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EMS Controversies in Prehospital Care Aric Storck PGY1 Dr. Andy Anton June 26, 2003 Objectives Public Access – Better or worse than targeted first responder programs? Defibrillation – Defibrillation +/- CPR Shock first or CPR first? Prehospital Triage – Is it accurate and is it safe? Background Cardiovascular disease is a major cause of death in North America – – – 1 million deaths per year in US ~450,000 sudden and unexpected Most occur outside of hospital Poor survival rates (1-5% in some major centres) The target of PAD Incidence of Unexpected Cardiac Arrest (NEJM 2002:347(16);1223-1224) Very, very good evidence that survival is intimately linked to CPR Timeliness of defibrillation NEJM 2002:347(16);1223-1224 Public Access Defibrillation What is it? – PAD is a strategy to improve survival from VF arrest by placing AED’s in the hands of trained (and untrained) laypersons What is the rationale? – Survival decreases by 7-10% for every passing minute of VF. PAD allows for earlier defibrillation. What is an Automatic External Defibrillator? JAMA 2001 285(9)1193 Sequence of AED voice prompts during mock cardiac arrest. Circulation 1999;100(16):1703-1707 Electrocardiograms From a Person in Cardiac Arrest JAMA 2001;285(9):1196 What about EMS and AED’s? Many studies (which will not be reviewed here) show AED’s to be an effective part of EMS – Some studies suggest AEDs more effective than manual defibrillators among paramedics – Many studies have shown increased survival with targeted first responders (police, firefighters, etc.) carrying AEDs AEDs Outside the Traditional EMS System Some (including AED manufacturers …) have argued for a “fire extinguisher” model AEDs widely located in public and private places to achieve defibrillation ASAP Public Access Defibrillation VF is the most frequent initial rhythm in witnessed cardiac arrest Electrical defibrillation is the most effective treatment of VF Probability of successful defibrillation diminishes rapidly over time VF tends to converts to asystole after a few minutes Time to Defibrillation vs Rates of Survival to Hospital Discharge Rates given for 4 years of consecutive patients (1112) initially discovered in ventricular fibrillation. Response times are known for 942 cases. Both witnessed and unwitnessed cases in this 4-year period are considered. The average (SD) response time for first emergency unit was 3.0 (1.5) minutes and for paramedics was 6.5 (3.2) minutes after dispatch. VF indicates ventricular fibrillation. JAMA 2001;285(9):1196 Expected Survival According to the Interval between Collapse and the Administration of the First Shock by the Defibrillator. NEJM 2002;347(16):1223-1224 So What Does the Literature Say… Outcomes of Rapid Defibrillation by Security Officers After Cardiac Arrest in Casinos Valenzuela T, et al. NEJM. 2000;343(17):1206-1209. Casinos are unique environments amenable to a rapid defibrillation program – – – Security officer visible from every point at all times Security cameras closely monitor public areas Many elderly patrons in poor health Methods Prospective study Prospective target of 100 VF arrests 32 participating casinos in Nevada, Pennsylvania, and Mississippi AEDs placed at intervals to ensure <3 minute elapsed time between collapse and defibrillation Training Security officers required to have basic CPR 6 hour course in AED use – – Theoretical and practical training 75% required on exam to pass Subjects Inclusion – – – – Unconscious Unresponsive No palpable pulse No spontaneous respiration Exclusion – – <9 years old <36 kg Protocol When informed of “sick person” the nearest officer procedes to the patient – Begins CPR if needed Second officer brings nearest AED to patient AED immediately attached and prompts followed Resuscitation continued until EMS arrival or return of spontaneous circulation and respiration Data Colection Time of collapse obtained from security cameras or interview with witness (if not in a public area) AED recorded – – Rhythm strip for analysis Time of shocks Outcome Variables Predictor variables – – Time from collapse to CPR Time from