Patient Care, Special Topics

PCRF 2015 Clinical Abstracts

Docs in the Street: Evaluating the Perceived Usefulness of Field EMS Medical Director Involvement

Author: Dr. Drew Harrell, MD
Associate Authors: Jacob Gonzales, MSIV, Jon Femling, MD/PhD, Steve Weiss, MD


Introduction
The EMS subspecialty is a growing field producing specially trained EMS physicians. Previous studies have focused on the quantity, rather than the quality, of medical direction involvement and have not addressed the perceptions of EMS providers.

Objective
ALS EMS providers are more likely than non-ALS providers to report direct on-scene EMS physician contact as making a significant impact on their practice. The primary outcome is the percent of respondents reporting physician contact as having impacted their practice. Dependent variables are level of EMS training, time since last physician interaction, and demographic data of the respondents, such as age.

Methods
The authors surveyed 970 EMS providers in three EMS agencies in Bernalillo County, N.M., during regularly scheduled training. In all, 668 (68.8%) of surveys were completed and returned, and 26% (n=-174) of respondents practiced at the ALS level.

Results
Eighty percent (N=776) of respondents report having had on-scene EMS physician contact within the past  year. ALS-level respondents were more likely to report that physician contact impacted their practice as compared to non-ALS respondents (69% vs. 50%, p=0.0001, Fisher’s exact test). Providers who had contact within the last six months rated physician contact as more useful than those with last contact between six and 12 months before the survey p=0.0068, Student’s t-test). In addition, younger providers perceived a greater benefit from on-site medical direction.

Conclusion
This study confirms that prehospital providers find benefit from on-site medical direction by EMS trained physicians. It also reveals that frequent on-scene interactions benefit prehospital EMS, especially younger ALS providers and suggests a strategy of more frequent interactions targeting ALS-level providers, especially those early in their career, may improve pre- hospital provider satisfaction.


Trends in Prehospital Intraosseous Use Since 2001

Author: Devin Price, MICP, PhDc

Associate Authors: Charles Foat, PhD, Ron Lawler, BUS, NRP, Christopher Ford, MD, Angela Finney, MSN, CCEMTP, NREMT-P, EMSI, Erich Berg, BA, Amy Ham- mond, BS, Hanorah Vanni, BA, Luke Stanke, PhDc, Susan Furness, PhDc

Introduction
It is unknown to what extent the use of intraosseous (IO) access for IV solutions in the prehospital setting has changed over time. Factors that might have impacted rates of IO use include: recommendations in the 2005 American Heart Association Guide- lines, advances in IO technology, and changes in scope of practice.

Objective
To  determine whether the proportion of patients on which insertion of an IO device was attempted in the prehospital environment has increased across all patient conditions since 2001.

Methods
Between January 2001 and December 2013, students reported their clinical experiences using Fisdap, an online database that stores student information. Inclusion criteria consisted of student consent and instructor verification of student records. Data points queried were: all IV and IO attempts, year of patient, age of patient,  indicators of cardiac arrest (primary impression/secondary impression, chest compressions, EPI IV/IO use), medications administered, and region of the United States. A logistic regression was fit to the data in which the choice between IO and IV was the outcome variable and was compared to the year of the incident. In cases in which both IO and IV were performed, the outcome was set to 0.5. Region, age, and indicator of cardiac arrest were control variables. This is retrospective study used prospectively collected, self-reported data. Some students or programs might have limited access to IOs, which might have changed over time. This data include observed IO interventions, which might impact the data.
 
Results
IO use was low and flat through 2006. Then the data show an increase in the likelihood that a patient would receive an IO. This escalated throughout the rest of the study period. Cardiac arrest shows a very marked increase in the use of IOs over IVs.
 
Conclusion
The proportion of patients on which insertion of an IO was attempted in the prehospital environment increased across all patient conditions during the study period, starting in 2006. Additional research is required to examine the factors that might have influenced this increase.


