PCRF 2019 Research Abstracts

Established in 1992, the Prehospital Care Research Forum (PCRF) is dedicated to the promotion, creation, and dissemination of prehospital research. In this, our third year of partnership with EMS World, we are proud to feature selected abstracts from the International Scientific Symposium, to be held during EMS World Expo, Oct. 14–18 in New Orleans, as well as proceedings from the 24th annual National Association of EMS Educators Symposium, which occurred in August. 

The PCRF is proud to highlight the work of EMS providers who advance the profession with science. We believe it is the responsibility of emergency medical professionals worldwide to practice evidence-based medicine and develop a body of evidence that examines prehospital emergency care.

Each year we make research more accessible and understandable through the publication of these abstracts. We hope you will join us in creating a culture of science in EMS by participating in our symposia, workshops, and monthly journal clubs. 

On the second Monday of every month at 1 p.m. Eastern, podcasts focus on the content of Dr. Tony Fernandez’s “PCRF Journal Club” (Journal Watch) column in EMS World Magazine. On the fourth Friday of every month, we host a joint podcast with the National Association of EMS Educators during which Dr. Megan Corry focuses on the “PCRF Research Alert” articles she authors for EMSWorld.com. Register for all podcasts at www.prehospitalcare.org.

We would like to thank our volunteer board of advisors and 33 associates. Without the dedication of these volunteers, none of this would be possible. In addition to the hard work of many people, much of our success can be attributed to the commitment of organizations dedicated to research in prehospital care. I would like to acknowledge our strategic partner, EMS World; education partner, the National Association of EMS Educators; founder, iSimulate; benefactor, ESO Solutions; partners, FirstWatch, Limmer Creative, and Jones & Bartlett Learning; and friends, Fisdap and Weber State University. The generous support of these fine organizations and our affiliation with the National Association of EMTs and the International Academies of Emergency Dispatch are what enable the PCRF to fulfill our mission.

The future of EMS depends on the quality and quantity of research we produce. We invite you to take a stand, conduct research in your community, and submit it in 2020 for the greater benefit of EMS. Our PCRF mentors are standing by to assist you.

Sincerely,

David Page, MS, NRP 

—Director, Prehospital Care Research Forum at UCLA

 

CLINICAL ABSTRACTS

Disparate Treatment of the Pediatric Diabetic Patient in the Prehospital Setting

Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic

Associate Authors: Lee VanVleet, MHS, NRP; Bradley Baggett, BS, NRP, FP-C; April Elmore, NRP; Michael Ross, BS, NRP, CCEMT-P; Melisa Martin, EdD(c), Paramedic

Introduction: Current research indicates the adult population demonstrates higher tendencies in poor glycemic control based on race, ethnicity, and socioeconomic status. Assuming a similar tendency in the pediatric population, it is important to identify any disparities in prehospital treatment. 

Objective: To identify disparities in the prehospital treatment of pediatric diabetic emergencies.

Methods: A retrospective observational study of pediatric diabetic emergencies was conducted using national ESO reporting data from January 1, 2017–December 31, 2017. The database contains prehospital patient care records for over five million EMS responses from more than 900 agencies across the United States and encompasses a broad range of practice settings from urban to rural. Inclusionary criteria consisted of patients whose lowest blood glucose level (BGL) was less than 70 mg/dL, had a total Glasgow Coma Score of 14 or less, and had a primary impression that suggested a potential BGL abnormality. A multivariate logistic regression was used to calculate the odds ratio for hypoglycemic treatment (D10, D25, D50, Glucagon, and/or oral glucose) while controlling for age, weight, gender, minority status, and primary impression.

Results: A total of 251 patients met our inclusionary criteria, of whom 58.2% were Caucasian and 51.8% were male. A total of 36.7% patients received an included treatment modality, and 63.3% patients were not treated. A primary impression of altered level of consciousness was statistically significant (OR 8.05, p=0.029) regarding the treatment of prehospital pediatric hypoglycemia. Age, weight, gender, and minority status revealed no statistically significant influence on treatment.

Conclusions: The study identified no discernable disparity in the treatment of prehospital pediatric diabetic patients filtered by age in years, weight, gender, or minority status. Further study is indicated to identify the rationale for whether a patient is treated when altered mental status is identified as a primary impression. 

