Miems, part 2: The Maryland emergency medical services communications system.
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Emergency Medical Services↗
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Systems approaches in emergency medical services: the history, the impact, and the future.
Systems approaches have been important in planning and evaluating emergency medical services (EMS) systems. However, maximal use of systems approaches are limited by small political boundaries, the lack of user-friendly systems tools, and the need for EMS planning staffs who are familiar with these systems tools. Developing technology, particularly communications, will continue to have a great impact on EMS delivery. In addition, the need is seen for continuing advances in systems concepts, and in particular, the promotion and incorporation of health and prevention of injury as systems concepts.
Emergencies↗
Monitoring EMS protocol deviations: a useful quality assurance tool.
STUDY OBJECTIVE: To determine the incidence, type, and outcome of protocol deviations in an emergency medical services (EMS) system. DESIGN: Retrospective consecutive case series. SETTING: Seven advanced life support ambulance services servicing five area hospital emergency departments. PATIENTS: 1,246 patients requiring advanced life support care. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Advanced life support ambulance runs during a two-month period were examined for protocol deviations. Of 1,246 runs examined, 16% had deviations. Approximately 55% of these deviations were minor, 38% were serious, and 7% were very serious in nature. The effects of the errors were evaluated using hospital records. Results showed that 89.5% of patients were unaffected, 5.0% improved, and 5.5% suffered complications from deviations. Emergency medical technicians committed 69% of the deviations without the consent of medical control, medical control committed an additional 18%, and both were responsible in 13% of cases. Incomplete histories were found in 8% of cases. CONCLUSION: Protocol deviations committed in prehospital care do not usually cause direct harm to patients. On review of these deviations, however, several disturbing trends were uncovered, including misconceptions in the use of IV therapy, a number of serious deviations in advanced cardiac life support protocols, and lack of communication with medical control. This type of quality assurance study has the ability to identify areas of strength and weakness in an EMS system, allowing planning of ongoing educational efforts in the system.
Clinical Protocols↗
[The emergency telephone number--the essential weak link in an emergency system. Prospective studies involving cardiac arrests observed by bystanders].
The first link in the "chain of survival" concept is the activation of the emergency medical system (EMS) by a bystander after recognition of cardiac arrest (CA) or its immediate prodrome. Our ongoing study is aimed at evaluating the current effectiveness of bystander EMS activation for all cases of CA in the city and area of Mainz. Methods. Starting February 1991, we began to prospectively examine collapse-intervention intervals in all cases of CA treated by our physician-manned ambulance. Precision voice recorders carried by the ambulance crews are activated and linked to the EMS dispatcher to time the arrival of the ambulance vehicle. Time intervals starting from the time of collapse are then reconstructed from the dispatcher's time and the tapes. The emergency phone number dialled initially by the bystander and the time of collapse in witnessed cardiac arrests are identified. RESULTS. Sixty-six CAs were witnessed and included in this study. In 20% of those cases, the number dialled initially by the bystander was 19222 (EMS dispatcher), in 38% 110 (police), and in 42% other numbers (family practitioners or their on-call service, fire department). The time interval, as median (25th percentile; 75th percentile), between collapse and receipt call by the emergency dispatchers was 4 min (2; 8) for all patients (n = 66), and 6.5 min (3; 12) whenever numbers other than emergency phone numbers were dialled. All following time intervals (start of BLS or ACLS procedures) showed differences (P less than 0.05) between the 110 or 19222 group [BLS: 8.5 min (4.8; 13.1) or 10 min (7.35; 12.1); ACLS: 11.3 min (9.1; 13.45) or 12.9 min (10.6; 21.5)] vs the group, in which other phone numbers were initially dialled [BLS: 15.25 min (9.25; 19.4); ACLS: 20.11 min (12.6; 28.3)]. The first ECG rhythm showed VF in 56% and 54% in case 110 and 19222 were dialled, but only in 32% in the other group. CONCLUSION. Even one single weak link in the "chain of survival" can lower overall survival rates. An indispensable, but apparently underrated component of an effective EMS includes an informed citizenry able to call swiftly for help. Lack of an unequivocal emergency number, well known and accepted by the citizens, produces confusion and delays. In our systems, the correct medical emergency phone number (19222) was dialled in 20% of the cases only, thus demonstrating clearly the lack of public awareness of this 5-digit number. In a higher percentage, the three-digit police number (110) was dialled. In cases where numbers other than emergency numbers were dialled (42%), the longest time intervals between collapse and receipt of call by the dispatchers occurred, associated with the longest time intervals until initiation of CPR and the lowest percentage of patients found in ventricular fibrillation. We conclude that establishment of a simple three-digit EMS phone number, preferentially Europe-wide, in combination with an intensification of public awareness, could be a vital step not only to reduce time intervals between collapse and CPR in our EMS system but also to improve survival.