collapse to defibrillation Primary outcome variable – Survival to hospital discharge Results Total Cardiac Arrests - N = 148 Initial rhythm VF = 105 Initial rhythm PEA = 17 Initial rhythm asystole = 26 NB: No subjects without VF as initial rhythm survived Ventricular Fibrillation 105/148 arrests (71%) 15/105 unobserved collapse – 3/15 (20%) survival to discharge 4/105 pronounced dead on scene 35/105 pronounced dead at hospital ER 10/105 admitted to hospital but died before d/c 56/105 (53%) survived to hospital discharge Witnessed VF Arrests 90/105 VF arrests 54% received CPR prior to arrival of AED Collapse to CPR 2.9+/-2.8 minutes Collapse to defibrillation 4.4 +/- 2.9 Collapse to arrival of EMS 9.8+/-4.3 Survival to hospital discharge 53 (59%) Valenzuela, et al. NEJM 2000 The importance of time … Defibrillation < 3 minutes after witnessed arrest – Defibrillation > 3minutes after witnessed arrest – Survival 74% (26/35) Survival 49% (27/55) P=0.02 Implications Rapid AED use by targeted responders is an effective and feasible strategy – Much improved survival compared with previous estimates of out of hospital arrest survival Minimally trained personnel (ie. security officers) can safely and effectively operate AEDs Waiting for paramedics would have added ~5 minutes to time to defibrillation Limitations Casinos are atypical environments – – Very intense monitoring Very high density of cardiac arrests Survival very dependent on collapse to defibrillation interval – Must be able to ensure very rapid response times Use of AEDs by a U.S. Airline Page R, et al. NEJM. 2000;343:1210-6. Aircraft are unique settings for cardiac arrest – – – Stress/exertion associated with flying Disruption of circadian rhythms Decreased oxygen tension in cabin VF arrests on airplanes rarely survive due to the delay obtaining EMS and defibrillation – Minimum 20 minutes required for emergency landing under the best of circumstances Methods In 1997 American Airlines began installing AEDs on all aircraft All 24,000 flight attendants were trained in AED use – – – One hour classroom Four hour workshop 1.5 hour refresher courses Use of AEDs monitored for a 2 year period AED Protocol When SSx of possible cardiac arrest – – – – – Patient moved to aisle, galley, bulkhead Clothing covering chest is removed Electrodes placed on chest Assistance of medical personnel is solicited Flight attendants follow instructions on AED Results Patient characteristics – N=200 66% male Mean age 58 years – – 191 aboard aircraft 9 in terminals Indications for AED use LOC - 99 (49.5%) Chest Pain – 62 patients Dyspnea 19 Nausea / malaise – 8 Light-headedness – 3 Palpitations – 3 Stroke – 1 Unclear reasons – 5 NB – physician assisted with 139 patients (69.5%) Electrocardiographic Data 185 electrocardiograms available for review – 145 – sinus rhythm – – 15 lost due to device malfunction, memory erased, etc 14 sinus bradycardia 21 sinus tachycardia 8 – atrial fibrillation 3 – junctional rhythm SVT – 1 MAT -1 Agonal rhythm – 13 Ventricular fibrillation - 14 Shocks and survival 13/14 patients with documented VF defibrillated – 13/13 – VF terminated with first shock Recurrent VF in 8 patients – defibrillation withheld at request of one patient’s family 7/8 successfully resuscitated with subsequent shocks NB – two patients defibrillated for presumed VF but data lost in machine. Both patients died Outcomes 6/15 (40%) patients defibrillated were discharged home from hospital with full neurologic recovery Use of defibrillator as a monitor Used and recorded ECG on 171 patients without VF 101/200 patients did not have LOC In no case was a shock inappropriately administered Specificity for algorithm = 100% No shocks recommended or delivered inappropriately Sensitivity 100% Specificity 100% Page R, et al. NEJM 2000;343:1210-6. Frequency of defibrillator use 200 uses on – – – 627,956 flights 896,000,000 miles 70,801,874 passengers AED used once per 3288 flights Death or resuscitation once per 21,654 flights Conclusions AEDs 100% sensitive and 100% specific VF terminated after first shock 100% of time Rate of survival to discharge 40% AEDs safe for use as monitor – Allows further assessment of need to divert aircraft or utilize medications in the emergency medical kit What about Real Public Access Defibrillation? Public Use of Automatic External Defibrillators Caffrey S, et al. NEJM. 2002;347(16):1242-1247. AEDs shown to save lives when used by designated personnel in certain public places Prospective study to determine whether random bystanders could successfully retrieve and use AEDs for cardiac arrest Methods AEDs placed at 60-90 second intervals in three Chicago area airports (100 million passengers per year) Use of AEDs promoted in media, pamphlets, and videos in waiting areas Outcomes – – – – Time from notification of dispatchers to defibrillation Survival at 72 hours and one year Neurologic status Characteristics of rescuers Study design Study sites – O’Hare – 80,000,000 passengers/year 59 AED’s – Midway – 20,000,000 passengers/year 10 AED’s – Meigs field – 77,000 passengers/year 1 AED CPR/AED training provided to 450 employees – – – Airport police Security Public safety dispatchers Voluntary training of 3,000 / 40,000 other airport employees AEDs Housed in glass cabinet 60-90sec apart Highly visible signs indicating location of nearest AED Cabinets equipped with alarms / dispatcher alerts Data collected Dispatch time Defibrillation time Recovery time (return of consciousness) ECG tracing Audio recording Complications Defibrillator tampering Inappropriate delivery of shocks Failure to deliver shock in VF Injury to rescuers Map of O'Hare International Airport, Showing the Locations of Automated External Defibrillators in Public Areas and the Locations of 20 Patients with Witnessed Cardiac Arrest. Results 2 year study period AED used – O’Hare – 21 patients – Midway – 5 patients – Meigs – none 4 patients did not have cardiac arrest – 2 seizures – 1 SOB – 1 feigned LOC to avoid immigration official 4 additional patients defibrillated with AED’s from outside the study – – Three from nearby airplanes One from a nearby paramedic Total of 22 cardiac arrests in study group – – One traumatic arrest (33 y.o. fall) One patient found dead on transit train 21 non-traumatic arrests – – – – 19 men / 2 women 19 travelers 1 employee 1 visitor 20 witnessed non-traumatic arrests – – PEA x 2 VF x 18 Characteristics of 18 Patients with VF Who Received Defibrillator Shocks from AEDs Installed at Chicago Airport Terminals between June 1, 1999, and May 31, 2001. Outcomes Long-term survival – – 10/18 (56%) of all non-traumatic, witnessed VF arrests 8/12 (67%) among those defibrillated within 5 minutes Rescuer characteristics All but two were good Samaritans (passengers or employees) with no duty to act 6/11 successful resuscitations performed by rescuers who had never been trained in AED use (although 3 were MDs) Implications With public education untrained laypeople can effectively use AEDs Much increased survival rate (56% vs ~5% with conventional EMS) Cost effective – – – Estimated cost $35,000 per year $3,000 per patient $7,000 per life saved Limitations Airports are unique environments – – – Intensive monitoring of public areas Almost always trained personnel nearby (MD, etc.) Very busy with a high density of cardiac arrests makes PAD cost effective Cost calculations did not include training, retraining, time away from job, promotion, etc. Okay, so people in airports can use AEDs. Can other people? Comparison of Naive Sixth-Grade Children With Trained Professionals in the Use of an AED Gundry J, et al. Circulation. 1999;100:1703-1707. Primary end point – time to defibrillation Secondary end points – pad placement and safety Subjects – – 15 sixth graders - only shown the pacing pads and told they had to peel the sticker off 22 EMTs - extensive training and experience Results Time to defibrillation – – – Children – 90 +/- 14 seconds EMTs – 67 +/- 10 seconds P < 0.0001 Electrode pad placement and safety – 100% in both groups Conclusions Faster time to defibrillation among EMT’s (22 seconds) – Clinical significance of difference is unclear Minimal training required to educate the public in AED use It’s not possible to put AEDs everywhere …. so where should they be? Public Locations of Cardiac Arrest Implications for Public Access Defibrillation Becker L, et al. Circulation. 