Prehospital Emergency Care最新文献

Objectives: The objectives of this study were to: (1) understand the personal impact of workplace violence (WPV) on staff within a large multistate emergency medical services (EMS) agency, (2) describe the impact of WPV on subsequent patient interactions, examining how experiences of violence affect the quality of care provided by EMS clinicians, (3) examine the influence of WPV on perceived workplace safety among prehospital personnel and its correlation with retention in the EMS field, and (4) solicit recommendations from staff for the prevention and mitigation of WPV in the future.

Methods: We conducted virtual focus groups and individual interviews with 22 prehospital personnel using a descriptive qualitative design within a large multistate Midwest EMS agency between 4/5/2023-6/20/2023. Data were analyzed using Thematic Analysis to identify common perceptions among and across participants.

Results: Major themes of personal impact; impact on patient interactions; influence of WPV on career longevity/sustainability; and relationship between EMS culture and WPV were identified. Overall, participants shared the perception that WPV is "part of the job", and that verbal abuse was so common that they hadn't previously considered it as violence. Participants provided several examples of WPV and described how these experiences impacted them personally (e.g., hypervigilance) and impacted their subsequent interaction with patients (e.g., quicker to use restraints, loss of empathy). Participants shared the perception that EMS is no longer valued or respected by patients or communities. Several voiced concerns for the next generation of colleagues and nearly all participants reported the need for education and training in situational awareness, de-escalation, and self-defense tactics. Participants referenced desire for more coordination and communication with law enforcement, change in culture of abuse from patients without repercussions, and improved agency mental health support and peer support/mentoring following a violent event. Despite experiences with WPV, the majority reported plans to remain in EMS.

Conclusions: Emergency Medical Services personnel are commonly traumatized by violence in their work and nonphysical violence is underappreciated. Despite its impact on staff and subsequent patient interactions, most participants reported plans to remain within EMS. Multi-faceted system-focused efforts are needed to shift toward and support a zero-tolerance culture for WPV.

Objectives: Clinical judgment describes the process an emergency medical service clinician uses to evaluate problems and make decisions in the out-of-hospital setting. As part of the redesign of the Advanced Life Support (ALS) certification examinations, the National Registry of Emergency Medical Technicians is developing and evaluating items that measure clinical judgment, with the intention of assessing these as a new domain in the ALS certification examinations. In this study, we provide evidence around the redesign by evaluating the reliability and validity of the advanced emergency medical technician (AEMT) and paramedic certification examinations when clinical judgment is included as a sixth domain along with the five current domains.

Methods: Pretest (i.e., pilot, unscored) clinical judgment items were included as a new sixth clinical judgment domain. We then used the combination of operational (i.e., scored) and pretest items for all six domains and scored the redesigned AEMT and paramedic certification examinations. We evaluated the psychometric properties of these ALS examinations within the Rasch measurement framework with multiple assessments of reliability and validity including item-level statistics (e.g., mean-square infit and outfit, local dependence) and examination-level statistics (e.g., person reliability, item reliability, item separation, decision consistency, decision accuracy). Wright Maps were produced to evaluate whether the examination item difficulty statistics aligned with the candidate ability continuum.

Results: The total population of all examination forms included were 20,136 (AEMT 4,983; paramedic 15,153). The Rasch-based statistics for the redesigned AEMT and paramedic examinations, for both item and examination-level statistics, were well within the psychometric standard values. Wright maps demonstrated that the developed items fall along the candidate ability continuum for both examinations. Further, the distribution of clinical judgment item difficulties fell within the current item distribution, providing evidence that these new items are of similar difficulty to the items measuring the five current domains.

Conclusion: We demonstrate strong reliability and validity evidence to support that the integrity of the examinations is upheld with the addition of clinical judgment items, while also providing a more robust candidate evaluation. Most importantly, the pass/fail decisions that candidates receive accurately reflect their level of ALS knowledge at the entry-level.

Objectives: Benzodiazepines are the primary antiseizure medication used by Emergency Medical Services (EMS) for seizures. Available literature in the United States and internationally shows 30% to 40% of seizures do not terminate with benzodiazepines called benzodiazepine refractory status epilepticus (BRSE). Ketamine is a potential treatment for BRSE due to its unique pharmacology. However, its application in the prehospital setting is mostly documented in case reports. Little is known about its use by EMS professionals for seizure management, whether as initial treatment or for BRSE, creating an opportunity to describe its current use and inform future research.