An Assessment of the Agree-ment Between the Complaint Reported by Dispatch and the EMS Provider’s Primary Impression of the Patient’s Most Significant Condition in North Carolina
Author: Dr. Antonio Fernandez, PhD, NRP, FAHA
Associate Authors: Kevin M. Sullivan, MS, NREMT-P, Sean Patrick Kaye, BA, EMT-P, Michael T. Mastropole, BS, EMT-B, Tom Mitchell, EMT-P, James E. Win- slow, MD, MPH


Introduction
Accurate reporting of the prehospital patient’s most significant condition by dispatch allows EMTs and paramedics to better prepare for emergency calls before arrival on scene and potentially reduce prehospital treatment and transport delays.
 
Objective
The study objective was to assess the agreement between the Complaint Reported by Dispatch (CRD) and the EMS Provider’s Primary Impression (PPI) of the patient’s most significant condition. Secondarily, CRD and PPI agreement was compared by community size. The study was conducted in North Carolina.

Methods
This retrospective study assessed all emergency calls included in the NC State EMS Data System from Jan. 1, 2013, to Dec. 31, 2013. Calls were excluded if CRD or PPI were not reported or a dispatch delay of uncooperative caller, language barrier, or technical failure was reported. North Carolina EMS data are collected in the National EMS Information System (NEMSIS) standard. NEMSIS elements E03_01 (Complaint Reported by Dis- patch) and E09_15 (Provider’s Primary Impression) were analyzed. A matrix identifying acceptable PPIs for each CRD was developed and used to facilitate calculations of percent agreement and 95% confidence intervals. Univariate odds ratios (OR), 95%CI, and chi-square tests were used to examine differences in CRD and PPI agreement in urban and rural areas.

Results
In 2013, there were 1,132,839 emergency calls in the NC State EMS Data System. Of those, 654,755 (57.8%) calls were excluded due to undocumented CRD or PPI and 232 (<0.1%) reported dispatch delays of uncooperative caller, language barrier, or technical failure, leaving 477,852 (42.2%) calls available for analysis. The overall agreement of CRD and PPI in NC was 72.8% (95%CI: 72.7% to 73.0%). There was a statistically significant difference noted when comparing percent agreement of CRD and PPI in rural (73.6%) and urban (72.5%) areas (OR=1.06, 95%CI: 1.04-1.07; p <0.01).

Conclusion
This study challenges commonly held opinions that dispatch complaints are not predictive of patient complaints. There was agreement between CRD and PPI on almost three-quarters of the 9-1-1 calls in North Carolina, suggesting that dispatch complaint has predictive value on the patient’s most significant condition. Future research should evaluate whether emergency communication centers have the potential to correctly identify the acuity of the patient’s condition and should explore challenges with data completeness.


Estimates of Cost-Effectiveness of Implementing a Statewide Tranexamic Acid (TXA) Proto- col in North Carolina
Author: Lesley Hammontree, EMT-B

Associate Authors: Rebecca Shepard, EMT-P, Muhned Aljaizani, EMT-B, Lee Van Vleet, MHS, NREMT-P, Sara Houston, BS, NREMT-P, Michael Hubble, PhD, NREMT-P

Introduction
Hemorrhage is responsible for about 33% of all traumatic deaths. The CRASH-2 trial was a randomized control trial of early Tranexamic Acid (TXA) administration to bleeding trauma patients and it showed a reduction in overall mortality associated with TXA use. Since publication of the trial results TXA has been included in both military and civilian prehospital trauma protocols; however the cost-effectiveness of widespread adoption of TXA by EMS is unknown.

Objective
To calculate the cost-effectiveness of incorporating TXA into North Carolina State EMS protocols.

Methods
A retrospective analysis was conducted using data from the North Carolina Prehospital Care Reporting System (PreMIS). The sample included all statewide trauma cases from July 31 to Dec. 31, 2012. Using age and race-adjusted life tables, the average life years saved was calculated for each potential life saved by TXA administra- tion. Implementation costs consisted of stocking and training costs. Stocking cost was the cost associated with placing 2 gms of TXA on each paramedic ambulance, assuming a shelf life of 3 years. Training costs were calculated as the average paramedic hourly pay rate plus 30% for benefit and employer-associated costs. It was assumed that TXA protocol training would require 1 hour and would be repeated every 3 years. The economic analysis was conducted from the per- spective of the state EMS system.