1998;97:2106-2109. Studied the incidence of annual cardiac arrest in 71,000 public locations in Seattle Identified sites with >0.03 cardiac arrests per year (>1 per 30 years) and postulated that an AED should be located at each of these Results 7185 non-traumatic arrests in 5 year period 1130 (16%) were in public places Calculated that placement of 276 AED’s in 172 areas would have treated 134 cardiac arrests over 5 years – Estimated 8-32 lives saved in 5 years To cover the remaining 347 arrests occuring in public places (excluding vehicles and public outdoors) would require AEDs at 71,000 sites Incidence of Cardiac Arrest per Site: Higher-Incidence Location Categories Circulation 1997;97(21):2106-2109 Implications PAD has the potential to reduce the time to defibrillation and increase survival It is not cost effective to place AEDs at every site where a cardiac arrest occurs Placement of AEDs at targeted public locations is a feasible way of reducing mortality Defibrillation First vs CPR First In Delayed Resuscitation 1992 American Heart Association Guideline “Because the most important determinant of survival in out-ofhospital VF is rapid defibrillation, shocks should be given as soon as a defibrillator arrives.” JAMA 1992;268:2212 Time-sensitive defibrillation the controversy Present ACLS Treatment Algorithm – VF = defibrillation regardless of downtime – 3 unsuccessful shocks = CPR + drugs + more defibrillation attempts New evidence suggests … Present ACLS approach not optimal in all patients Present approach may be harmful in delayed defibrillation Niemann J, et al. Treatment of prolonged VF: immediate countershock vs high-dose epinephrine and CPR preceding countershock. Circulation. 1992;85:281-287. An animal model VF induced in dogs After 7.5 minutes animals randomized to 1) 2) Immediate defibrillation 5 minutes CPR plus epinephrine then defibrillation Results Immediate defibrillation group – – Countershock rhythm of asystole in 10/14 dogs Resuscitation successful in 3/14 CPR grounp – – Countershock rhythm of asystol in 3/14 (p<0.01) Resuscitation successful in 9/14 (p=0.01) Resuscitation After Cardac Arrest A 3-Phase Time-Sensitive Model Weisfeldt M, et al. JAMA 2002:288(23);3035-3038. Phase One – The Electrical Phase – – – – – First 4 minutes of VF Excellent data to support immediate defibrillation (class I recommendation) Basis of the highly effective Implantable Cardioverter Defibrillator (ICD) Survival rates of ~50% shown in several trials This strategy is presently the standard of care for all VF regardless of time Phase 2 – The Circulatory Phase – – – – 4-10 minutes after arrest Many animal models have shown improved survival when CPR for 1-6 minutes provided provided to defibrillation Hypothesis: during this time period oxygen delivery (CPR) takes precedence over defibrillation Implication – EMS resuscitates most people during this phase … Phase 3 – The Metabolic Phase >10 minutes after arrest Very poor outcomes with defibrillation +/- CPR Global whole-body ischemia Reperfusion can contribute to cell death independently of ischemia Promising therapies include – – Therapeutic hypothermia (even hours after ROSC) Apoptosis inhibitors No practical, proven therapies for EMS yet … So …. since we’ve already figured out phase one, and have no clue about phase three, we should work to improve phase two… right? Influence of CPR Prior to Defibrillation in Patients With Outof-Hospital Ventricular Fibrillation Cobb L, et al. JAMA 1999:281(13);1182-1188. Background – – – Introduction of AE’s in Seattle decreased time to defibrillation by 3-4 minutes Survival increased in certain subsets of patients (short downtime) but overall survival was unchanged animal models showed increased survival with prolonged downtimes if CPR initiated before defibrillation Objective – Methods – To evaluate effect of 90 seconds CPR prior to delivery of first shock Observational study of 42 months of preintervention and 36 months post intervention data Intervention – Provision of 90 seconds CPR prior to