Jennifer A. Frey

Paramedic ability to recognize ST-segment elevation myocardial infarction on prehospital electrocardiograms.

Abstract Background. Identifying ST-segment elevation myocardial infarctions (STEMIs) by paramedics can decrease door-to-balloon times. While many paramedics are trained to obtain and interpret electrocardiograms (ECGs), it is unknown how accurately they can identify STEMIs. Objective. This study evaluated paramedics’ accuracy in recognizing STEMI on ECGs when faced with potential STEMI mimics. Methods. This was a descriptive cohort study using a survey administered to paramedics. The survey contained questions about training, experience, and confidence, along with 10 ECGs: three demonstrating STEMIs (inferior, anterior, and lateral), two with normal results, and five STEMI mimics (left ventricular hypertrophy [LVH], ventricular pacing, left and right bundle branch blocks [LBBB, RBBB], and supraventricular tachycardia [SVT]). We calculated the overall sensitivity and specificity and the proportion correct with 95% confidence intervals (CIs). Results. We obtained 472 surveys from 30 municipal emergency medical services (EMS) agencies in five counties with 15 medical directors from seven hospitals. The majority (69%) reported ECG training within the preceding year, 31% within six months; and 74% were confident in recognizing STEMIs. The overall sensitivity and specificity for STEMI detection were 75% and 53% (95% CI 73%–77%, 51%–55%), respectively. Ninety-six percent (453/472, 95% CI 94%–98%) correctly identified the inferior myocardial infarction (MI), but only 78% (368/472, 94% CI 74%–82%) identified the anterior MI and 51% (241/472, 46%–56%) the lateral MI. Thirty-seven percent (173/472, 95% CI 32%–41%) of the paramedics correctly recognized LVH, 39% (184/472, 95% CI 35%–44%) LBBB, and 53% (249/472, 95% CI 48%–57%) ventricular pacing as not a STEMI. Thirty-nine percent (185/472, 95% CI 35%–44%) correctly identified all three STEMIs; however, only 3% of the paramedics were correct in all interpretations. The two normal ECGs were recognized as not a STEMI by 97% (459/472, 95% CI 95%–99%) and 100% (472/472, 95% CI 99%–100%). There was no correlation between training, experience, or confidence and accuracy in recognizing STEMIs. Conclusions. Despite training and a high level of confidence, the paramedics in our study were only able to identify an inferior STEMI and two normal ECGs. Given the paramedics’ low sensitivity and specificity, we cannot rely solely on their ECG interpretation to activate the cardiac catheterization laboratory. Future research should involve the evaluation of training programs that include assessment, initial training, testing, feedback, and repeat training.

In situ simulation to assess workplace attitudes and effectiveness in a new facility.

Introduction In situ simulation within new facilities holds the promise of identifying latent safety threats. The aim of this study was to identify if in situ simulation can also impact important employee perceptions and attitudes. Methods In the current study, health care professionals of an adult, urban, community teaching hospital level 1 trauma center participated in simulated scenarios in a new emergency department. Before and after the simulated scenarios, participants provided responses to the variables regarding their ability to work in the new facility and other work-related variables. Results Significant increases in communication (P = 0.05), facility clinical readiness (P < 0.05), self-efficacy (P < 0.01), trauma readiness (P < 0.01), and work space satisfaction (P < 0.05) were found from presimulation to postsimulation. The results also demonstrated a significant decrease from presimulation to postsimulation with performance beliefs (P < 0.001). Finally, cardiac readiness did not reveal a significant change from presimulation to postsimulation. Discussion In situ simulation exercises before practicing clinically in a new facility can both increase familiarity with new clinical environments and impact important organizational outcomes. Thus, simulation in a new work space can influence factors important to employees, organizations, and patients.

Characteristics of prehospital ST-segment elevation myocardial infarctions.