Pediatric Cardiac Arrest Resuscitation by EMS (CARE)

Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic

Associate Authors: Bradley Dean, MA, NRP; Sara Houston, MHS, NRP; Stephen Taylor, MHS, Paramedic; Steven Howell, BS, NRP; Cody Cornelius, Paramedic

Introduction: Epidemiology of pediatric out-of-hospital cardiac arrest (pOHCA) and return of spontaneous circulation (ROSC) rates varies greatly. A paucity of literature exists concerning pOHCA and the factors that affect field ROSC and thus potential survivability. 

Objective: To examine factors influencing the likelihood of achieving field ROSC in pOHCA.
Methods: We conducted a retrospective analysis of field ROSC using electronic patient care records from the 2017 ESO research database. The database contains prehospital patient care records for over five million EMS responses from more than 900 agencies across the United States and encompasses a broad range of practice settings from urban to rural. Inclusion criteria consisted of pOHCA patients aged 18 years or less for whom resuscitation was attempted. Patients with traumatic or “other” OHCA etiologies were excluded. Data were analyzed using univariate tests and logistic regression with p≤0.05 indicating significance. Patients were stratified by age (newborn: 0–1 year and child: 2–18 years) for analysis. 

Results: A total of 656 pOHCA patients met inclusion criteria. The mean (+SD) age was 4.8 (+6.5) years, of which most were 1 year of age or less (59.5%); 55.9% were Caucasian, 59.5% were male, and 24.7% attained ROSC. Compared to unwitnessed arrests, patients were more likely to achieve ROSC when arrests were witnessed by a healthcare provider (OR 6.53, p=0.003), bystander (OR 2.94, p=0.001), or family member (OR 2.77, p=0.016). Field ROSC was also associated with Caucasian race (OR 2.39, p=0.004), use of CPR feedback device (OR 2.21, p=0.007), and quicker epinephrine administration (OR 0.98, p=0.042 per minute from 9-1-1 call received time to first epinephrine administration). The child age group (2–18 years) also exhibited improved odds of ROSC (OR 2.11, p=0.008). Factors that did not influence the likelihood of ROSC included gender, shockable presenting rhythm, and layperson CPR.

Conclusions: In this retrospective analysis of pOHCA, witnessed arrests and those receiving CPR feedback-guided resuscitations were more likely to achieve ROSC. Caucasian pOHCA and early epinephrine administration also increased the likelihood of ROSC. Additional prospective investigation is needed to elucidate determinants of ROSC in pOHCA.

Impact of Delayed Epinephrine Administration on Return of Spontaneous Circulation During Pediatric Out-of-Hospital Cardiac Arrest

Author: Emily A. Burchette, BS, NRP

Associate Authors: Michael W. Hubble, PhD, MBA, NRP; Ginny K. Renkiewicz, PhD(c), MHS, Paramedic; David Stallings, MHS, NRP; Helen  Tripp, LPCA, MA, NRP

Introduction: Epinephrine is the only vasopressor associated with return of spontaneous circulation (ROSC). While current guidelines recommend rapid and frequent vasopressor administration during cardiac arrest, delays in administration in out-of-hospital cardiac arrest (OHCA) remain a concern. Consequently, this study evaluated the effect of vasopressor administration delay on field ROSC in pediatric OHCA. 

Methods: This was a retrospective analysis of electronic patient care records from the 2017 ESO research database. The 2017 research database contains patient care records for over five million EMS responses from more than 900 agencies across the United States and encompasses a broad range of practice settings from urban to rural. All patients aged less than 18 years who suffered a nontraumatic OHCA prior to EMS arrival and for whom resuscitation was attempted were included. Data were analyzed using univariate tests and logistic regression with p≤0.05 indicating significance.
Results: A total of 412 patients met inclusion criteria with a mean age of 5.0 (±6.5) years. Mean EMS response time was 9.1 (±6.1) minutes, 28.4% were witnessed arrests, 42.5% received bystander CPR, 8.3% had shockable initial rhythms, and 22.6% experienced ROSC. The mean and 90th-percentile call-receipt-to-pressor intervals were 31.0 and 51 minutes, respectively. Patients receiving advanced airway control prior to epinephrine administration had longer scene-arrival-to-pressor intervals (24.9 vs. 19.3 minutes, p<0.01). Significant adjusted odds ratios for ROSC included call-receipt-to-pressor interval (per minute; OR 0.97, p<0.01); patient age (per year; OR 1.06,p<0.01); non-Caucasian race (OR 0.43, p=0.01); and witnessed arrests (OR 2.88, p<0.01). In addition, compared to arrests of cardiac etiology, arrests of respiratory (OR 2.42, p=0.01) and other etiologies (OR 2.12, p=0.04) were more likely to attain ROSC. An increased likelihood of ROSC was associated with an initial ECG of VF/VT or shockable AED rhythm (OR 3.06, p<0.01), PEA (OR 5.97, p<0.01), and unknown AED nonshockable rhythm (OR 8.42, p=0.03) when compared to asystole.