delivery of first shock Hypothesis – Greater survival benefit in cases where the AED response intervals were longest Outcomes – – Primary – survival to hospital discharge Secondary – neurologic status Results JAMA 1999;281(13):1182-1188. JAMA 1999;281(13):1182-1188. Survival of the 2 Study Periods According to the Response Intervals of the First Arriving Unit JAMA 1999;281(13):1182-1188. JAMA 1999;281(13):1182-1188. Conclusions Results are consistent with animal models Current ACLS guidelines may not provide optimal treatment for prolonged VF Patients with delayed EMS response (>4minutes) were most likely to benefit from CPR first. Other patients did not seem harmed by provision of 90 seconds CPR Limitations 90 second duration of CPR arbitrary. Further studies needed to optimize duration. Prospective RCT’s needed to definitively prove the superiority of CPR before defibrillation Did not include Norwegians Delaying Defibrillation to Give Basic CPR to Patients with Out-of-Hospital VF A Randomized Trial Wik L, et al. JAMA 2003;289(11):1389-1395. Context – A non-randomized study (Cobb, et al.) showed that 90 seconds of CPR prior to defibrillation improved survival in patients where response time was >4 minutes Objective – Determine effect of CPR prior to defibrillation in patients with VF and response times more and less than five minutes Methods Prospective, randomized trial of 200 patients with out of hospital VF Patients received either i. ii. Standard care with immediate defibrillation (N=96) 3 minutes of CPR prior to defibrillation (N=104) The remainder of the resuscitation proceeded identically A priori subgroup analysis of cases with response times more and less than five minutes Flow Diagram of CPR First and Standard Care JAMA 2003;289(11)1389-1395 Outcomes Primary – Survival to hospital discharge Secondary – – – Hospital admission with ROSC 1 year survival Neurological outcome Results JAMA 2003;289(11)1389-1395 JAMA 2003;289(11)1389-1395 Estimated Probability of Survival to Hospital Discharge Plotted Against Response Time JAMA 2003;289(11)1389-1395 Conclusions No overall differences in survival for patients with out of hospital VF among two study groups Among patients with longer ambulance times (>5 minutes), those receiving prior CPR had improved rates of hospital discharge and one year survival Further research necessary What is the optimum amount of time initial CPR should be performed At precisely what time does the optimum strategy become one of performing CPR first Prehospital Triage Is it accurate? Is it safe? Background Overcrowding of ED’s is a problem Reasons are complex and multifactorial Prehospital discharge and/or diversion of patients to alternate sites of care has been suggested as a way of alleviating the problem Schmidt T, et al. Evaluation of Protocols Allowing Emergency Medical Technicians to Determine Need for Treatment and Transport. Acad Emerg Med 2000;7:663-669 Study Objective “…whether it is feasible and safe to develop a set of protocols allowing EMTs to offer alternatives to an ED for patients who access the 911 system.” Study Design Prospective observational study of scene categorization by EMTs using a triage protocol Associated retrospective chart review by an expert panel. Triage Protocols Developed by multidisciplinary expert panel Protocol assumptions 1. Triage guidelines are conservative • 2. 3. overtriage better than undertriage Triage guidelines must be easy to use Triage guidelines must offer appropriate alternatives to ambulance transport and not refuse anyone proper care. Traige Protocols Categorize patients by presentation to 1. 2. 3. 