Methods: We performed a retrospective review of 9-1-1 EMS encounters with a primary or secondary impression of seizure using the ESO Data Collaborative from 2018 to 2021. We isolated encounters during which ketamine was administered. We excluded medication administrations prior to EMS arrival and encounters without medication administration. Subgroup analysis was performed to control for airway procedure as an indication for ketamine administration. We also evaluated for co-administration with other antiseizure medications, dose and route of administration, and response to treatment.

Results: We identified 99,576 encounters that met inclusion. There were 2,531/99,576 (2.54%) encounters with ketamine administration and 50.7% (1,283/2,531) received ketamine without an airway procedure. There were 616 cases (48%, 616/1,283) where ketamine was given without another antiseizure medication (ASM) and without any airway procedure. The remaining 667 (52%) cases received ketamine with at least one other ASM, most commonly midazolam (89%, 593/667). Adjusted for the growth in the ESO dataset, ketamine use by EMS professionals during encounters for seizures without an airway procedure increased from 0.90% (139/15,375) to 1.45% (416/28,651) an increase of 62% over the study period.

Conclusions: In this retrospective review of the ESO Data Collaborative, ketamine administration for seizure encounters without an airway procedure increased over the study period, both as a single agent and with another ASM. Most ketamine administrations were for adult patients in the south and in urban areas. The frequency of BRSE, the need for effective treatment, and the growth in ketamine use warrant prospective prehospital research to evaluate the value of ketamine in prehospital seizure management.

Objectives: The American Board of Emergency Medicine (ABEM) Emergency Medical Services Medicine (EMS) subspecialty was approved by the American Board of Medical Specialties on September 23, 2010. Subspecialty certification in EMS was contingent on two key elements-completing Accreditation Council for Graduate Medical Education (ACGME)-accredited EMS training and passing the subspecialty certification examination developed by ABEM. The first EMS certification examination was offered in October 2013. Meaningful certification requires rigorous assessment. In this instance, the EMS certification examination sought to embrace the tenets of validity, reliability, and fairness. For the purposes of this report, the sources of validity evidence were anchored on the EMS core content, the examination development process, and the association between fellowship training and passing the certification examination.

Methods: We chose to use validity evidence that included: 1) content validity (based on the EMS core content); 2) response processes (test items required intended cognitive processes); 3) internal structure supported by the internal relationships among items; 4) relations to other variables, specifically the association between examination performance and ACGME-accredited fellowship training; and 5) the consequences of testing.

Results: There is strong content validity evidence for the EMS examination based on the core content and its detailed development process. The core content and supporting job-task analysis was also used to define the examination blueprint. Internal structure support was evidenced by Cronbach's coefficient alpha, which ranged from 0.82 to 0.92. Physicians who completed ACGME-accredited EMS fellowship training were more likely to pass the EMS certification examination (chi square, p < 0.0001; Cramér's, V = 0.24). Finally, there were two sources of consequential validity evidence-use of test results to determine certification and use of the resulting certificate.

Conclusions: There is substantial and varied validity evidence to support the use of the EMS certifying examination in making summative decisions to award certification in EMS. Of note, there was a statistically significant association between ACGME-accredited fellowship training and passing the examination.

Non-ST segment elevation myocardial infarction (NSTEMI) is a relatively unknown complication of injecting sublingual Suboxone (buprenorphine/naloxone). Buprenorphine/naloxone should be taken as a sublingual tablet or a buccal film and not injected, so its effects from this mode of administration are not well known. While the differential diagnosis for chest pain is very broad, many practitioners do not associate chest pain with the use of buprenorphine/naloxone. We recommend considering serial electrocardiograms (ECGs) and high-sensitivity troponins for a patient who presents with chest pain after buprenorphine/naloxone use.

Objectives: This study assesses the feasibility, inter-rater reliability, and accuracy of using OpenAI's ChatGPT-4 and Google's Gemini Ultra large language models (LLMs), for Emergency Medical Services (EMS) quality assurance. The implementation of these LLMs for EMS quality assurance has the potential to significantly reduce the workload on medical directors and quality assurance staff by automating aspects of the processing and review of patient care reports. This offers the potential for more efficient and accurate identification of areas requiring improvement, thereby potentially enhancing patient care outcomes.

Methods: Two expert human reviewers, ChatGPT GPT-4, and Gemini Ultra assessed and rated 150 consecutively sampled and anonymized prehospital records from 2 large urban EMS agencies for adherence to 2020 National Association of State EMS metrics for cardiac care. We evaluated the accuracy of scoring, inter-rater reliability, and review efficiency. The inter-rater reliability for the dichotomous outcome of each EMS metric was measured using the kappa statistic.