Conclusion: The odds of ROSC decrease 3% per minute of call-receipt-to-drug-administration delay. Airway control procedures account for a substantial portion of the delay in epinephrine administration and reduce the likelihood of ROSC.

Descriptives and Effectiveness of Opioid-Based Analgesics for Managing Pain for Wyoming EMS Incidents: Fentanyl and Morphine

Author: Morgan Anderson, MPH

Associate Authors: Douglas Butler, Jr., Clinical Specialist; Jay Ostby, Reporting Data Analyst

Purpose: To describe the patient characteristics for use of fentanyl compared to morphine for pain management and identify factors associated with effective pain management (EPM) using fentanyl and morphine in Wyoming.

Methods: EMS treated and transported patient records were analyzed from the state of Wyoming from January 2016 through May 2019. All patients aged 12 years or older who had self-assessed pain scores were included in the analyses. EPM was determined for patients experiencing pain scores of 4 or more where their final pain score was reduced by at least 2 points. A logistic regression (adjusted) model was performed looking at the odds of effective pain intervention by fentanyl and morphine. 

Results: From Jan 2016 to May 2019, 5,394 patients over the age of 12 years received fentanyl (82%), 1,059 (16%) received morphine, and 177 (2%) patients received both fentanyl and morphine independently during EMS care. Initial pain scores were missing for 1,130 (14%) patients. Multivariate analyses found strong evidence to suggest morphine had less EPM compared to fentanyl (OR 0.78, 95% CI, 0.68–0.90). There was less EPM in older age groups (50–69 years: OR 0.69, 95% CI, 0.60–0.79; 70 years or more: OR 0.82, 95% CI, 0.72–0.93) compared 12–29-year-olds, and for those experiencing abdominal/GI pain (OR 0.85, 95% CI, 0.73–0.99) compared to traumatic injuries. There was increased EPM for those where transportation time was greater (8–10 minutes: OR 1.26, 95% CI, 1.10–1.46; 11–21 minutes: OR 1.56, 95% CI, 1.35–1.78; 22 minutes or more: OR 2.03, 95% CI, 1.76–2.34) compared to 7 minutes or less and those experiencing back pain (OR 1.30, 95% CI, 1.03–1.64) compared to traumatic injuries.

Conclusion: Within this study only 51% of the population had EPM during their EMS treatment and transport. Based on this study’s results, fentanyl was a more EPM medication, and older age groups had less EPM, specific conditions such as abdominal/gastrointestinal pain/issues experienced less EPM, and longer transport times showed a trend in increased EPM. Although not analyzed within this study, results suggest analgesic dosage protocols may be an area to reevaluate due to only about half the population experiencing effective pain management.

Air Medical Pediatric Rapid Sequence Intubation

Author: David Olvera, NRP, FP-C, CMTE

Associate Author: Daniel Davis, MD

Background: Advanced airway management, including the use of rapid sequence intubation (RSI), is a fundamental skill in resuscitation. However, the reported experience with pediatric patients is limited as most institutions do not accumulate a large number of emergency RSI procedures in children. 
Objective: To document the experience with pediatric RSI in a large air medical database. 

Methods: Air Methods Corporation includes more than 150 bases throughout the United States. Air medical crews, including a flight nurse and flight paramedic, respond to both scene calls and interfacility transports. The RSI procedure includes either etomidate or ketamine for induction followed by paralysis with either succinylcholine or rocuronium. Video or direct laryngoscopy are available, including smaller blades for pediatric patients. Air medical crews document up to 150 data elements regarding the airway management procedure in a protected performance improvement database. All pediatric patients (age less than 18 years) were included in this analysis; patients were divided into three subgroups based on age (0–2 years, 3–8 years, 9–17 years). The primary variables of interest reflected intubation success: overall successful intubation (Overall), first attempt intubation success (FAS), and first attempt intubation success without desaturation (FASWD). 