Results
Based on the TXA inclusionary criteria (age≥16 years, suspected hemorrhage, penetrating or blunt injury, BP<90 mmHg, and HR>110), 114 patients could potentially receive TXA per year in North Carolina. Based on the CRASH-2 trial, TXA yields an absolute mortality reduction of 2.1%, thus saving an additional 2.4 lives per year in North Carolina with an estimated 41.5 life years saved. The statewide TXA implementation cost was $494, 291 yielding a cost per life saved of $68, 773 and $1,657 per life year saved when implementation costs are amortized over a three-year period.

Conclusion
Medical interventions are generally considered to be cost-effective at $50,000 or less per life year gained. TXA implementation in North Carolina is well below this threshold, representing a cost-effective addition to state-wide EMS protocols.


Factors Effecting the Decision to Initiate Resuscitative Efforts in Traumatic Cardiac Arrests

Author: Katlyn Williams, EMT

Associate Authors: Youssef Alamri, EMT, Lance Rhyne, EMT, Evelyn Wilson, MHS, NRP, NCEE, Susan Crisp, EdD, NRP
 
Introduction
Current trends in EMS have noted enhanced paramedic autonomy in the decision making process of prehos- pital traumatic cardiac arrest. Other studies have addressed disparities in care for traumatized patients, as related to demographics such as age, race, ethnicity and gender. This retrospective epidemiological study evaluated variables potentially  influencing paramedic decisions to attempt resuscitation of traumatic cardiac arrest. In addition to the aforementioned demographic groups, clinical variables such as mechanism of injury and presenting cardiac rhythm were considered.

Objective
To determine the variables influencing the paramedic decision to resuscitate traumatic cardiac arrests.

Methods
This retrospective study used the North Carolina Prehospital Care Reporting System (PreMIS) to examine resuscitation attempts among traumatic cardiac arrests between July and December 2013. All attempted resuscitations of traumatic cardiac arrest patients resulting from blunt or penetrating trauma were included. Patients with Do Not Resuscitate Orders (DNR) or where resuscitation efforts were considered futile were excluded, as were patients with multiple mechanisms of injury (e.g, combination of burn, blunt, and penetrating trauma). A logistic regression was performed to test factors predictive of the paramedic decision to attempt resuscitation of the traumatic cardiac arrest patient.

Results
Resuscitation efforts were initiated in 142 cases. Resuscitation efforts included any combination of CPR, assisted ventilations, defibrillation, and medication administration. The factors examined were age, gender, ethnicity and race, mechanism of injury, and first presenting cardiac rhythm. All variables were statistically nonsignificant. These findings suggest that the paramedic decision to attempt  resuscitation in traumatic cardiac arrest is complex and cannot be explained by demographic, mechanism of injury, and limited clinical variables alone.

Conclusions
This study was not able to identify common mechanism of injury, demographics or clinical variables as reliable predictors of resuscitation attempts by paramedics working a traumatic cardiac arrest. These findings suggest that the decision-making process by paramedics in determining whether to initiate resuscitation is complex and warrants further  study.


Pain Management in Geriatric Fall Patients with Injuries
Author: Wills Dean, EMT-P

Associate Authors: Ali Alsiwar, EMT- B, Walt Nessizius, EMT-B, Denise Wilfong, Ph.D., NREMT-P, Sharon Schiro, Ph.D.

Introduction
Quality pain assessment and management are considered standard of care for all patients in the prehospital setting. The North Carolina Office of EMS protocols recommend assessment of pain and treatment with appropriate narcotic and/or non-narcotic options. However, comorbidities and drug interactions could impact decisions on pain management by the prehospital provider.

Objectives
To investigate the prehospital management of pain in the geriatric fall population.