Emergency Medical Service Communication Systems↗
Personal emergency response systems.
A personal response system is a signaling device that summons help during an emergency. Although personal response systems vary widely, there are three components. The first component is the electronic hardware in the home, which consists of portable and installed sensors and the control console. The second component is the emergency response center, which is either provider-based or manufacturer-based. The third component involves the dispatch of appropriate assistance. The primary users of personal response systems are women in their seventies and eighties who live alone and who have cardiac and musculoskeletal problems, which make them prone to falls. The frequency of personal response system use varies from an average of 0.44 to 0.84 emergencies per subscriber per year. Program coordinators believe that personal response systems help to delay institutionalization, reduce admissions to hospitals, substantially shorten hospital stays, and reduce the duration of home attendant services. The most favorable impact of the personal response system has been its psychologic value to the users and their families.
Aged↗
Advances in pediatric emergency medical service systems.
Only recently has attention turned to the needs of children in the EMS system, and it has been shown that there is work to be done if these needs are to be met. The founders of EMS systems were trained in adult specialties and worked without input from the pediatric community. It is not surprising that the special needs of children within an adult-oriented EMS system were underemphasized. Children make up less than 10% of prehospital runs and less than 5% of the critically ill patients. Numerous EMS systems nationwide are undertaking this work and federal support is evident through the Maternal and Child Health EMSC program. Vital issues include the need for experts in emergency medical services to work together with experts in pediatric emergency care and for sound program evaluations to be performed to demonstrate the efficacy of these new programs.
Child↗
[Outpatient emergency services].
Emergency is felt very differently according to the level of education, and the sensitivity of the patient and his family circle. Pain is often the alarm but a physician only is able to appreciate the seriousness and the development of a seriously threatening emergency, which slowly evolves in their beginning but becomes degraded afterwards. The only victims who are operated on the first hour, the golden hour, take chance to survive. But there are only 2 or 3 golden minutes to rescue a cardiac arrest. Quicker an effective treatment is done, better the results are. If time is lost, a tissular hypoxia settle and lead to multiple organ failure especially in the brain. Then the dead come in more or less longer time whatever it is done: it's the irreversible shock which drive to the brain death. In the beginning the only patient and his family circle are able to do something. From that you can understand the importance of public education and alert organization for getting suited and early aid. The attending physician have to educate his patients as they are able to recognize the signs of a real seriousness. Telephone play an essential role especially because the dial 15 for health free call is now put in service in France. The phone questioning allows medical regulation of "SAMU-15" (EMS-dial 15 Centre) to dismiss most of the ill-founded calls and to carry the patient in an hospital able to immediately treat him efficiently. The emergencies organization is inspired by two principles: 1. without any loss of time all patient shall fully treated, possibly on the spot. 2. effective intensive care shall be done to avoid tissular hypoxia. Hence the rescue medicalization and the emergency medical system. These principles are the basis of organization of french SAMU whom control role is also to inform the receiving hospital for preparing the reception. The 6.1.1986 french law had defined the emergency medical system, legalizing the SAMU, and fixing their role in connection with policy and firemen. The equipment of ambulances is well standardized and they should radio connected with SAMU. Helicopters may give inestimable service to carry patients in well equipped center as U.S. trauma centres. Small hospitals should only treat small emergency according their means in personnel and equipment.
Emergencies↗
The impact of the M1 air crash on the radiological services at the Queen's Medical Centre, Nottingham.
Following the M1 air crash on 8 January 1989, 39 casualties were taken to the Queen's Medical Centre, Nottingham. A team of 31 radiographers and four radiologists used all five X-ray rooms adjacent to the Accident and Emergency Department. Patients with head and spinal injuries were further assessed in the CT suite by four radiographers and a neuroradiologist. The volume of work in the first few hours and in the subsequent days is described. All radiological examinations have been reviewed and the injuries, including those missed at initial assessment, are discussed. The role of the radiologists was to issue immediate reports, manage examinations so as to minimize any delay and assess the need for further specialized investigation. Important problems were identified, specifically: the call-out system; patient deterioration and lack of resuscitation equipment; patient flow; documentation; radiology equipment; and missed injuries. These problems are discussed and recommendations are made for X-ray Departments in dealing with disasters.
