Ian E. Blanchard

Emergency Medical Services Response Time and Mortality in an Urban Setting

Abstract Background. A common tenet in emergency medical services (EMS) is that faster response equates to better patient outcome, translated by some EMS operations into a goal of a response time of 8 minutes or less for advanced life support (ALS) units responding to life-threatening events. Objective. To explore whether an 8-minute EMS response time was associated with mortality. Methods. This was a one-year retrospective cohort study of adults with a life-threatening event as assessed at the time of the 9-1-1 call (Medical Priority Dispatch System Echo- or Delta-level event). The study setting was an urban all-ALS EMS system serving a population of approximately 1 million. Response time was defined as 9-1-1 call receipt to ALS unit arrival on scene, and outcome was defined as all-cause mortality at hospital discharge. Potential covariates included patient acuity, age, gender, and combined scene and transport interval time. Stratified analysis and logistic regression were used to assess the response time–mortality association. Results. There were 7,760 unit responses that met the inclusion criteria; 1,865 (24%) were ≥8 minutes. The average patient age was 56.7 years (standard deviation = 21.5). For patients with a response time ≥8 minutes, 7.1% died, compared with 6.4% for patients with a response time ≤7 minutes 59 seconds (risk difference 0.7%; 95% confidence interval [CI]: –0.5%, 2.0%). The adjusted odds ratio of mortality for ≥8 minutes was 1.19 (95% CI: 0.97, 1.47). An exploratory analysis suggested there may be a small beneficial effect of response ≤7 minutes 59 seconds for those who survived to become an inpatient (adjusted odds ratio = 1.30; 95% CI: 1.00, 1.69). Conclusions. These results call into question the clinical effectiveness of a dichotomous 8-minute ALS response time on decreasing mortality for the majority of adult patients identified as having a life-threatening event at the time of the 9-1-1 call. However, this study does not suggest that rapid EMS response is undesirable or unimportant for certain patients. This analysis highlights the need for further research on who may benefit from rapid EMS response, whether these individuals can be identified at the time of the 9-1-1 call, and what the optimum response time is.

Part 9: First Aid 2015 International Consensus on First Aid Science With Treatment Recommendations

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Part 9: First aid

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Carbon Footprinting of North American Emergency Medical Services Systems

Abstract Objectives. This study was undertaken to characterize the carbon emissions from a broad sample of North American emergency medical services (EMS) agencies, and to begin the process of establishing voluntary EMS-related emission targets. Methods. Fifteen diverse North American EMS systems with more than 550,000 combined annual responses and serving a population of 6.3 million reported their direct and purchased (“Tier 2”) energy consumption for one year. We calculated total carbon dioxide equivalent (CO2e) emissions using Environmental Protection Agency, Energy Information Administration, and locality-specific emission conversion factors. We also calculated per-response and population-based emissions. We report descriptive summary data. Results. Participants included government “third-service” (n == 4), public utility model (n == 1), private contractor (n == 6), and rural rescue squad (n == 4) systems. Call volumes ranged from 800 to 114,280 (median 20,093; interquartile range [[IQR]] 1,100–55,217). Emissions totaled 46,941,690 pounds of CO2e (21,289 metric tons); 75%% of emissions were from diesel or gasoline. For systems providing complete Tier 2 data, median emissions per response were 80.7 (IQR 65.1–106.5) pounds of CO2e and median emissions per service-area resident were 7.8 (IQR 4.7–11.2) pounds of CO2e. Two systems reported aviation fuel consumption for air medical services, with emissions of 2,395 pounds of CO2e per flight, or 0.7 pounds of CO2e per service-area resident. Conclusion. EMS operations produce substantial carbon emissions, primarily from vehicle-related fuel consumption. The 75th percentiles from our data suggest 106.5 pounds of CO2e per unit response and/or 11.2 pounds of CO2e per service-area resident as preliminary maximum emission targets. Air medical services can anticipate higher per-flight but lower population-based emissions.

A validation of ground ambulance pre-hospital times modeled using geographic information systems

BackgroundEvaluating geographic access to health services often requires determining the patient travel time to a specified service. For urgent care, many research studies have modeled patient pre-hospital time by ground emergency medical services (EMS) using geographic information systems (GIS). The purpose of this study was to determine if the modeling assumptions proposed through prior United States (US) studies are valid in a non-US context, and to use the resulting information to provide revised recommendations for modeling travel time using GIS in the absence of actual EMS trip data.MethodsThe study sample contained all emergency adult patient trips within the Calgary area for 2006. Each record included four components of pre-hospital time (activation, response, on-scene and transport interval). The actual activation and on-scene intervals were compared with those used in published models. The transport interval was calculated within GIS using the Network Analyst extension of Esri ArcGIS 10.0 and the response interval was derived using previously established methods. These GIS derived transport and response intervals were compared with the actual times using descriptive methods. We used the information acquired through the analysis of the EMS trip data to create an updated model that could be used to estimate travel time in the absence of actual EMS trip records.ResultsThere were 29,765 complete EMS records for scene locations inside the city and 529 outside. The actual median on-scene intervals were longer than the average previously reported by 7–8 minutes. Actual EMS pre-hospital times across our study area were significantly higher than the estimated times modeled using GIS and the original travel time assumptions. Our updated model, although still underestimating the total pre-hospital time, more accurately represents the true pre-hospital time in our study area.ConclusionsThe widespread use of generalized EMS pre-hospital time assumptions based on US data may not be appropriate in a non-US context. The preference for researchers should be to use actual EMS trip records from the proposed research study area. In the absence of EMS trip data researchers should determine which modeling assumptions more accurately reflect the EMS protocols across their study area.