Methods
This retrospective study of the North Carolina Prehospital Medical Information System (PreMIS) included records from June to December 2012 for patients who fell, were age 65 or older, and who had documented pain-scale values. Statistical methods consisted of descriptive statistics, as well as multivariate logistic regression to calculate the odds ratio of pain  medication administration as a function of patient contact time, initial pain scale, and other demographic and clinical variables.

Results
Of the 4,382 patients who met inclusion criteria, 1,062 (24.2%) received pain medications, of whom 96% (1,020) received narcotic pain medications and 4% received non-narcotic medications. Transport time (OR=1.03, p<0.0001), first pain scale (OR=1.46, p<0.0001), and time on scene with patient (OR=1.065, p<0.0001) were associated with receiving pain medication. Age, gender, race, insurance, alcohol or drug use, GCS, or systolic blood pressure did not influence the decision to administer pain medication. Average pain scale change improved by 3 points on a 10-point scale for patients who received pain medication. Of the patients who did not receive pain medications, average pain relief was 0.25 on a 10-point scale and 27% reported severe pain.

Conclusion
This study found that most  geriatric fall patients did not receive prehospital pain medication, and receiving pain medication was significantly correlated with the first pain scale value and patient contact time. Narcotics were the predominant class of medication given, regardless of initial pain scale value, and patients who did receive pain medication reported their pain decreased.


Disparities in Spinal Clearance: Age-Based Immobilization in the Patient with Known Drug or Alcohol Use
Author: Emily Burchette, EMT-I

Associate Authors: Ginny K. Renkiewicz, MHS, EMT-P, Candi Van Vleet, DHA(c), NRP, Joseph D. de Give, EMT-B, Nicholas J. Wall, EMT-B

Introduction
In the prehospital setting, patients with perceived or self-reported  drug or alcohol use (impaired) provide a unique challenge to the EMS provider. Clinical guidelines exist to address management of adult and geriatric populations with known drug or alcohol use. However, it is unclear how rigorously EMS providers adhere to spinal clearance protocols in injured patients.

Objective
To identify adult and geriatric patients with known drug or alcohol use who did not receive spinal immobilization when indicated.

Methods
This study is a retrospective observational analysis of trauma patients from July 1, 2012, to December 31,2012, using the North Carolina Prehospital Care Reporting System (PreMIS). Parameters for analysis were based on the spinal clearance protocol used in North Carolina at the time data were reported. The procedure specified that patients aged 65 or older, or with any evidence of intoxication, required immobilization. Patient groups included those between 18 and 64 years and those 65 or older with perceived or self-reported drug or alcohol use who suffered blunt trauma. Mechanisms most likely to produce patients who needed spinal immobilization (motor vehicle collisions and falls) were analyzed. Patients whose chief complaints were behavioral in origin or deceased on arrival were excluded. Based on the reported mechanism of injury, chi-square analysis was used to determine whether patients received spinal immobilization when indicated by protocol.

Results
A total of 38,052 patients met inclusion criteria with 16,925 (44.5%) patients aged 65 years or older. Adults involved in an MVC (n=11,796 [31%]) who were impaired were not immobilized 36.3% of the time, compared to 52.1% in the unimpaired group (p<0.01). There was no difference in immobilization between impairment groups for geriatric MVC patients (n=1,170, 41.7% v. 56.3%, p=0.309). Adult fall patients (n=9,331) showed a significant difference when comparing non-immobilization rates based on impairment group (62.6% v. 68.9%, p<0.01). Lastly, geriatric fall patients (n=15,755; 93.1% of older patients) not immobilized and with known impairment was significant between impairment groups (71.0% v. 62.0%, p<0.01).

Conclusion
This study found disparities for spinal immobilization in adult and geriatric patients with perceived or self-reported drug or alcohol use. This informaton could be useful for those tasked with quality performance assessments or initiatives in EMS.