4. Ambulance (ALS) transport to an ED Transport to an ED by alternate means (BLS, etc.) Referral to a primary care provider within 24 hours Treatment at the scene only Cardinal Conditions protocol always requires ALS transport (category 1) Unconscious or ALOC Respiratory distress Sustained abnormal VS – sBP<90 – HR<60 or >110 – RR<12 or >24 Compromised airway Uncontrolled bleeding Suspected abuse of any type Suspected c-spine injury Infants less than 3 months of age Triage Protocol Example MSK Injury Category 1: – – – – – – – Amputations Femur fracture Multiple trauma NV compromise Severe pain Open fractures Hip#/disclocation Category 2: – – Avulsion of digit tips Isolated extremity injury Category Three – – Isolated injury with no loss of function, point tenderness, or swelling Need for tetanus prophylaxis Category Four – – Contusions Abrasions Training Video describing study and protocols Workbook and 50 question exam asking EMTs to categorize patients using protocols Passing score: 90% Outcome Measure Critical Events in Ambulance used to identify need for ambulance transport CPR Intubation Assisted ventilation Extensive bleeding controlled in ambulance Cardioversion or pacing SaO2<90% or transported on O2 sBP < 90 (or age appropriate) Dysrhythmia treated Traction placed for femur fracture Needle thoracotomy Cricothyrotomy GCS<12 Spinal precautions Received medication during transport Criteria for trauma activation >1 litre fluid infused Results 1300 patients transported and categorized – – – – 1023 patients category 1 (needed ambulance) 277 patients category 2 63 patients category 3 14 patients category 4 Comparison of triage category and critical events 277 patients categorized as not needing ambulance 30/277 (10.8%) – had critical event 7/277 (2.5%) – had critical event warranting ambulance transport Acministration of NTG for chest pain GCS 10, 12 SaO2 83%, 86% sBP <90mmHg 6/7 critical events requiring ALS ambulance were misclassified (provider error) 1/7 critical events involved protocol error Conclusion – 3-11% of patients categorized as not needing an ambulance actually did Limitations – – BLS considered acceptable option for category 2 patients Applicability to ALS only system unclear Pointer J et al. Can paramedics using guidelines accurately triage patients? Ann Emerg Med 2001;38:268-277. Study Hypothesis “…paramedics can use written guidelines to accurately and safely triage patients in the field.” Protocol Paramedics assign triage category based on chief complaint – Used same four triage categories as Schmidt Added two cardinal conditions – – Trauma activation (was a critical event in Schmidt’s study) Suspected stroke <6 hours ago Training – – – 30 minute overview of project Study workbook and multiple choice exam Passing grade = 80% Data Analysis Gold Standard – – Panel of three emergency physicians Assignment to same categories using retrospective review of: ED treatment / monitoring Diagnosis Need for admission Results Paramedic Score MD Score 1 2 3 4 1 127 592 83 2 2 0 140 52 4 3 1 81 65 1 4 0 17 14 1 Results Need to come to ED (categories 1,2) vs no need to come to ED (categories 3,4), kappa=0.28 113/1180 (9.6%) undertriaged by paramedics – – Represent 43 different diagnoses 19.5% admitted 99/1180 (8.4%) triaged away from ED inappropriately – – paramedics category 3-4, MD category 1-2 Represents 55% of all patients rated 3-4 by paramedics Incidence of incorrect assignment of category 4 (no MD follow-up necessary ) was 2.6% – – Three patients required admission CHF, ARF, psychosis Why were patients undertriaged? Guidelines not applied correctly in 55 cases No appropriate guideline in 32 cases 9 patients with “occult conditions” not detectable in field even with improved guidelines and training Conclusions Even with use of guidelines, the accuracy of paramedic triage was unacceptably low Given the potentially serious consequences of undertriage, 9.6% is an unacceptably high rate Silvestri S et al. Can paramedics accurately identify patients who do not require emergency department care. Prehospital Emergency Care 2002;6:387. Objective “To determine whether paramedics can identify patients contacting 9-1-1 who do not require emergency department care.” Methodology Subjective (no guidelines) classification of patients by paramedics as either 1. 2. 3. 4. Needs ED care Needs medical care within 24 hours Needs medical care in greater than 24 hours Medical care is not required Gold Standard Patients deemed to have required ED care if they: 1. 2. 