Prasanthi Govindarajan

Practice variability among the EMS systems participating in Cardiac Arrest Registry to Enhance Survival (CARES)

STUDY OBJECTIVE To describe the demographic, organizational and provider characteristics of the Emergency Medical Services (EMS) agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES). METHODS A web based survey instrument was developed by the CARES investigators and distributed to the EMS agencies participating in CARES in 2008. Survey questions addressed three domains related to prehospital care: (1) descriptors of the participating EMS agencies, (2) methods of clinical care and clinical protocols used by EMS agencies to deliver out-of-hospital cardiac arrest care and (3) use of resuscitation techniques by EMS agencies. Survey responses were collated and analyzed using descriptive statistics. RESULTS Surveys were received from 21/25 (84%) sites. The EMS agency characteristics including the response areas served by the agencies, organizational structure, medical direction status and deployment status are described. All respondents were non-volunteer agencies with a large number of them being fire-based (43%). Significant variability among the communities was observed with respect to their medical direction status and deployment status. We also observed differences in the management of OHCA among the participating agencies which included implementation of ACLS guideline updates, presence of termination of resuscitation protocol and destination policies for OHCA subjects. Similar variations between agencies were also observed in the use of resuscitation techniques. CONCLUSIONS Differences were observed between the EMS agencies participating in CARES. The clinical impact of these observed differences in agency and provider characteristics on OHCA outcomes deserves study.

A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study

Objectives: In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations. Methods: We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval). Results: We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to −0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92–0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites. Conclusions: Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.

Patients' perspectives of enrollment in research without consent: the patients' experiences in emergency research-progesterone for the treatment of traumatic brain injury study.

Objective:Research in acute illness often requires an exception from informed consent. Few studies have assessed the views of patients enrolled in exception from informed consent trials. This study was designed to assess the views of patients and their surrogates of exception from informed consent enrollment within the context of a randomized, placebo-controlled trial of an investigational agent for traumatic brain injury. Design:Interactive interview study. Setting:Nested within the Progesterone for the Treatment of Traumatic Brain Injury trial, a Phase III randomized controlled trial in acute traumatic brain injury. Subjects:Patients and surrogates (for patients incapable of being interviewed) enrolled in Progesterone for the Treatment of Traumatic Brain Injury under exception from informed consent at 12 sites. Interventions:None. Measurements and Main Results:Interviews focused on respondents’ acceptance of exception from informed consent enrollment in Progesterone for the Treatment of Traumatic Brain Injury, use of placebo and randomization, understanding of major study elements, and views regarding regulatory protections. Descriptive statistical analysis was performed; textual data were analyzed thematically. Eighty-five individuals were interviewed. Eighty-four percent had positive attitudes toward Progesterone for the Treatment of Traumatic Brain Injury inclusion. Seventy-eight percent found their inclusion under exception from informed consent acceptable, and 72% found use of exception from informed consent in Progesterone for the Treatment of Traumatic Brain Injury acceptable in general. Only two respondents clearly disagreed with both personal and general exception from informed consent enrollment. The most common concerns (26%) related to absence of consent. Eighty percent and 92% were accepting of placebo use and randomization, respectively. Although there were few black respondents (n = 11), they were less accepting of personal exception from informed consent enrollment than white respondents (55% vs 83%; p = 0.0494). Conclusions:Acceptance of exception from informed consent in this placebo-controlled trial of an investigational agent was high and exceeded acceptance among community consultation participants. Exception from informed consent enrollment appears generally consistent with patients’ preferences.

Comparative Evaluation of Stroke Triage Algorithms for Emergency Medical Dispatchers(MeDS): Prospective Cohort Study Protocol

BackgroundStroke is a major cause of death and leading cause of disability in the United States. To maximize a stroke patients chances of receiving thrombolytic treatment for acute ischemic stroke, it is important to improve prehospital recognition of stroke. However, it is known from published reports that emergency medical dispatchers (EMDs) using Card 28 of the Medical Priority Dispatch System protocols recognize stroke poorly. Therefore, to improve EMDs recognition of stroke, the National Association of Emergency Medical Dispatchers recently designed a new diagnostic stroke tool (Cincinnati Stroke Scale -CSS) to be used with Card 28. The objective of this study is to determine whether the addition of CSS improves diagnostic accuracy of stroke triage.Methods/DesignThis prospective experimental study will be conducted during a one-year period in the 911 call center of Santa Clara County, CA. We will include callers aged ≥ 18 years with a chief complaint suggestive of stroke and second party callers (by-stander or family who are in close proximity to the patient and can administer the tool) ≥ 18 years of age. Life threatening calls will be excluded from the study. Card 28 questions will be administered to subjects who meet study criteria. After completion of Card 28, CSS tool will be administered to all calls. EMDs will record their initial assessment of a cerebro-vascular accident (stroke) after completion of Card 28 and their final assessment after completion of CSS. These assessments will be compared with the hospital discharge diagnosis (ICD-9 codes) recorded in the Office of Statewide Health Planning and Development (OSHPD) database after linking the EMD database and OSHPD database using probabilistic linkage. The primary analysis will compare the sensitivity of the two stroke protocols using logistic regression and generalizing estimating equations to account for clustering by EMDs. To detect a 15% difference in sensitivity between the two groups with 80% power, we will enroll a total of 370 subjects in this trial.DiscussionA three week pilot study was performed which demonstrated the feasibility of implementation of the study protocol.

Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study

BackgroundNumerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.MethodsWe linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.ResultsTwenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.ConclusionsED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.

Community Consultation for Prehospital Research: Experiences of Study Coordinators and Principal Investigators

Abstract Objective. To assess principal investigators’ and study coordinators’ views and experiences regarding community consultation in a multicenter trial of prehospital treatment for status epilepticus conducted under an exception from informed consent for research in emergency settings. Methods. Principal investigators and study coordinators at all 17 hubs for the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) were invited to complete a web-based survey regarding community consultation at their site for RAMPART. Major domains included 1) perceived goals of community consultation, 2) experiences with and views of community consultation methods used, 3) interactions with IRB regarding community consultation, and 4) general satisfaction and lessons learned. Descriptive statistics were tabulated for Likert scale data; relevant themes were reported for text-based data. Results. Twenty-eight individuals (16 coordinators and 12 investigators) representing all 17 RAMPART hubs completed the survey. Respondents considered multiple community consultation goals to be important, with least support for the role of community consultation in altering study design. All sites used multiple methods (median = 5). The most widely used, and generally favored, method was attending previously scheduled meetings of existing groups. Respondents expressed frustration with low attendance and responsiveness at open public meetings. Conclusions. Coordinators and investigators in this trial viewed community consultation efforts as successful but reported real challenges generating public interest. Individuals with the condition under study were found to be more engaged and supportive of the trial. Respondents endorsed numerous potential goals of the community consultation process and often combined methods to achieve these goals.

Prehospital aspirin administration for acute coronary syndrome (ACS) in the USA: an EMS quality assessment using the NEMSIS 2011 database

Introduction National practice guidelines recommend early aspirin administration to reduce mortality in acute coronary syndrome (ACS). Although timely administration of aspirin has been shown to reduce mortality in ACS by 23%, prior regional Emergency Medical Service (EMS) data have shown inadequate prehospital administration of aspirin in patients with suspected cardiac ischaemia. Objectives Using the National EMS Information System (NEMSIS) database, we sought to determine (1) the proportion of patients with suspected cardiac ischaemia who received aspirin and (2) patient and prehospital characteristics that independently predicted administration of aspirin. Methods Analysis of the 2011 NEMSIS database targeted patients aged ≥40 years with a paramedic primary impression of ‘chest pain’. To identify patients with chest pain of suspected cardiac aetiology, we included those for whom an ECG or cardiac monitoring had been performed. Trauma-related chest pain and basic life support transports were excluded. The primary outcome was presence of aspirin administration. Patient (age, sex, race/ethnicity and insurance status) and regional characteristics where the EMS transport occurred were also obtained. Multivariate logistic regression was used to assess the independent association of patient and regional factors with aspirin administration for suspected cardiac ischaemia. Results Of the total 14 371 941 EMS incidents in the 2011 database, 198 231 patients met our inclusion criteria (1.3%). Of those, 45.4% received aspirin from the EMS provider. When compared with non-Hispanic white patients, several groups had greater odds of aspirin administration by EMS: non-Hispanic black patients (OR 1.49, 95% CI 1.44 to 1.55), non-Hispanic Asians (OR 1.62, 95% CI 1.21 to 2.18), Hispanics (OR 1.71, 95% CI 1.54 to 1.91) and other non-Hispanics (OR 1.27, 95% CI 1.07 to 1.51). Patients living in the Southern region of the USA (OR 0.59, 95% CI 0.57 to 0.62) and patients with governmental (federally administered such as Veterans Health Care, but not Medicare or Medicaid) insurance (OR 0.67, 95% CI 0.57 to 0.78) had the lowest odds of receiving aspirin. Age and sex (OR 1.00, 95% CI 1.00 to 1.00) were not associated with aspirin administration. Conclusions It is likely that prehospital aspirin administration for patients with suspected cardiac ischaemia remains low nationally and could be improved. Reasons for disparities among the various groups should be explored.

