Edward N. Barthell

Prehospital External Cardiac Pacing: A Prospective, Controlled Clinical Trial

This prehospital prospective, controlled study was conducted to determine if prehospital cardiac pacing affects survival. The study involved 239 patients, 226 pulseless, nonbreathing patients (rhythms of asystole and electromechanical dissociation with heart rates less than 70) and 13 patients with hemodynamically significant bradycardia (heart rate less than 60; blood pressure less than 90 mm Hg; not responding to atropine). Patients were assigned to treatment or control groups on an every-other-day basis. One hundred three patients were treated with an external cardiac pacing device; 22 (21.4%) were resuscitated (arrival at admitting hospital with pulse and blood pressure) and seven (6.8%) were saved (survival to hospital discharge). One hundred thirty-six patients were not paced and served as controls; 28 (20.6%) were resuscitated (P = .90) and six (4.4%) were saved (P = .71). Analysis of pacing times showed increased resuscitation in patients paced early. All surviving paced patients were paced in 17 minutes or less. Analysis of rhythm subgroups showed no significant difference in the resuscitation or survival rates of paced and control groups for primary asystole, primary electromechanical dissociation, and secondary asystole and electromechanical dissociation occurring after countershock treatment of ventricular fibrillation when compared respectively. However, among patients with hypotensive bradycardia, six of six paced patients were resuscitated and five were saved, while only two of seven controls were resuscitated (P = .01) and one was saved (P = .01). Interpretation of the bradycardic patient data is limited by inequalities noted between control and treatment groups with regard to the administration of isoproterenol.(ABSTRACT TRUNCATED AT 250 WORDS)

THE EFFECT OF BYSTANDER CPR ON NEUROLOGIC OUTCOME IN SURVIVORS OF PREHOSPITAL CARDIAC ARRESTS

The efficacy of CPR has been questioned. A major criticism is that neurologic outcomes have not been adequately studied. For a 26-month period, 138 patients from six major receiving hospitals were discharged alive following prehospital cardiac arrests. For 65/138 (47.1%) patients, either the patient or a direct family member was contacted for information concerning neurologic outcome. For 63/138 (45.7%) patients, contact with patient or family was unsuccessful, consequently neurologic outcome at time of discharge was obtained from the medical record. For 10/138 (7.2%) patients, no data on neurologic outcome was obtainable. Neurologic outcome was rated by a 5-point Cerebral Performance Categories Scale (CPC); (1) Minimal Disability; (2) Moderate; (3) Severe; (4) Vegetative; and (5) Brain Dead. The bystander/first responder CPR group had 55.1% CPC-1; 24.4% CPC-2; 16.7% CPC-3; and 3.8% CPC-4 outcomes. The bystander/first responder NO CPR group had 58.0% CPC-1; 18.0% CPC-2; 16.0% CPC-3; and 8.0% CPC-4 outcomes. There was no significant difference at any CPC level (P not significant). Furthermore, there was no statistical difference between either group when compared for age, response time, resuscitation time, witnessing of arrest or distribution of presenting rhythms. In conclusion, no significant effect in neurologic outcome among saved cardiac arrest victims was found between bystander/first responder CPR and bystander/first responder NO CPR groups in the paramedic program studied.

Assuring community emergency care capacity with collaborative Internet tools: the Milwaukee experience.

Hospital overcrowding and diversion of ambulances from emergency departments are being recognized as increasing problems in the health care system. This article, a descriptive narrative, examines the various factors contributing to the problem and describes how collaborative approaches to public health issues can be applied. It describes Milwaukees experience with a collaborative approach. The use of a technological tool to assist with tracking and reporting on ambulance diversion and emergency department overload is explained, and data are provided to show the impact of various methods to blunt the impact of the flu season on diversion frequency. The article encourages use of similar collaborative approaches and Internet-based technology to address other public health problems.

Syndromic surveillance using regional emergency medicine internet

Abstract Study objective We demonstrate the feasibility and utility of emergency department (ED) syndromic surveillance using a regional emergency medicine Internet application to minimize impact on ED and public health staffing. Methods Regional (multi-ED) surveillance was established for 2 periods, one characterized by a high-profile national sports event and the other during an international disease outbreak. Counts of patient visits meeting syndrome criteria and total patient visits were reported daily on the secure regional emergency medicine Internet site and downloaded by public health staff. Trends were analyzed and displayed on the secure Web site. ED participants were surveyed about the acceptability and time cost of the project. Results In the first (“All Star Game”) project, 8 departments reported daily counts for 4 weeks, covering more than 26,000 patient visits. In the second (“severe acute respiratory syndrome” [SARS]) project, an average of 11 departments in the same region reported daily data on febrile respiratory illnesses, travel, and contacts for 10 weeks. Experience with the first project allowed for rapid implementation of the second project during a 3-day period. In both instances, the surveillance efforts were undertaken without the need for extraordinary ED or public health staffing requirements. Conclusion A regional emergency medicine Internet approach permitted rapid implementation of multisite syndromic surveillance without additional staff. Some problems were identified with the first project, related to clinician checklist completion and manual data tabulation and entry. The SARS project addressed these by simplifying data collection and restricting it to triage.

