS responses and EMS patients based upon dispatch information when using the Priority Medical Dispatch protocols and a certified 911 call center. 77 PATTERN OF EMS CALLS FOR ASSAULTS IN AN URBAN ENVIRONMENT Ronald Low, Yu-Feng Chan, Trevor Talbert, Keith McCabe, John Erickson, Karen Onufer, Tiffany Murano, Tamika Hibodeaux, UMDNJ