Does Prehospital Choice of Administered Paralytic Affect Intubation Success Rates?
Author: Morgan Reed, EMT-I

Associate Authors: Ali Alyami, EMT-B, Dana Hunnewell, NREMT- P, Melisa McNeil, MHS, EMT-P, Greg Miller, EMT-P

Introduction
Conflicting conclusions regarding the preferred and more efficacious paralytic in rapid sequence induction (RSI) have been reported in the medical literature. The use of depo- larizing paralytics in RSI have been associated with higher success rates and fewer attempts at intubation  in the aeromedical environment. Additional studies among emergency department patients found no statistically significant difference in success rates based upon the type of paralytic administered. While research exists examining paralytic efficacy in settings such as the ED and aeromedical transport agencies, there is a paucity of research in the traditional prehospital environment.

Objective
To compare the prehospital RSI success rates between depolarizing and non-depolarizing paralytic agents.
 
Methods
The authors conducted a retrospective observational study of trauma patients using the North Carolina Prehospital Care Reporting System (PreMIS) from July 1, 2012 to December 31, 2012. Inclusionary criteria were patients 12 years of age or older with an intubation or RSI  attempt, and administration of a depolarizing (succinylcholine) or nondepolarizing (vecuronium, rocuronium, pancuronium) paralytic. Logistic regression was used to determine the influence of paralytic type on RSI success while controlling for potentially confounding variables.

Results
Eighty patients met inclusionary criteria, in which xx% were Caucasian and xx% were male. The mean age and Glasgow Coma Score were xx.x years and 6.34 respectively. Blunt trauma was the mechanism of injury in  xx% of patients. More patients received a depolarizing paralytic (86%) than a nondepolarizing agent (14%). Paralytic type was not associated with intubation success. Patients with higher GCS were more likely to be successfully intubated (OR=1.357, p=0.21), and blunt trauma patients were less likely to be successfully intubated (OR=0.139, p=0.040).

Conclusion
No statistically significant difference was found in paralytic type and intubation success. Further studies are needed to determine specific injury types and patient factors that affect prehospital intubation success.


Statewide Analysis of Endotra- chealo and Rapid Sequence In- tubation Success Reviewed with Capnography
Author: Christopher Warr, RNEMT-P

Associate Authors: Michael Hub- ble, PhD, NREMT-P, Sara Houston, BS, NREMT-P, Stephen Taylor, BS, EMT-P, Chris Kepley, BA, EMT-P, Mary Richardson, MBA, EMT-P, Stephen Blackburn, AAS, EMT-P
 
Introduction
Disparities between prehospital endotracheal intubation (ETI) and rapid sequence induction (RSI) have been widely discussed in the literature. Success rates of other research, reported by region or localized data, lacked statewide investigation among prehospital trauma patients.

Objective
To examine across North Carolina ETI and RSI, both first attempt success and ever successful, and the correlation of documented tube placement with capnography.

Methods
This retrospectively reviewed observational study of prehospital ETI and RSI used data from the North Carolina Prehospital Care Reporting System (PreMIS) and the North Carolina Hospital Trauma Registry from July 1, 2012 to December 31, 2012. Inclusion criteria included trauma patients 18 years of age or older excluding cardiac arrest after EMS arrival. A chi-square test was used to correlate capnography documentation with frequency of ETI and RSI.

Results
Data for intubated trauma patient encounters (N=511) were retrospectively reviewed and analyzed. Of these patients, 372 (72.8%)received ETI and the remaining 139 (27.2%) ETI accompanied by RSI medications. Success rates were higher among noncardiac arrest patients when RSI was used. Documented capnography performed with ETI 82.4% (141/171) p = 0.001 and ETI with RSI 89.7% (65/73) p = 0.393.

Conclusion
Comparing both the first attempt success and ever-successful intubations with and without the uses of RSI medications in trauma patients, this study shows that airway management success both on first attempt and eventual success increased with the use of RSI medications. Use of capnography as a confirmation of successful intubation showed room for improvement.


 
Effects of Spinal Immobilization on Oxygenation and Ventilation in Healthy Adults

Author: Anne Gravitt, B.S., N.R.P.