Accidents, Aviation↗
Self-administered analgesia with nitrous oxide. Adjunctive aid for emergency medical care systems.
Analgesia with a mixture containing 50% nitrous oxide and 50% oxygen (Nitronox) was evaluated in 47 patients with abdominal pain, chest pain, musculoskeletal trauma, and burns. Of these, 93.6% experienced either partial or complete relief of pain. There were no complications attributed to its application; the short duration of action makes its use suitable during emergency transportation.
Adolescent↗
The St Croix disaster and the National Disaster Medical System.
The National Disaster Medical System was designed to respond to a catastrophic disaster by creating a group of specially trained civilian disaster medical assistance teams. The teams would be transported to the periphery of the event to triage, stabilize, and then prepare victims for evacuation to facilities elsewhere in the United States that have agreed in advance to accept such patients. Hurricane Hugo's devastation in St Croix offered the first opportunity to test the system. The event was an example of a type of medical disaster that resulted in a sudden reduction in medical resources without a great increase in casualties. Background information and operation of the New Mexico disaster medical assistance team are presented with a clinical profile of the patients seen during the disaster. We describe the first actual deployment of a disaster medical assistance team and the issues that must be addressed before future deployments.
Disaster Planning↗
Role of emergency medical services.
For thrombolytic therapy to be effective in the treatment of acute myocardial infarction, the patient must enter the health care center delivery system in an efficient manner. Some entry delays are due to patient decisions and interactions with others. In the United States, prehospital care is delivered by a variety of different systems, varying from public service types such as fire-department based to private types of service. These personnel vary in level of training from paramedics with a high level of training to Emergency Medical Technicians-Ambulance with basic training (first aid), even less in some areas. The training should be upgraded so that training as an emergency medical technician with the ability to defibrillate would be the minimum level for emergency ambulance personnel; wherever economically and logistically feasible, ambulance personnel should be paramedics. Although the 911 emergency telephone system exists in some areas, there is no centralized, universal system for access, causing confusion and delays in obtaining care in critical situations such as cardiac arrest. There is a need for a national emergency number--911--with the ability to identify the calling number and address. Since dispatchers have little medical dispatch training, needed instructions are not given to the caller, which can reduce the patient's chance of survival. Trained dispatchers are needed to dispatch resources efficiently and to offer assistance until trained rescuers arrive. Ambulances are inefficiently located in some areas of the United States, slowing response to the patient.(ABSTRACT TRUNCATED AT 250 WORDS)
Emergency Medical Service Communication Systems↗
The potential for prehospital thrombolytic therapy.
Several large trials of thrombolytic therapy have shown that treatment initiated in the first 1 or 2 hours following the onset of symptoms of acute myocardial infarction (AMI) is more effective than therapy started later in the course of illness. From our experience in three thrombolytic trials we concluded it would be difficult to reduce the total time from symptom onset to therapy without a major change in patient management. To accomplish this goal we have initiated MITI (Myocardial Infarction Triage and Intervention Project), a program for the prehospital diagnosis of AMI using specially trained paramedics, a checklist to establish eligibility for and contraindications to thrombolytic therapy, and a portable, battery-powered 12-lead electrocardiography (ECG) cellular telephone system that allows an electrocardiographic diagnosis to be made remotely by an emergency department physician. In the feasibility phase of MITI, 2,472 patients with chest pain of presumed cardiac origin were evaluated; 677 (27%) met the rigorous history and physical exam inclusion and exclusion criteria for potential thrombolytic therapy and had an ECG performed in the field. Of these ECGs, 522 were transmitted successfully by cellular telephone to a base station physician. Of the 522 patients, 107 had ST-segment elevation and met our criteria for initiation of thrombolytic therapy. Of the 2,472 patients with chest pain evaluated by the emergency medical technicians, 453 (18%) were diagnosed with AMI during hospitalization. Of these AMI patients, only 105 (23%) met the clinical examination and ECG criteria for pre-hospital thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Emergency Medical Service Communication Systems↗
Time delays in the diagnosis and treatment of acute myocardial infarction: a tale of eight cities. Report from the Pre-hospital Study Group and the Cincinnati Heart Project.