Results: Human reviewers showed high interrater reliability, with 91.2% agreement and a kappa coefficient 0.782 (0.654-0.910). ChatGPT-4 achieved substantial agreement with human reviewers in EKG documentation and aspirin administration (76.2% agreement, kappa coefficient 0.401 (0.334-0.468), but performance varied across other metrics. Gemini Ultra's evaluation was discontinued due to poor performance. No significant differences were observed in median review times: 01:28 min (IQR 1:12 - 1:51 min) per human chart review, 01:24 min (IQR 01:09 - 01:53 min) per ChatGPT-4 chart review (p = 0.46), and 01:50 min (IQR 01:10-03:34 min) per Gemini Ultra review (p = 0.06).

Conclusions: Large language models demonstrate potential in supporting quality assurance by effectively and objectively extracting data elements. However, their accuracy in interpreting non-standardized and time-sensitive details remains inferior to human evaluators. Our findings suggest that current LLMs may best offer supplemental support to the human review processes, but their current value remains limited. Enhancements in LLM training and integration are recommended for improved and more reliable performance in the quality assurance processes.

Objectives: Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS.

Methods: In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes.

Results: Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34-51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the "psychologically taxing" nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive.

Conclusions: Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.

Objectives: The strength and stability of the paramedic workforce is dependent on the continual flow of EMS clinicians into the field. Workforce entry requires three distinct steps: program completion, certification attainment, and affiliation with an EMS agency. At each of these steps, future EMS clinicians may be lost to the workforce but the contribution of each is unknown. Our objective was to evaluate these inflection points using a state-based registry of EMS clinicians from their point of entry into the EMS education system to eventual EMS agency affiliation.

Methods: This is a retrospective cohort evaluation of paramedic students in the Commonwealth of Virginia. We included any student who enrolled in a paramedic program in 2017 or 2018. Data were provided by the Virginia Office of Emergency Medical Services, who tracks the development of EMS clinicians from the point of entry into an educational program through their affiliation with an EMS agency upon employment. Our primary outcomes include proportions of enrolled students who complete a program, graduating students who attain national/state certification, and nationally certified EMS clinicians who affiliate with an EMS agency. Proportions were calculated at each step and compared to the overall population of students enrolled.

Results: In 2017 and 2018, 775 and 603 students were enrolled in paramedic programs, respectively. Approximately a quarter of students did not complete their paramedic program (2017: 25% [192/775]; 2018: 28% [170/603]). Of those who graduated, the proportion of students not gaining certification was lower (2017: 11% [62/583]; 2018: 17% [75/433]). Of those who certified, those not affiliating was similarly low (2017: 15% [77/521]; 2018: 13% [46/358]). Evaluating the effect of each of these steps on the total entry into the workforce, nearly half of those who originally enrolled did not join the workforce through agency affiliation (2017: 43% [331/775]; 2018: 48% [291/603]).

Conclusions: There are multiple areas to enhance retention of potential EMS trainees from program enrollment to EMS agency affiliation. This analysis suggests that educational attrition has a larger impact on the availability of new paramedics than certification examinations or agency affiliation decisions, though is limited to a singular state evaluation.

Objectives: During a drug overdose, research suggests individuals may not call 9-1-1 out of fear of criminal justice concerns. Of those that call, research is inconclusive about the disposition of the emergency transport. We evaluated transport outcomes for adults with opioid-related overdose in the Emergency Medical Services (EMS) of a large metropolitan city in the United States.

Methods: We reviewed the EMS incident report database from the patient care record system for years 2018 to 2022. We queried all records, searching for relevant terms, and two reviewers cross-checked the database to identify cases that did not result in death at the scene. Study outcome was defined as hospital transportation or no transportation. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for hospital transport with patient age, sex, race and ethnicity as the independent variables.

Results: We identified 5,482 cases of nonfatal opioid-related overdose. Of these, 4,984 (90.9%) were transported to the hospital; 37 (0.7%) were placed in police custody; 304 (5.5%) were not transferred; and 157 (2.9%) had unknown outcomes. Among 5,288 with data on the transport outcome, the majority were male (65%), and the highest proportion were White (39%). Compared to those who were not transported, each 1-year increase in age was related to a 2% increase in the odds of transportation (OR: 1.02, 95% CI: 1.01-1.02). Compared to White patients, Black and Hispanic patients were 43% OR: 1.43, 95% CI: 1.07-1.90) and 44% (OR: 1.44, 95% CI: 1.03-2.00) more likely to be transported.

Conclusions: Individuals with suspected opioid-related overdose who call 9-1-1 are most often transported to the hospital. Current EMS procedures are successful at on-scene treatment and transportation; however, data on the long-term impact of opioid-related overdoses are still needed.