Associate Authors: Scott Davis, B.S., N.R.P., Britni Price, B. S., N.R.P., Jordan Keyser, B.S., N.R.P., Elliot Carhart, Ed.D., R.R.T., N.R.P

Introduction
Previous studies have demonstrated reductions in pulmonary function associated with spinal immobilization, but have not examined the physiologic effects of spinal immobilization on SpO2 or ETCO2.

Objective
To determine the effects of spinal immobilization on SpO2 and ETCO2 in healthy adults.

Methods
This pre/post test experiment used a convenience sample of healthy adult volunteers who were randomly assigned to one of three conventional immobilization techniques. Baseline SpO2 and ETCO2 values were obtained for all participants in a standing position and again after 30-minutes of immobilization.

Results
Sixty participants enrolled in the study, but three opted out before completion (N=57). Participants in all three groups experienced a non-significant increase in ETCO2, H(2, N=57)=.984, p=.061. The baseline to 30-minute SpO2 change was not significantly different between the three individual immobilization methods, but there was a significant difference between the combined LSB [LSB ??} groups and the third group placed semi-Fowler on a stretcher with a C-collar and Kendrick Extrication Device, U=153, p<0.01.

Conclusion
The results of this study indicated a significant difference in the effect different immobilization methods had on oxygenation. This was likely a result of regional changes in ventilation/perfusion matching associated with positioning of those patients. Unlike the participants placed on an LSB, those placed semi-Fowler on a stretcher with a C-collar and KED experienced a drop in SpO2. This has potential implications for the use of this method as an alternative to the LSB in patients who cannot tolerate supine positioning due to co-morbid respiratory impairment.


Improvised Chest Seals Are Less Effective Than Commercially Manufactured Vented Chest Seals
Author: Dr. Elliott Carhart, Ed.D., R.R.T., N.R.P
Associate Authors: Scott Larry Stewart, B.S., N.R.P., Joshua Epperson, B.S., N.R.P, Tim Carter, B.S., NRP, Jarrett Coleman, NRP


Introduction
Penetrating chest wounds have traditionally been treated with improvised chest seals using a petroleum gauze bandage taped on three sides. These seals are intended to prevent the development of tension pneumothorax by sealing the chest, while allowing pressure inside the thoracic cavity to vent through the exposed side. No known studies have examined the effectiveness of improvised chest seals with regard to their venting characteristics.

Objective
To compare the effectiveness of improvised chest seals against commercially manufactured vented chest seals.

Methods
The authors used a series of pressurized vessels with integrated manometers to serve as thoracic models for testing the pressure relief threshold of various chest seals. Four types of simulated chest wounds were created in the sidewall of separate pressurized vessels (0.5” slit, 1” slit, 0.5” hole, 1” hole). Two types of commercially manufactured vented chest seals were tested on each wound type (Asherman, Bolin) as were with the previously described improvised chest seals. Comparisons of chest seal effectiveness were made based on differences in relief pressure thresholds.

Results
A Mann-Whitney U test showed a significant difference in the pressures at which improvised chest seals activated (n=12) as compared to commercially manufactured vented chest seals (n=8), U=20.5, p=.031. The mean relief pressure for improvised chest seals was 21.5 cmH2O (SD=25.9), while the commercially manufactured vented seals had a mean relief pressure of 2.5 cmH20 (SD=1.7). Commercially manufactured vented chest seals performed consistently for all wound types. However, the results of a Kruskal-Wallis one-way ANOVA showed a significant difference in relief pressures for improvised chest seals associated with the size of the wound, H(3, n=8)=10.238, p=.017.

Conclusion
Commercially manufactured vented chest seals were significantly more effective in relieving pressure in this study’s model thoracic cavities than the improvised chest seals, regardless of the wound type. The pressures at which the improvised chest seals vented for the smaller wounds would likely result in the development of a tension pneumothorax, thus rendering them useless. Results showed that commercially manufactured vented chest seals are significantly more effective at relieving pressure than improvised chest seals.