To establish the magnitude of prehospital and hospital delays in initiating thrombolytic therapy for acute myocardial infarction, the time from telephone 911 emergency medical system (EMS) activation to treatment and its components were analyzed from eight separate ongoing trials. This included estimates of ambulance response time, prehospital evaluation and treatment time, and time from admission to the hospital to initiation of thrombolytic therapy. The average time from EMS activation to patient arrival at the hospital was prospectively determined to be 46.1 +/- 8.2 minutes in 3715 patients from eight centers. The time from admission to the hospital to initiation of thrombolytic therapy was retrospectively determined to be 83.8 +/- 55.0 minutes in a separate group of 730 patients from six centers. Both the prehospital and hospital time delays were much longer than those perceived by paramedics and emergency department directors. Shorter hospital time delays were observed in patients in whom a prehospital ECG was obtained as part of a protocol-driven prehospital diagnostic strategy and a diagnosis of acute infarction made before arrival at the hospital (36.3 +/- 11.3 minutes in 13 patients). These results show that the magnitude of time required to evaluate, transport, and initiate thrombolytic therapy will preclude initiation of treatment to most patients within the first hour of symptoms. Implementation of a protocol-driven prehospital diagnostic strategy may be associated with a reduction in time to thrombolytic therapy.
Electrocardiography↗
Prehospital diagnosis and treatment of acute myocardial infarction: a north-south perspective. The Cincinnati Heart Project and the Nashville Prehospital TPA Trial.
Intravenous thrombolytic therapy improves left ventricular function and reduces mortality in patients with acute myocardial infarction (AMI). In European and Middle Eastern trials, prehospital delivery of thrombolytic agents by physician-directed mobile intensive care units has been successful. This report describes two independently conceived and performed trials that used cellular telephone transmission of 12-lead ECGs to deliver recombinant tissue plasminogen activator (r-tPA) in the field to patients with AMI. In the Nashville Prehospital TPA Trial, 85 patients with chest pain were evaluated in the field for possible administration of r-tPA over a 6-month period. Three of 85 patients (3.5%) were found to be actual candidates for r-tPA treatment in the field. In phase II (dry-run phase) of the Cincinnati Heart Project, 374 patients were evaluated in the field with 14 documented cases of AMI (3.7%) before r-tPA was placed in ambulances for administration by paramedics. In phase III (active with r-TPA in ambulances), over a 1-year period 103 patients were evaluated with six (5.8%) documented cases of AMI. Three of five r-tPA field treatment decisions by emergency physicians using transmitted 12-lead ECGs were accurate (60%). When patients in phases II and III were combined, only 20 of 477 total patients (4.2%) were documented to have AMI. A decline in paramedic skills was noted because of the infrequent administration of the thrombolytic agent. Combining the Nashville and Cincinnati experiences, only 27 of 562 total patients with chest pain (4.8%) were candidates for prehospital thrombolysis. We conclude that few patients evaluated in the prehospital setting are actual candidates for thrombolytic therapy. Substantial allocation of financial and human resources for prehospital delivery of intravenous thrombolytic therapy does not appear warranted.
Adolescent↗
Lessons for mobile medical teams following the Lockerbie and Guthrie Street disasters.
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Accidents, Aviation↗
Cardiac arrest telephone numbers.
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Emergency Medical Service Communication Systems↗
Efficiency and cost-effectiveness of advanced EMS in West Germany.
A model study was performed by an economist in Lower Frankonia (a mostly rural area of West Germany with several urban centers) to examine the efficiency and cost-effectiveness of the emergency medical service that included prehospital physician presence. To perform this examination about $3.5 million were spent to improve organization and communication within the local emergency medical service, to purchase additional equipment and further emergency vehicles, and to install prehospital emergency physician service. The median response time was lowered to 6 minutes. This report surveys whether these reforms and extra fundings were beneficial and cost-efficient.
Cost-Benefit Analysis↗
Roadside medical care in Cambridgeshire.
The Mid-Anglia General Practitioner Accident Service (MAGPAS), established in 1972 to provide medical care at accident sites before the arrival of the ambulance and to assist ambulance crews with the severely injured, is discussed. Analysis of accident report forms returned by MAGPAS doctors is given.
Accidents↗