Lack of Emergency Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trauma Care

From the Journal of the American College of Surgeons:

Our previous Delphi study identified several audit filters considered sensitive to deviations in prehospital trauma care and potentially useful in conducting performance improvement, a process currently recommended by the American College of Surgeons Committee on Trauma. This study validates 2 of those proposed audit filters.

STUDY DESIGN

We studied 4,744 trauma patients using the electronic records of the Central Region Trauma registry and Emergency Medical Services (EMS) patient logs for the period January 1, 2002, to December 31, 2004. We studied whether requests by on-scene Basic Life Support (BLS) for Advanced Life Support (ALS) assistance or failure by EMS personnel to record basic patient physiology at the scene was associated with increased in-hospital mortality. We performed multivariate analyses, including a propensity score quintile approach, adjusting for differences in case mix and clustering by hospital.

RESULTS

Overall mortality was 6.1%. A total of 28.2% (n = 1,337) of EMS records were missing patient scene physiologic data. Multivariate analysis revealed that patients missing 1 or more measures of patient physiology at the scene had increased risk of death (adjusted odds ratio = 2.15; 95% CI, 1.13 to 4.10). In 17.4% (n = 402) of cases BLS requested ALS assistance. Patients for whom BLS requested ALS had a similar risk of death as patients for whom ALS was initially dispatched (odds ratio = 1.04; 95% CI, 0.51 to 2.15).

CONCLUSIONS

Failure of EMS to document basic measures of scene physiology is associated with increased mortality. This deviation in care can serve as a sensitive audit filter for performance improvement. The need by BLS for ALS assistance was not associated with increased mortality.

CT Preferred for Pulmonary Embolism Diagnosis

From MedPage Today:

Emergency physicians and radiologists overwhelmingly choose computed tomography (CT) imaging to diagnose pulmonary embolism, a potentially deadly blockage of lung arteries, a new study found.

Ninety percent of radiologists and 96% of emergency physicians use CT as their first-line choice for the diagnosis of pulmonary embolism, according to a report published online December 22 in the American Journal of Roentgenology.

Other diagnostic techniques were used less regularly, with magnetic resonance imaging (MRI) used infrequently and ventilation-perfusion scintigraphy typically used in patients with renal failure or allergies to the iodine-based contrast material used for CT.

Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest

From Resuscitation:

Clinicians often place high priority on invasive airway placement during cardiopulmonary resuscitation. The benefit of early vs. later invasive airway placement remains unknown. In this study we examined the association between time to invasive airway (TTIA) placement and patient outcomes after inhospital cardiopulmonary arrest (CPA).

Methods

We analyzed data from the National Registry of Cardiopulmonary Resuscitation (NRCPR). We included hospitalized adult patients receiving attempted invasive airway placement (endotracheal intubation, laryngeal mask airway, tracheostomy, and cricothyrotomy) after the onset of CPA. We excluded cases in which airway insertion was attempted after return of spontaneous circulation (ROSC). We defined TTIA as the elapsed time from CPA recognition to accomplishment of an invasive airway. The primary outcomes were ROSC, 24-h survival, and survival to hospital discharge. We used multivariable logistic regression to evaluate the association between the patient outcome and early (<5min) vs. later (≥5min) TTIA, adjusted for hospital location, patient age and gender, first documented pulseless ECG rhythm, precipitating etiology and witnessed arrest.

Results

Of 82,649 CPA events, we studied the 25,006 cases in which TTIA was recorded and the inclusion criteria were met. Observations were most commonly excluded for not having an invasive airway emergently placed during resuscitation. The mean time to invasive airway placement was 5.9min (95% CI: 5.8–6.0). Patient outcomes were: ROSC 50.3% (49.7–51.0%), 24-h survival 33.7% (33.1–34.3%), survival to discharge 15.3% (14.9–15.8%). Early TTIA was not associated with ROSC (adjusted OR: 0.96, 0.91–1.01) but was associated with better odds of 24-h survival (adjusted OR: 0.94, 0.89–0.99). The relationships between TTIA and survival to discharge could not be determined.

Conclusions

Early invasive airway insertion was not associated with ROSC but was associated with slightly improved 24-h survival. Early invasive airway management may or may not improve inhospital cardiopulmonary resuscitation outcomes.

The Coming U.S. Doctor Shortage

From Business Week:

Presuming Congress passes some version of a health-care bill and it is signed into law, some 30 million currently uninsured people will suddenly find themselves with access to doctors. But there may not be enough doctors to see them.