3. Were admitted Required surgical, surgical subspecialty, obstetric, or gynecologic consultation Required advanced radiological procedures (excluding plain films) Results 313 patients enrolled Paramedic assessment: – – – – 81% sensitivity (CI 72-88%) 34% specific (CI 28-41%) 50% PPV (CI 44-56%) 68% NPV (CI 56-79%) Paramedics triaged 85 patients as not needing ED transport Of these, 27 (32%) met criteria for ED treatment – – – – 15 (18%) admitted 5 (6%) admitted to ICU 19 (22%) required advanced radiologic imaging 1 (1%) required surgical consultation Of 15 admitted patients felt not to need ED, paramedics stated – – – 2 could be seen at health care clinic within 24 hours 1 could be seen >24 hours later 12 did not require any medical attention Final Diagnoses in these patients Femur fracture Aspiration pneumonia MRSA pneumonia Osteomyelitis Pancreatitis Tibia fracture Septic arthritis CHF CVA Cellulitis Pericardial effusion Syncope Hepatitis Cocaine toxicity Conclusions Unacceptable rate of undertriage in seriously ill patients (6 ICU admissions!) “…use of paramedic discretion to determine whether patients calling 9-1-1 required ED care was inaccurate.” Hauswald M. Can paramedics safely decide which patients do not need ambulance transport of emergency department care? Prehospital Emergency Care 2002;6:383-386. Objectives “To determine whether paramedics can safely decide which patients do not require ambulance transport or emergency department care.” Methods Prospective survey and linked chart review Paramedics were asked: – – “Could this patient have been safely transported by a non-medical transport service?” “Could this patient have been safely transported to a clinic or urgent care center?” Responses were yes/no, and were purely subjective (ie: no guidelines used) Gold Standard Criteria ED MD reviewed medical records Ambulance transport was “needed” if the charted DDx included Dx that could necessitate treatment in an ambulance – – eg. ASA for possible MI eg. rapid transport for head injury ED care was “needed” if patient required diagnostic or therapeutic procedures not available outside of hospital. – – Eg. CT scans Eg. fracture reduction Results 183 patients enrolled Paramedics felt that – 97 patients (53%) did not need ambulance – 23 (24%) of these needed ambulance by gold standard 71 (38%) were appropriate for triage to alternative care site 32 (45%) of these needed ED care by gold standard ED Diagnoses of patients for whom paramedics recommended alternative transportation Alcohol intoxication Assault Coma x 4 days Chest pain Dislocated hip Hepatic failure Hypoxia Laceration (severe bleeding) MVC / C-spine precautions Narcotic overdose Pyelonephritis – 6 months pregnant Adult first seizure Sepsis syncope ED Diagnoses of patients for whom paramedics recommended alternative care Assault (multiple injuries) Child abuse Chest pain (neg workup) Alcohol abuse Multiple medical problems (died in hospital) Adult first seizure Narcotic OD Active labor Laceration (required extensive repair) MVC – C-spine precautions Multiple drug overdose Post traumatic headache Hypoxia Hepatic failure Conclusions “…prehospital triage will result in an unacceptably high number of inappropriate non-transports.” “Allowing paramedics to transport to non-ED care settings will result in many patients requiring a second transport from clinic to ED.” “Paramedics as currently trained are not capable of making these decisions accurately or safely.” Conclusions Paramedics are taught to, and are excellent at providing initial treatment, and transport of patients with life-threatening complaints They are not taught to diagnose and manage less acute complaints Many important diagnoses and disposition decisions cannot be made without tests available in the ED Implications for Calgary Some of the literature not directly applicable to Calgary as we have an ALS only system Calgary EMS has treat and release protocols for hypoglycemia and narrow complex tachycardia Ongoing QA is required to ensure that the protocols are adequate and that they are being followed It is possible that Urgent Care Centres (eg. 8th and 8th) will begin to accept ambulances Protocols must be established and ongoing QA is necessary to ensure that patients are appropriately triaged to these sites