Airway & Respiratory, Patient Care

Study Analyzes Effectiveness of Triaging Intoxicated Individuals

Issue 5 and Volume 38.

Detox vs. ED
Ross DW, Schullek JR, Homan MB. EMS triage and transport of intoxicated individuals to a detoxification facility instead of an emergency department. Ann Emerg Med. 2013;61(2):175–184.

Congratulations to American Medical Response, Colorado Springs, for getting EMS research published in this prestigious academic journal. This is more proof that quality prehospital care research is getting due recognition in the wider medical community.

The topic of triaging inebriated patients has come up before in this column (Fowler et al in November 2011 and Cornwall et al in November 2012, for example). In previous research we’ve reviewed EMS clinicians were asked to hypothetically predict who needed emergency department (ED) care. Results showed high sensitivity (casting a wide enough net to catch those that need ED care), but low specificity (overtriaging so many patients who do not need evaluation still get taken to the ED).

Critics might be quick to point out that this was a quality improvement project that became a retrospective review of records. But one has to wonder if institutional review board (IRB) approval could have been obtained with such a scarcity of previous research. Kudos to Colorado Springs paramedics for actually determining an alternate transport disposition using a 29-question checklist. And even bigger kudos for only having a 1% adverse event rate that did not affect outcomes.

Results: In total, 718 patient encounters were reviewed for this study. Of those, 130 (19.2%) patients were transported directly to the detox facility with the remainder being transported to an ED. Of the 29 questions on the form, the most common exclusion criteria was an inability to ambulate without difficulty. Patients had to be willing to go to the detox center voluntarily.

Of the 580 patients brought to the ED, 184 did not require care beyond a blood glucose or breathalyzer. This checklist resulted in a high sensitivity but low specificity in predicting the need for ED care. The specificity was approximately 42%.

Four patients brought to detox required hospitalization within their 12-hour stay, but none appear to have had bad outcomes due to the delay.

It is interesting to note that breathalyzer values were similar across all patients, making that a poor triage tool, useful only to confirm alcohol use. Also notable was that 25 patients (6%) called more than four times during the study period, accounting for 30% of cases. Clearly, targeting these repeat offenders would be a great way to improve their health and reduce system overload.

This excellent scientific write-up opens the doors to the rest of us to do future projects with some prediction of safety. Will your service step up to the challenge of doing research?

(Note: The full text of the research article is available online here.)

Treating Status Epilepticus
Hillman J, Lehtimäki K, Peltola J, et al. Clinical significance of treatment delay in status epilepticus. Int J Emerg Med. 2013:27;6(1):6.

This retrospective chart review of 109 consecutive patients with status epilepticus sought to determine whether delays in treatment resulted in poor outcomes. The average delay in arrival was 30 minutes. The authors report difficulty in determining the duration of condition since it is unknown how long it was occurring prior to the call for help. Patients found to have continuing epileptiform activity were three times more likely to have a bad outcome. Administration of anti-epileptic medication within an hour of ED arrival was associated with significantly increased odds of good outcomes (82% of patients in this group had good recovery).

One concern is that 56 cases (>50%) of status epilepticus did not get prehospital anti-epileptic medication. The authors attribute this to a lack of recognition that SE was occurring, perhaps due to cases without large motor activity. This is a good lesson for all of us to brush up on status epilepticus and be ready to give an intramuscular benzodiazepine, since this has been proven to be faster than starting an IV.

Readers should be vigilant about the statistics used in this study and their conclusions. The sample size in this study is too small for some of the conclusions to be meaningful. The data related to the better outcomes from paramedics giving an anti-epileptic medication appears to be moving toward significance but is not quite there yet.

Watch Box: Comparing Video Laryngoscopes
Burnett AM, Frascone R, Wewerka S, et al. Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial. Prehosp Emerg Care. 2013; 17(1):103–134.

Stay tuned for the full story on this video laryngoscope product comparison from Regions Hospital in St. Paul. This was an oral abstract presentation at the January National Association of EMS Physicians meeting and ranked in the top ten projects selected.

In a nutshell, the study evaluated placement success rates with the Storz CMAC and King Vision. This was a prospective multi-agency non-randomized trial on adult patients requiring endotracheal intubation. Ninety-seven patients were enrolled. The success rate was significantly higher for the CMAC (79% vs. 53%, odds ratio of 3.39, probability of 0.0008). Complications were similar across devices and overall success rate was similar to previously published endotracheal intubation success rates.

(Dr. Burnett and Josh Salzman are co-authors and regular guests on the PCRF Podcasts linked to this column).

Glossary
Institutional Review Board (IRB): An IRB is made up of a group of reviewers who ensure the protection of human subjects are adhered to during research. IRBs can be great resources for ethics and project design and should be consulted prior to the start of any research effort. EMS agencies that do not have an IRB should seek out hospitals and academic institutions affiliated with medical directors or educational programs to review and approve prehospital projects.