In 1997, lawmakers placed a cap on the number of medical residencies—hospital training required for all doctors—in order to contain costs under Medicare, which pays for most of these training slots. Today the U.S. is in the grip of a nationwide doctor shortage, brought on by an aging population demanding access to specialists. Medical schools have stepped up to the plate, announcing plans to add 3,000 new positions for first-time students by 2018. But because the residency cap is still in place, these efforts may not be sufficient.

Woman Gives Birth Aboard Helicopter in Arizona

From Fox News:

PHOENIX — Authorities say a Supai woman has given birth aboard a helicopter.

The 33-year-old woman was in labor Tuesday at a clinic near the Grand Canyon.

A state Department of Public Safety helicopter took her to Kingman Regional Medical Center, about 130 miles from the Supai Village clinic, so she could deliver the baby at the hospital.

Shortly before landing in Kingman, DPS medics aboard the helicopter delivered the baby boy.

Authorities said no complications were reported. The name of the woman had not been released.

Okaloosa County EMS Offers Free Rides on Christmas Eve, Day

From JEMS:

FORT WALTON BEACH, Fla. –  EMS workers in the Panhandle will be offering free rides to residents who don’t have a way to visit friends and family this Christmas.

Patients in skilled nursing and senior housing facilities can get a ride with Okaloosa County Emergency Medical Services as part of its “Home for the Holidays” program.

The free rides are first-come, first-serve, and only within Okaloosa County on Christmas Eve and Christmas Day.

EMS chief Al Herndon says his crews love the program and don Santa Claus hats.

The Virtual Visit May Expand Access to Doctors

From the New York Times:

Americans could soon be able to see a doctor without getting out of bed, in a modern-day version of the house call that takes place over the Web.

OptumHealth, a division of UnitedHealth Group, the nation’s largest health insurer, plans to offer NowClinic, a service that connects patients and doctors using video chat, nationwide next year. It is introducing it state by state, starting with Texas, but not without resistance from state medical associations.

OptumHealth believes NowClinic will improve health care by ameliorating some of the stresses on the system today, like wasted time dealing with appointments and insurance claims, a shortage of primary care physicians and limited access to care for many patients.

But some doctors worry that the quality of care that patients receive will suffer if physicians neglect one of the most basic elements of health care: a physical exam.

Nurse finds hero among emergency room’s patients

From the Shenandoah News Leader:

I have the privilege and honor to be a nurse at Augusta Health Emergency Department. We care for many types of people … none more amazing than one Good Samaritan I met in the triage area on a busy weekend shift. He arrived by ambulance with a meek demeanor, not wanting to bother anyone with his ailments, quietly sitting in his chair to wait his turn. I turned and caught his image as he held his painful hands patiently waiting for some assistance. I was instantly moved to tears as he told his story. He was driving on I-64 and saw a car in front of him on fire and knew he had to stop. With seemingly no thought of his own risk of injury, he pulled over, got out and ran to the aid of the driver, who was himself on fire. With his hands, this kind gentle man pulled the burning driver through the window, sustaining burns to his own hands in the process. As I cared for this kind gentleman, I told him how he had affected all of the folks who cared for him that night. I asked if I could give him a hug. He allowed me to do so. As I wiped away the tears, I asked if he would mind if I used his name in a letter to the editor, and he granted me that permission.

No Man’s Land: Emergency response to remote areas sometimes is delayed by confusion

From the Farmington (NM) Times:

For at least 41 minutes, Patricia “Trish” Jacquez lay injured and dying in a ditch off La Plata Highway waiting for paramedics to respond.

Jacquez was killed Sept. 24 when her vehicle went off a 45-foot embankment just before 1 p.m. near the state line. The 26-year-old was not wearing a seat belt and was ejected from her vehicle. She landed about 20 feet off to the right.

Although police estimate the accident occurred shortly before 1 p.m., the length of time Jacquez waited is unclear.

“When in doubt, send them out,” is the motto for emergency responders in San Juan County and La Plata County, Colo.

But the numbers don’t agree with the words of officials because the time line paints a different picture.

About 20 minutes elapsed from the time the initial call to 911 was made to the time responders were first dispatched.

Uncertainty about the location of the accident, poor communication between dispatchers and witnesses, and lack of cell phone service all contribute to the confusing scenario that allowed time to pass before emergency vehicles were dispatched.

The confusion during which an injured woman lay waiting for medical help raises questions about the efficiency and reliability of emergency response in remote areas.

Press Release: $10 Billion More for Community Health Centers will Revolutionize Care

Ed. Emphasis added.

From Senator Bernie Sanders (VT):

A $10 billion investment in community health centers, expected to go to $14 billion when Congress completes work on health care reform legislation, was included in a final series of changes to the Senate bill unveiled today.

The investment would more than pay for itself by saving Medicaid $23 billion over five years on reduced emergency room use and hospital costs, according to a study conducted by George Washington University.