The National Emergency Medical Extranet Project

The National Emergency Medical Extranet (NEME) project was a collaborative multi-center effort to create a plan for a networked system to improve emergency clinical care through real-time information support, and simultaneously provide benefit through information support for public health initiatives. This article presents a review of the NEME project and its recommendations, which are particularly relevant given the desire for improved communication and surveillance systems in todays healthcare and public health environments. Participants in the NEME project performed an environmental assessment and a proposed conceptual architecture for NEME. A consensus conference was held to review the NEME concept to obtain feedback and delineate priorities for future development and testing. The NEME consensus conference used a modified version of the nominal group method. Recommendations for the following areas were established: Business/Organizational Issues [1) create a compelling provider driven NEME model, 2) provide a comprehensive policy framework, 3) address economics]; Clinical/Caregiver Issues [1) develop a NEME system that is integrated with Emergency Medicine workflow, 2) provide incentives to caregivers, 3) generate a critical mass of participation for maximum benefit]; Technical Issues [1) incorporate a robust security and confidentiality architecture, 2) utilize a master person index, where appropriate, 3) evaluate or adopt existing data standards]; Heart Attack Alert Functional Priorities for NEME [1) continuous quality improvement and research, 2) regional electrocardiogram server, 3) past medical history and medication server]; Next Generation Internet Functional Priorities for NEME [1) real time epidemiology/surveillance, 2) patient education, 3) real time clinical alerting]. In conclusion, issues and consensus recommendations in the planning of a NEME are documented. These recommendations should be considered in future efforts to design, develop and implement wide area information networks to support Emergency Medicine. A review of current activities evolving from NEME is presented, and further research and development is encouraged to create and implement NEME systems.

Milwaukee biosurveillance project: Real-time syndromic surveillance using secure regional internet

S i127 The nation’s emergency departments (EDs) are a potential source of surveillance information. The Frontlines of Medicine Project is a collaborative effort of emergency medicine, public health, emergency government, law enforcement, and informatics to develop nonproprietary, standardized methods for reporting emergency department patient data. An initial proposal, published in April 2002, proposed a standardized message structure based on XML (Extensible Markup Language) for reporting triage information from emergency departments to regional surveillance centers and called for reader comments. Subsequently, a consensus conference, with attendees chosen through a modified nominal consensus process, was held to discuss the initial Frontlines proposal and provide recommendations for next steps. Since the consensus conference, an Internet-based Delphi survey technique has been used to refine further the Frontlines recommendations. The technique was utilized for two rounds to yield a consensus exceeding 75% acceptance of the proposed data elements and preferred International Classification of Diseases, 9th Revision (ICD-9)–coded chief complaint values. The data elements for the triage surveillance report include provider facility ID, patient ID, encounter ID, patient age, age unit, gender, date/time first documented in ED, date/time symptom onset, chief complaint, first ED responsiveness assessment, first ED systolic blood pressure, first ED diastolic blood pressure, first ED heart rate, first ED temperature, ED temperature unit, and ZIP codes for home, work, and incident site. The preferred chief complaint categories include 159 complaints arranged in 16 hierarchical categories that are expected to describe the reason for visit in greater than 99% of ED encounters. Further details are available at www.frontlinesmed.org. Foodborne Outbreak Early Detection System (FOEDS) Paul C. Bartlett, Holly Wethington, Bryan DeZeeuw, Sally Bidol, John Tilden, Theresa Bernardo, Lixin Zhang, Dean Sienko, and Mary Grace Stobierski National Center for Food Safety and Toxicology, Michigan State University, Ingham County Health Department, Department of Epidemiology, University of Michigan, Food and Dairy Division. Michigan Department of Agriculture, Bureau of Epidemiology, Michigan Department of Community Health, Information Technology, Michigan State University College of Veterinary Medicine The FOEDS (Foodborne Outbreak Early Detection System) Forum (www.RUsick2.msu .edu) is a structured, Web-based forum that collects and shares data regarding a 4-day food history, food sources, animal contact, and other risk factors that are helpful in establishing the existence of a time-space cluster of possible foodborne origin. It is a syndromic surveillance system that allows users to search the database to evaluate the possibility that a group of people became sick with the same symptoms at about the same time after eating the same food from the same source. The FOEDS Forum is designed to identify suspicious time-space disease clusters that may, at the local health department’s discretion, be worthy of further investigation. As such, it can be viewed as a “front end” to our current national system for identifying and investigating foodborne outbreaks. Data collection was scheduled to begin in October 2002 in the three-county area of Greater Lansing, Michigan. Clinic-based and population-based advertisements were to encourage people with suspected foodborne disease to visit the Web site to determine if they ate the same food that others ate before becoming ill with similar symptoms. Input screens and output reports will be presented, as will program implementation in the three-county pilot area. The FOEDS Forum was developed by epidemiologists from state and local governmental agencies and academic departments working under the umbrella of the National Food Safety and Toxicology Center at Michigan State University.

Successful resuscitation using transcutaneous cardiac pacing.

Reported here is the case of a patient suffering from hemodynamically significant bradycardia in which the use of transcutaneous cardiac pacing resulted in successful resuscitation, obviating the need for invasive pacing. During pacing, intra-arterial recordings of blood pressure demonstrated higher pulse pressures for paced beats than for the patients own escape beats. Recent data regarding the use of non-invasive transcutaneous cardiac pacing is also reviewed.