Thomas E. Platt

THE EFFECT OF A VOICE ASSIST MANIKIN (VAM) SYSTEM ON CPR QUALITY AMONG PREHOSPITAL PROVIDERS

Numerous studies have documented poor cardiopulmonary resuscitation (CPR) performance among prehospital providers during both simulated andactual resuscitations. Previous studies have shown that a real-time, voice assist manikin (VAM) system may improve CPR performance. Objective. To determine whether VAM prompting would improve CPR performance by prehospital providers during simulated resuscitation. Methods. In this prospective, randomized, crossover design, 114 prehospital providers performed two 3-minute sessions of one-rescuer CPR on a VAM-resuscitation manikin: one round with the VAM feature turned on andone with the feature turned off. The primary outcomes were measured at 15-second intervals andincluded the fraction of correct compressions, the mean compression depth, the fraction of correct ventilations, andthe mean ventilation tidal volume. Generalized estimating equations were used to analyze the repeated measures. Results. The VAM prompting was not directly associated with correct compressions during one-rescuer CPR in a cohort of subjects naïve to the system. However, the general decay in correct compressions seen over 3 minutes was attenuated with VAM prompting. Neither the compression depth nor the decay in compression depth over time was affected by VAM prompting. In contrast, VAM prompting did affect the fraction of correct ventilations andattenuated the time-dependent decline in correct ventilations in tidal volume. Conclusions. Use of VAM did not directly improve compression or ventilation rate or quality in this cohort of prehospital providers. However, use of VAM did prevent decay of compression andventilation performance over time.

Program accreditation effect on paramedic credentialing examination success rate.

Objectives. Program accreditation is used to ensure the delivery of quality education andtraining for allied health providers. However, accreditation is not mandated for paramedic education programs. This study examined if there is a relationship between completion of an accredited paramedic education program andachieving a passing score on the National Registry Paramedic Certification Examination. Methods. We used data from the National Registry Paramedic Certification Examination for calendar year 2002. Successful completion (passing) of the examination was defined as correctly answering a minimum of 126 out of 180 (70%) of the questions andmeeting or exceeding the individual subtest passing scores. Accredited paramedic training programs were certified by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) on or before January 1, 2002. Candidates reported demographic characteristics including age, gender, self-reported race andethnicity, education, andemployer type. We examined the relationship between passing the examination andattendance at an accredited paramedic training program. Results. A total of 12,773 students completed the examination. Students who attended an accredited program were more likely to pass the examination (OR = 1.65, 95% CI: 1.51–1.81). Attendance at an accredited training program was independently associated with passing the examination (OR = 1.58, 95% CI = 1.43–1.74) even after accounting for confounding demographic factors. Conclusion. Students who attended an accredited paramedic program were more likely to achieve a passing score on a national paramedic credentialing examination. Additional studies are needed to identify the aspects of program accreditation that lead to improved examination success.

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the services clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system

Differences in Paramedic Fatigue before and after Changing from a 24-hour to an 8-hour Shift Schedule: A Case Report.

Abstract Emergency medical services (EMS) clinicians often work 24-hour shifts. There is a growing body of literature, with an elevated level of concern among EMS leaders that longer shifts contribute to fatigued workers and negative safety outcomes. However, many questions remain about shift length, fatigue, and outcomes. We describe a case of a 26-year-old male paramedic who switched shift schedules during the midpoint of a randomized trial that addressed fatigue in EMS workers (clinicaltrials.gov identifier: NCT02063737). The participant (case) began the study working full-time with a critical care, advanced life support EMS system that utilized 24-hour shifts. He then transitioned to an EMS system that deploys workers on 8-hour shifts. Per protocol for the randomized trial, the participant completed a battery of sleep health and fatigue surveys at baseline and at the end of 90 days of study. He also reported perceived fatigue, sleepiness, and difficulty with concentration at the beginning, every 4 hours during, and at the end of scheduled shifts, for a total of ten 24-hour shifts and twenty-four 8-hour shifts. We discuss differences in measures taken before and after switching shift schedules, and highlight differences in fatigue, sleepiness, and difficulty with concentration taken at the end of all 34 scheduled shifts stratified by shift duration (24 hours versus 8 hours). Findings from this case report present a unique opportunity to 1) observe and analyze a phenomenon that has not been investigated in great detail in the EMS setting; and 2) address an issue of significance to employers and EMS clinicians alike.

FEASIBILITY OF STERNAL INTRAOSSEOUS APPLICATION BY EMT-BASIC STUDENTS

presenting in VF during the first year using RLB defibrillators. There were 153 adult patients during the comparable year using MDS defibrillators. The 120-J RLB shock had a significantly higher first shock rate of successful VF termination (67%) compared with the 200 J MDS shock (48%, p, 0.0025). There were 50 (35%) patients who had a return of spontaneous circulation (ROSC) using the RLB waveform compared with 40 (26%) patients using an MDS waveform. Thirty-five (25%) of these patients were defibrillated to a sinus rhythm ROSC using the RLB defibrillator compared with 23 patients (15%, p = 0.05) using an MDS defibrillator. Patients resuscitated with shocks only were patients resuscitated to a sinus rhythm ROSC with less than three shocks total and with no drug therapy utilized. The RLB waveform resuscitated 24 (17%) of the 35 sinus rhythm ROSC patients with shocks only. The MDS waveform resuscitated 15 (10%) of the 23 sinus rhythm ROSC patients with shocks only. Conclusions: The RLB waveform defibrillated OHCA patients with significantly better rates using significantly less energy when compared with MDS waveforms. The RLB waveform shocked OHCA patients to normal sinus rhythm ROSC with significantly greater rates than MDS waveforms.