Review of: Klevens MR, Morrison MA, Nadle J, et al: "Invasive methicillin-resistant staphylococcus aureus infections in theUnited States." JAMA. 298(15):1763-1771, 2007.
Methicillin-resistant Staphylococcus aureus (MRSA) remains a topic of conversation and worry. This form of Staph was first identified in hospitals in the 1960s and in the general population in 1981. Subsequently, non-invasive MRSA has become the most common cause of skin and soft-tissue infections in the U.S. Outbreaks are relatively common in sports teams, prisons and day-care centers due to the close proximity of individuals, as well as the sharing of various personal items.
But it's invasive MRSA that has really captured our attention. This article published in JAMA looked at the incidence rate of both hospital- and community-acquired MRSA infections in theU.S. for 2005. The overall rate of invasive MRSA continues to be very low. The authors identified the risk for developing invasive MRSA, either in the hospital or community, as related to recent hospitalizations, weakened immune systems and an extended use of antibiotics.
Invasive MRSA -- the type that causes death -- is very rare and preventable. This is the time to stress the importance of hand washing, which should begin in our own organizations. Not only could we halt the spread of MRSA, but we could significantly impact all the other diseases spread by person-to-person contact. To assist your agency in getting the word out, this issue of JAMA also contains a great one-page information sheet (p. 1826) that can be copied for distribution (http://jama.ama-assn.org/cgi/reprint/298/15/1826).
For more on MRSA, read Dr. Harold Rodenberg's article"How Super is MRSA?"
Davis DP, Graydon C, Stein R, et al: "The positive predictive value of paramedic versus emergency physician interpretation of the prehospital 12-lead electrocardiogram." Prehospital Emergency Care. 11(4):399Ï402, 2007.
It's a well-known fact that we can significantly affect the amount of muscle loss from a myocardial infarction (MI) with early reperfusion. The implementation of prehospital 12-lead ECGs has been of tremendous value in improving the "9-1-1 to balloon" time. However, should the decision to activate the cardiac catherization lab be based solely on the 12-lead interpretation by the paramedic? These authors led a study to find out.
In Phase One of the study, paramedic interpretation was used for catherization-lab activation. In Phase Two, the emergency department (ED) physician on duty assessed the 12-lead transmitted from the scene. Of the 54 patients enrolled in Phase One, 78% were diagnosed with an ST-segment elevation MI (STEMI), 70% went for immediate angiography and 69% had a coronary lesion. Of the 56 patients enrolled by the ED physician, 96% were diagnosed with a STEMI, 91% went for immediate angiography and 89% had a coronary lesion.
Although the numbers for correct identification aren't terrible, they do tell us that prehospital misinterpretation of 12-lead information can incur significant cost for the hospital. The authors point out that the cost of upgrading to transmit 12-lead ECGs to the hospital was significantly less expensive than extended paramedic training. Before implementing any changes in local protocols,EMS agencies and medical directors should review the literature carefully to be sure they're making the best decision for their patient population.
Improving Stroke Care
Crocco TJ: "Streamlining stroke care: From symptom onset to emergency department." Journal of Emergency Medicine. 33(3):255Ï260, 2007.
In order to make an impact on the outcome from a stroke, the patient must be evaluated and treated within three hours of symptom onset. Meeting this timeframe is difficult because most people aren't aware of the signs and symptoms of a stroke.
The author believes that having the right tools to identify a stroke patient may be even more important than a provider's level of certification. With proper training and practice, an EMT-basic can be as successful as a paramedic in identifying stroke patients. Several tools are available for theEMS provider to utilize when examining a possible stroke patient, and all perform equally well.
Work with your staff and medical director to identify the populations at risk in your area, and then develop educational programs that will address their unique needs. Improving identification and streamlining stroke care will go a long way toward helping your community get early care.
Kerby JD, MacLennan PA, Burton JN, et al: "Agreement between prehospital and emergency department Glasgow Coma Scores." Journal of Trauma. 63(5):1026Ï1031, 2007.
The Glasgow Coma Scale (GCS) was first developed to evaluate the level of consciousness in patients who had suffered neurologic injury. Its clinical use was to evaluate patients six hours after the injury (not exactly the way we use it today). These authors set out to determine if there was a significant difference between prehospital and ED scores for the individual sections and the total of the GCS.
The results demonstrate that for patients with a mild head injury (score of 13Ï15) or severe head injury (score of 3Ï8) prehospital and ED scores were similar. The intermediate head injury group (score of 9Ï12) tended to be scored higher on ED arrival than in the field. Also, the authors found no correlation between prehospital and ED scores for any of the individual GCS components in the intermediate group.
This study shows that we may need a better tool to evaluate head injuries in the field. Because GCS was never intended for this purpose, we should consider the evaluation and adoption of a more consistent scale.