Comparison Study of the Tokyo Prehopital Stroke Screening System and the Cincinnati Prehospital Stroke Scale
Author: Kent Okawa, BA

Associate Authors: Marc Eckstein, MD, MPH, FACEP, Heron Amerkhanian, BS, Hiroyuki Yokota, MD, PhD
 
Introduction
Stroke is the fourth leading cause of mortality and the leading cause of disability both in the United  States and in Japan. For optimal stroke care, paramedics must accurately identify stroke patients in the field so the appropriate treatments can be started and the patient can be transported to the appropriate hospital with advance notification. This study evaluated the prehospital stroke screening process in Tokyo, Japan, and compared the process to that of the Cincinnati Prehospital Stroke Scale (CPSS), which is used in the United States.

Methods
All emergency calls in the Tokyo Metropolitan area from February 13, 2012, to February 20, 2012, were included in the study. The Tokyo prehospital screening process for stroke or TIA by paramedics were compared to the final diagnosis of stroke or TIA in the hospital. Presence or absence of symptoms from the CPSS  was also recorded by paramedics for the same sample. The sensitivities and the specificities of the two screening tests were calculated with confidence intervals and p-values.

Results
Out of 10,238 patients, 225 (0.02%) patients were considered to be in critical condition and were excluded in this analysis. Out of the remaining 10,013 patients, 314 (0.03%) were diagnosed with a stroke or TIA. The paramedics had identified 228 (72.6%) of these as suspicious for stroke, a sensitivity of 0.73 (95% CI, 0.68-0.76), while the CPSS in this same sample resulted in a sensitivity of 0.63 (95% CI, 0.57-0.68, p<0.025). Of the 9,699 patients not diagnosed with a stroke, paramedics believed 9,541 (98.4%) of them were not suspicious for a stroke. This Japanese process was associated with a high specificity for stroke diagnosis (0.98), but was not better that the CPSS (0.98).

Conclusion
Paramedics screening for stroke in Tokyo had a higher sensitivity  than the CPSS. Possible reasons for this include use of clinical gestalt, low threshold to suspect strokes, as well as using family members as important historians. Further research is necessary to identify differences in the screening methods to identify pos- sible criteria that could also improve the U.S. stroke screening process.


Epidemiology of Geriatric Trauma
Author: Sophie Tucker, EMT-I

Associate Authors: Stephen Taylor, BS, EMT-P, Chelsea Champion, EMT-B, Ali Alnakhli, EMT-B, Theodore Morgan, BS, FAWM, EMT-P, Ginny K, Renkiewicz, MHS, EMT-P

Introduction
In the United States, the post-WWII demographic (i.e., the “baby-boomer”) is aging, making geriatrics the  largest demographic subset of patients encountered by prehospital providers. As a result of this growth, the prevalence of geriatric trauma affects prehospital resources making it important to identify epidemiological factors to better understand and serve these patients.

Objective
To identify the epidemiology of geriatric trauma patients including the frequency of EMS transport.

Methods
The study is a retrospective observational study of the epidemiology of geriatric trauma using the North Carolina Prehospital Care Reporting System (PreMIS) which was queried from July 1, 2012, to December 31, 2012. All trauma patients 65 years of age or older were included. Patients with incomplete data points, those for whom no treatment was required, or those who refused transport were excluded. Descriptive statistics were used to produce frequency distributions for age, gender, race, location and time the injury occurred, cause of injury, and transport destination.
 
Results
A total of 33,241 patients met the inclusionary criteria. The mean age was 80 years, with females accounting for 66.7% (n=22,172) of the sample. Caucasians comprised 82.7% (n=27,490) of the sample while 12.1% were African-American. Traumatic injury occurred most frequently in the home (41.9%; n=13,928), followed by health care facilities (25.3%; n=8,410), and residential institutions including nursing homes or jails (13.3%;n=4,421). An analysis of 19,682 (59.2%) patients for cause of injury showed that 87% (N=17,123) suffered from a fall while 8.7% (N=6,076) were injured as a result of a motor vehicle collision. About three-quarters (73.4%; N=24,399) of geriatric trauma occurred between the hours of 8:00 a.m. and 8:00 p.m. An overall analysis of whether geriatric patients were transported showed that 88.5% (N=29,418) of patients were transported to an emergency department, 85.8% (N=25,241) of which were transported nonemergently.