Carbon footprinting of emergency medical services systems: A proof-of-concept study

Objective. In this proof-of-concept study, we evaluated the availability of emergency medical services (EMS) system energy consumption data required to calculate a carbon footprint. Methods. Two diverse North American EMS systems with more than 125,000 combined annual unit responses agreed to report their energy consumption for the last fiscal or calendar year using a data-collection tool based on Carbon Trust recommendations. They also identified the source of information (e.g., bills, logs, receipts), whether the amounts reported were directly measured or estimated, and whether any of the amounts were prorated from shared facilities (e.g., electricity for a shared office building). For this proof-of-concept study, we report only descriptive data about the availability of data and aggregate carbon emissions. Results. Both systems reported diesel fuel, gasoline, and electricity consumption. One system used natural gas; one system used aviation fuel. Direct measurement of consumption using utility bills and statements was possible for these energy types. One system prorated natural gas and electricity usage; one system was able to estimate commercial air travel. Annual carbon dioxide (CO2) emissions for these two systems totaled 11.1 million pounds of CO2. The largest source of CO2 emissions was diesel fuel (39%), followed by electricity (23%). Conclusion. These EMS systems were able to provide the data necessary to determine their carbon footprints. Future research could include broader study to establish EMS-specific norms for carbon emissions, benchmarking of these metrics between different EMS systems, and the assessment of programs designed to reduce EMS carbon emissions.

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.

Developing a Canadian emergency medical services research agenda: a baseline study of stakeholder opinions

PURPOSE This study forms the first phase in the development of the Canadian National EMS Research Agenda. The purpose was to understand the current state of emergency medical services (EMS) research through the barriers and opportunities perceived by key stakeholders in the Canadian system and to identify the recommendations this group had for moving forward. METHODS This qualitative study was conducted in the spring of 2011 using one-on-one semistructured telephone interviews. Purposeful sampling was used to recruit a cross section of EMS research stakeholders, representing a breadth of geographic regions and roles. Data were collected until thematic saturation was reached. A constant comparative approach was used to develop a basic coding framework and identify emerging themes. RESULTS Twenty stakeholders were invited to participate, and saturation was reached after 13 interviews. Thematic saturation was used to ensure that the findings were grounded in the data. Four major themes were identified: 1) the need for additional research education within EMS; 2) the importance of creating an infrastructure to support pan-Canadian research collaboration; 3) addressing the complexities of involving EMS providers in research; and 4) considerations for a national research agenda. CONCLUSION This hypothesis-generating study reveals key areas regarding EMS research in Canada and through the guidance it provides is a first step in the development of a comprehensive national research agenda. Our intention is to collate the identified themes with the results of a larger roundtable discussion and Delphi survey and, in doing so, guide development of a Canadian national EMS research agenda.

A prehospital treat-and-release protocol for supraventricular tachycardia

OBJECTIVE Paroxysmal supraventricular tachycardia (SVT) is a common dysrhythmia treated in the prehospital setting. Emergency medical service (EMS) agencies typically require patients treated for SVT to be transported to the hospital. This retrospective cohort study evaluated the impact, paramedic adherence, and patient re-presentation rates of a treat-and-release (T+R) protocol for uncomplicated SVT. METHODS Data were linked from the Alberta Health Services EMS electronic patient care record (EPCR) database for the City of Calgary to the Regional Emergency Department Information System (REDIS). All SVT patients treated by EMS between September 1, 2010, and September 30, 2012, were identified. Databases were queried to identify re-presentations to EMS or an emergency department (ED) within 72 hours of T+R. RESULTS There were 229 confirmed SVT patient encounters, including 75 T+R events. Of these 75 T+R events, 10 (13%, 95% confidence interval [CI] [7.4, 23]) led to an EMS re-presentation within 72 hours, and 4 (5%, 95% CI [2.1, 13]) led to an ED. All re-presentations were attributed to a single individual. After excluding 15 records that were incomplete due to limitations in the EPCR platform, 43 of 60 (72%) T+R encounters met all protocol criteria for T+R. CONCLUSION The T+R protocol evaluated in this study applied to a significant proportion of patients presenting to EMS with SVT. Risk of re-presentation following T+R was low, and paramedic protocol adherence was reasonable. T+R appears to be a viable option for uncomplicated SVT in the prehospital setting.

The Canadian national EMS research agenda: Impact and feasibility of implementation of previously generated recommendations

BACKGROUND A recent mixed-methods study on the state of emergency medical services (EMS) research in Canada led to the generation of nineteen actionable recommendations. As part of the dissemination plan, a survey was distributed to EMS stakeholders to determine the anticipated impact and feasibility of implementing these recommendations in Canadian systems. METHODS An online survey explored both the implementation impact and feasibility for each recommendation using a five-point scale. The sample consisted of participants from the Canadian National EMS Research Agenda study (published in 2013) and additional EMS research stakeholders identified through snowball sampling. Responses were analysed descriptively using median and plotted on a matrix. Participants reported any planned or ongoing initiatives related to the recommendations, and required or anticipated resources. Free text responses were analysed with simple content analysis, collated by recommendation. RESULTS The survey was sent to 131 people, 94 (71.8%) of whom responded: 30 EMS managers/regulators (31.9%), 22 researchers (23.4%), 15 physicians (16.0%), 13 educators (13.8%), and 5 EMS providers (5.3%). Two recommendations (11%) had a median impact score of 4 (of 5) and feasibility score of 4 (of 5). Eight recommendations (42%) had an impact score of 5, with a feasibility score of 3. Nine recommendations (47%) had an impact score of 4 and a feasibility score of 3. CONCLUSIONS For most recommendations, participants scored the anticipated impact higher than the feasibility to implement. Ongoing or planned initiatives exist pertaining to all recommendations except one. All of the recommendations will require additional resources to implement.