Abstract Introduction. Despite attention directed at treatment times of ST-segment elevation myocardial infarctions (STEMIs), little is known about the types of STEMIs presenting to the emergency department (ED). Objective. The purpose of this study was to determine the relative frequencies and characteristics of emergency medical services (EMS) STEMIs compared with those in patients who present to the ED by walk-in. This information may be applied in EMS training, system planning, and public education. Methods. This was a query of a prospectively gathered database of all STEMIs in patients presenting to Summa Akron City Hospital ED in 2009 and 2010. We collected demographic information, chief complaint, mode and time of arrival, and STEMI pattern (anterior, lateral, inferior, or posterior). We excluded transfers and in-hospital STEMIs. We calculated means, percentages, significance, and 95% confidence intervals (CIs) ± 10%. Results. We analyzed data from 308 patients. Most patients (241/308, 78%, CI 73%–83%) arrived by EMS, were male (203/308, 66%, CI 60%–71%), and were white (286/308, 93%, CI 89%–96%). Patients arriving by EMS were older (average 63 years, range 35–95) than walk-in patients (average 57 years, range 24–92). Two percent (5/241, 2%, CI 1%–5%) of EMS STEMI patients were under 40 years of age, compared with 10% (7/67, 10%, CI 4%–20%) of walk-in patients (p = 0.0017). The most common chief complaint was chest pain (278/308, 90%, CI 86%–93%). Inferior STEMIs were most common (167/308, 54%, CI 49%–60%), followed by anterior (127/308, 41%, CI 48%–60%), lateral (8/308, 3%, CI 1%–5%), and posterior (6/308, 2%, CI 1%–4%). A day-of-the-week analysis showed that no specific day was most common for STEMI presentation. Forty percent (122/308, 40%, CI 34%–45%) of patients presented during open catheterization laboratory hours (Monday through Friday, 0730–1700 hours). There was no significant statistical difference between EMS and walk-in patients with regard to STEMI pattern or patient demographics. Conclusions. In this study, 95% (294/308) of all STEMIs were inferior or anterior infarctions, and these types of presentations should be stressed in EMS education. Most STEMI patients at this institution arrived by ambulance and during off-hours. Younger patients were more likely to walk in. We need further study, but we may have identified a target population for future interventions. Key words: emergency medical services; allied health personnel; electrocardiography; myocardial infarction; heart catheterization; STEMI

Use of Radio Frequency Identification to Establish Emergency Medical Service Offload Times.

Abstract Emergency medical services (EMS) crews often wait for emergency department (ED) beds to become available to offload their patients. Presently there is no national benchmark for EMS turnaround or offload times, or method for objectively and reliably measuring this. This study introduces a novel method for monitoring offload times and identifying variance. We performed a descriptive, observational study in a large urban community teaching hospital. We affixed radio frequency identification (RFID) tags (Confidex Survivor™, Confidex, Inc., Glen Ellyn, IL) to 65 cots from 19 different EMS agencies and placed a reader (CaptureTech Weatherproof RFID Interpreter, Barcoding Inc., Baltimore, Maryland) in the ED ambulance entrance, allowing for passive recording of traffic. We recorded data for 16 weeks starting December 2009. Offload times were calculated for each visit and analyzed using STATA to show variations in individual and cumulative offload times based on the time of day and day of the week. Results are presented as median times, confidence intervals (CIs), and interquartile ranges (IQRs). We collected data on 2,512 visits. Five hundred and ninety-two were excluded because of incomplete data, leaving 1,920 (76%) complete visits. Average offload time was 13.2 minutes. Median time was 10.7 minutes (IQR 8.1 minutes to 15.4 minutes). A total of 43% of the patients (833/1,920, 95% CI 0.41–0.46) were offloaded in less than 10 minutes, while 27% (513/1,920, 95% CI 0.25–0.29) took greater than 15 minutes. Median times were longest on Mondays (11.5 minutes) and shortest on Wednesdays (10.3 minutes). Longest daily median offload time occurred between 1600 and 1700 (13.5 minutes), whereas the shortest median time was between 0800 and 0900 (9.3 minutes). Cumulative time spent waiting beyond 15 minutes totaled 72.5 hours over the study period. RFID monitoring is a simple and effective means of monitoring EMS traffic and wait times. At our institution, most squads are able to offload their patients within 15 minutes, with many in less than 10 minutes. Variations in wait times are seen and are a topic for future study.