Conclusion
This study shows that falls serve as the primary cause of injury for an overwhelming majority of geriatric trauma patients. The significant morbidity and cost associated with these injuries might signify the need for more efficient, cost-effective trauma management. This study might prove useful for EMS agency managers tasked with community education programs focused on reducing incidence and prevalence of falls in this growing patient population.


Sidestepping the Road to Diversion: Utilizing the Medical Duty Officer as an Alternative to a Statewide Hospital Alerting System
Author: Daniel Ramos
Associate Authors: Andrew J. Bouland, Megan Halliday, Benjamin J. Lawner, DO, MS, EMT-P, FACEP


Objective
Ineffective communication between local EMS jurisdictions and hospital emergency departments may contribute to extended at-hospital times for EMS transport units. Previously, ED diversion status was determined by a statewide hospital monitoring system. The effectiveness of a jurisdictional EMS officer to determine ED diversion status and re-route EMS transport units was evaluated.

Methods
A senior EMS Medical Duty Officer (MDO) was placed in the communications bureau for the Baltimore City Fire Department (BCFD), Baltimore, Md. to monitor EMS unit availability. The MDO had the operational authority to suggest alternative hospital destinations in the event that one receiving facility was experiencing delays. The MDO monitored the CAD system in real time and provided feedback to responding medic units about the relative availability of ED resources. Similarly, hospital EDs that experienced a temporary surge of activity could call the MDO and request an internal bypass. Data were collected from the BCFD computer aided dispatch (CAD) system. The intervals analyzed using the CAD data included: response time (from to dispatch to arrive on scene), at-hospital times (at hospital time to back in service), and total call time (dispatch to back in service). It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the CAD-recorded EMS at hospital or out of service intervals.

Results
As compared to the previous statewide hospital alerting system, implementation of a jurisdictional MDO with the capacity to divert EMS units decreased average at-hospital time for EMS transport units, systemwide EMS response time and systemwide turnaround and total call time.

Conclusion
A proactive deployment of a designated MDO leads to more effective hospital utilization and a reduction in average at-hospital and response times within an urban EMS jurisdiction.
 
Incidence of Adverse Reactions to Initial Antibiotic Administra- tion in Severe Sepsis Patients
Author: T. Ryan Mayfield, MS, NREMT-P
Associate Authors: Mary Meyers, MHA, EMT-P, Judith Mackie, RN


Introduction
One of the goals for treatment of patients with severe sepsis is to reduce the delay in antibiotic administration. Administration of antibiotics by prehospital personnel is one possible solution to reducing the time to treatment. Before widespread adoption, further data must be available to determine if it is safe.

Hypothesis
There will be less than a 1% incidence of adverse reactions to the initial antibiotic administered to severe sepsis patients transported by EMS.

Methods
In this retrospective, IRB-approved study, all patients with severe sepsis 18 years old or older and not pregnant who were transported by EMS between January 1, 2010, and December 31, 2012, were included. Data related to antibiotic, antihistamine, and steroid administrations were pulled from the electronic patient care record. Patients who received a steroid or antihistamine within 24 hours of the initial antibiotic administration were individually reviewed to determine if it was to treat an antibiotic reaction.

Results
During the study period, 436 patients with severe sepsis who met the parameters were transported by EMS. Out of the 436 patients, 425 (97.5%) were given an antibiotic and 79 (18.1%) received either an antihistamine or steroid during their hospital stay. After individual chart review it was determined only 1 patient (0.235%) had a reaction to the initial antibiotic administered.
 
Conclusion
In the population studied, the incidence of adverse reactions to a first line antibiotic was extremely low. Given the small number of first line antibiotics used in severe sepsis (90% of patients received 1 of 4); it appears feasible that with additional training, paramedics could administer antibiotics prior to hospital arrival.