Nationwide Patterns of Hospitalization after Transient Ischemic Attack

BACKGROUND Little is known about nationwide patterns of hospitalization after transient ischemic attack (TIA). METHODS In a nationally representative sample of Emergency Department (ED) visits included in the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 through 2008, we estimated rates of hospitalization among patients with a primary ED diagnosis of TIA (International Classification of Diseases, 9th Revision (ICD-9), code 435). We used multiple logistic regression analysis to examine the association between hospitalization and demographic characteristics, geographic region, year of the visit, time of the visit, and markers of stroke risk. RESULTS On the basis of 782 cases of TIA sampled by the NHAMCS, 57% (95% confidence interval [CI], 52%-61%) of patients with TIA nationwide were hospitalized. A higher proportion of patients was hospitalized in 2003 to 2008 (62%; 95% CI, 56%-68%) than in 1997 to 2002 (52%; 95% CI, 46%-58%; P = .02). Compared with the US Northeast, patients were less likely to be hospitalized in the Midwest (odds ratio [OR], 0.5; 95% CI, .3-.9), the South (OR, 0.3; 95% CI, .2-.5), or the West (OR, 0.2; 95% CI, .1-.4). Compared with white patients, hospitalization was more likely among patients who were black (OR, 2.4; 95% CI, 1.3-4.5), Hispanic (OR, 3.8; 95% CI, 1.4-10.2), or of other races (OR, 3.5; 95% CI, 1.3-9.6). Patients with Medicaid were admitted less often than those with private insurance (OR, 0.3; 95% CI, .2-.8). CONCLUSIONS Nationwide patterns of hospitalization after TIA show significant regional and demographic variation. These results may provide a useful roadmap for efforts to improve systems of care for TIA across the country.

Paramedic Perspectives on Barriers to Prehospital Acute Stroke Recognition.

ABSTRACT Background: Emergency Medical Service (EMS) providers are tasked with rapid evaluation, stabilization, recognition, and transport of acute stroke patients. Although prehospital stroke scales were developed to assist with stroke recognition, unrecognized challenges exist in the prehospital setting that hinder accurate assessment of stroke. The goal of this qualitative study was to systematically understand the challenges and barriers faced by paramedics in recognizing stroke presentations in the field. Methods: Paramedics from 12 EMS agencies serving a mix of rural, suburban, and urban communities in the State of California participated in five focus group discussions. Group size ranged from 3–8, with a total of 28 participants. Demographics of the participants were collected and focus group recordings were transcribed verbatim. Transcripts were subjected to deductive and inductive coding, which identified recurrent and divergent themes. Results: Strong consensus existed around constraints to prehospital stroke recognition; participants cited the diversity of stroke presentations, linguistic diversity, and exam confounded by alcohol and or drug use as barriers to initial evaluation. Also, lack of educational feedback from hospital staff and physicians and continuing medical education on stroke were reported as major deterrents to enhancing their diagnostic acumen. Across groups, participants reported attempting to foster relationships with hospital personnel to augment their educational needs, but this was easier for rural than urban providers. Conclusions: While challenges to stroke recognition in the field were slightly different for rural and urban EMS, participants concurred that timely, systematic feedback on individual patients and case-based training would strengthen early stroke recognition skills.

National trends in the utilization of emergency medical services for acute myocardial infarction and stroke.

Introduction The emergency medical services (EMS) system plays a crucial role in the chain of survival for acute myocardial infarction (AMI) and stroke. While regional studies have shown underutilization of the 911 system for these time-sensitive conditions, national trends have not been studied. Our objective was to describe the national prevalence of EMS use for AMI and stroke, examine trends over a six-year period, and identify patient factors that may contribute to utilization. Methods Using the National Hospital Ambulatory Medical Care Survey-ED (NHAMCS) dataset from 2003–2009, we looked at patients with a discharge diagnosis of AMI or stroke who arrived to the emergency department (ED) by ambulance. We used a survey-weighted χ2 test for trend and logistic regression analysis. Results In the study, there were 442 actual AMI patients and 220 (49.8%) presented via EMS. There were 1,324 actual stroke patients and 666 (50.3%) presented via EMS. There was no significant change in EMS usage for AMI or stroke over the six-year period. Factors independently associated with EMS use for AMI and stroke included age (OR 1.21; 95% CI 1.12–1.31), Non-Hispanic black race (OR 1.72; 95% CI 1.16–2.29), and nursing home residence (OR 11.50; 95% CI 6.19–21.36). Conclusion In a nationally representative sample of ED visits from 20003–2009, there were no trends of increasing EMS use for AMI and stroke. Efforts to improve access to care could focus on patient groups that underutilize the EMS system for such conditions.