Evaluation of ED patient and visitor understanding of living wills and do-not-resuscitate orders ☆ ☆☆ ★

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Characteristics and Core Curricular Elements of Medical Simulation Fellowships in North America

Background In the past few years, there has been rapid growth in the number of simulation fellowships for physicians in the United States and Canada, with the objective of producing faculty with expertise and leadership training in medical simulation. Relatively little is known about the collective content and structure of these new fellowship opportunities. Objective We sought to identify a common set of core curricular elements among existing simulation fellowships and to obtain demographic background information on participants and leadership. Methods We designed a web-based survey and circulated it to simulation fellowship directors in the United States and Canada. The questions explored aspects of the fellowship curriculum. A grounded theory approach was used to qualitatively analyze fellowship goals and objectives. Results Of the 29 program directors surveyed, 23 responded (79%). The most commonly listed goals and objectives were to increase skills in simulation curriculum development, simulation operations and training environment setup, research, educational theory, administration, and debriefing. The majority of the responding fellowship directors (17 of 22, 77%) indicated that a set of consensus national guidelines would benefit their fellowship program. Conclusions Simulation fellowships are experiencing a period of rapid growth. Development of a common set of program guidelines is a widely shared objective among fellowship directors.

Telepresent mechanical ventilation training versus traditional instruction: a simulation-based pilot study

Background Mechanical ventilation is a complex topic that requires an in-depth understanding of the cardiopulmonary system, its associated pathophysiology and comprehensive knowledge of equipment capabilities. Introduction The use of telepresent faculty to train providers in the use of mechanical ventilation using medical simulation as a teaching methodology is not well established. The aim of this study was to compare the efficacy of telepresent faculty versus traditional in-person instruction to teach mechanical ventilation to medical students. Materials and methods Medical students for this small cohort pilot study were instructed using either in-person instruction or telementoring. Initiation and management of mechanical ventilation were reviewed. Effectiveness was evaluated by pre- and post-multiple choice tests, confidence surveys and summative simulation scenarios. Students evaluated faculty debriefing using the Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV). Results A 3-day pilot curriculum demonstrated significant improvement in the confidence (in person P<0.001; telementoring P=0.001), knowledge (in person P<0.001; telementoring P=0.022) and performance (in person P<0.001; telementoring P<0.002) of medical students in their ability to manage a critically ill patient on mechanical ventilation. Participants favoured the in-person curriculum over telepresent education, however, resultant mean DASH-SV scores rated both approaches as consistently to extremely effective. Discussion While in-person learners demonstrated larger confidence and knowledge gains than telementored learners, improvement was seen in both cases. Learners rated both methods to be effective. Technological issues may have contributed to students providing a more favourable rating of the in-person curriculum. Conclusions Telementoring is a viable option to provide medical education to medical students on the fundamentals of ventilator management at institutions that may not have content experts readily available.

Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban.

Heparin-induced thrombocytopenia (HIT) is a disorder characterized by antibodies formed against the heparin-platelet factor 4 (PF4) complex that results in thrombosis and platelet consumption. It can lead to extensive thromboembolic disease and coagulopathy. Diagnosis remains a challenge, but there are now assays that can be used for confirmation. A 56 year old female presented to the emergency department with a complaint of shortness of breath. She had been hospitalized five weeks prior for a laparatomy, which was complicated by pneumonia requiring intubation, and deep vein thrombosis. Initial platelet level was 63 x 10/L after being 275 upon discharge. Computed tomography angiography revealed massive bilateral saddle pulmonary emboli. She was hemodynamically stable when she was started on a heparin bolus and drip, but it was then revealed that she had received low molecular weight heparin (LMWH) as an outpatient. Her blood pressure dropped and the heparin was discontinued. She was given 100 mg of tissue plasminogen activator (tPA) over one hour rather than two, with symptomatic improvement. She was treated with argatroban and later tested positive for antibodies against the heparin-PF4 complex which confirmed the diagnosis of HIT. She was converted to and discharged on warfarin and has done well. This case demonstrates the proper diagnosis and workup for pulmonary embolism caused by HIT, with successful treatment of both the underlying disease and its life-threatening complications. It demonstrates that, though the risk of HIT is less with LMWH than for heparin, it is not zero.