Results: Over a three-year period, a total of 1,149 pediatric patients were identified. Intubation success for all patients and for each subgroup are included in the following table:

Age Group     n    Overall (%)    FAS (%)    FASWD (%)
0–2              269        96               87*             82*
3–8              263        97               92               89
9–17             617        98               93               90
All                1,149       97               91               88

*p<0.05 vs. 3–8 years and 9–17 years

Discussion: Overall pediatric RSI success rates were high despite less-than-optimal intubation conditions in the air medical environment. Rates for FAS and FASWD were lower for the youngest patients; this may represent an opportunity for education and training.

Evaluating the Current EMS Workforce in South Carolina

Author: Arnold Alier, EdD, NRP

Associate Authors: Sean P. Kaye, BS, EMT-P; Remle P. Crowe, PhD, NREMT; Robert A. Wronski, MBA, CPM, CEMSO, NRP; Jennifer K. Wilson, BS, EMT-B; J. Brent Myers, MD, MPH, FACEP

Introduction: Evaluating the current EMS workforce is important for planning routine field operations and preparing for disasters.

Objective: Describe the current EMS workforce in South Carolina with respect to patient contacts, number of agency rosters on which they appear, roles, and years of experience.

Methods: This cross-sectional evaluation included all certified South Carolina EMS professionals in 2019. Data were extracted from the South Carolina EMS data system and included number of patient contacts (patient care reports listing the individual as a patient care provider in the last 12 months), number of agency rosters, total years of experience (time from initial EMS certification to current certification expiration date), and roles (field provider, management/operations, leadership/administration, and educator). Roles were categorized in collaboration with the state EMS office to accurately reflect duties based on current jobs recorded in the South Carolina EMS data system. Roles were not mutually exclusive. Descriptive statistics were calculated. 

Results: There were 11,197 South Carolina EMS-certified individuals in 2019. Of those, 3,138 (27.9%) were not listed on any agency rosters. There were 8,069 (72.1%) who appeared on at least 1 agency roster. Number of rosters ranged from 1 to 20 with a median of 1 (interquartile range [IQR] 1–2). There were 1,757 (21.8%) individuals who appeared on a roster but had no patient contact within the last 12 months. There were 7,823 field providers. Experience ranged from less than 1 to 47.1 years with a median of 5.2 (IQR 2.4–11.3). There were 545 in management/operations. Experience ranged from less than 1 to 47 years with a median of 14.1 (IQR 6.3–24.6). There were 360 in leadership/administration. Experience ranged from less than 1 to 47 with a median of 17.0 (IQR 7.3–26.5). There were 29 educators. Experience ranged from 3.7 to 46.8 years with a median of 16.0 (IQR 8.9–27.2). 

Conclusion: Over one-quarter of EMS-certified individuals in South Carolina did not appear on an agency roster. Over one fifth of those on at least one roster have not had any patient contact in the last 12 months. Field providers had fewer years of experience compared to those in leadership, management, or educator roles. 

What Do We Truly Know About Situational Awareness in Paramedicine?

Author: Justin Hunter, PhD(c), MPA, NRP, FP-C

Background: Paramedics, crews, patients, and the public may be at risk for injury or medical error without situational awareness (SA). Currently SA has received very little attention in the setting of paramedicine. 

Objective: Review and identify the current literature related to SA and paramedicine

Methods: Extensive searches of electronic databases (5) were conducted to identify papers published related to paramedicine and SA. A narrative approach was then used to synthesize and map the literature. 

Results: Utilizing the two concepts of paramedicine and SA, 1,125 papers were initially identified. After screening, 20 papers were then included for qualitative synthesis. It was identified that there is very little empirical understanding of paramedicine in the context of SA.

Conclusions: Industries such as commercial aviation, offshore oil drilling, and nuclear energy have all been shown to experience few errors and a reduction in accidents when each professional possesses SA. However, SA has not been researched in paramedicine to the same degree as these other industries. Further research is needed in order to identify the potential effects of possessing or not possessing SA in the setting of paramedicine. 

Monitoring for Carboxyhemoglobinemia During Fire Rehab With the Nonin CO-Met Noninvasive Oximetry System Is More Reliable and Faster Than the Rad-57

Author: Adam Valine, BS, NREMT

Associate Authors: Allen Wesley, MD; Marcus Kramer 

Background: The National Fire Protection Association suggests assessment of firefighters for CO poisoning after potential exposure. As such, many EMS services have adopted the Rad-57 pulse oximetry system for monitoring COHb as a part of their standard fire rehabilitation. However, multiple studies have indicated varying reliability and accuracy of the Rad-57 for CO monitoring. Nonin Medical recently developed an oximetry system capable of measuring dyshemoglobins with clinical accuracy during hypoxia. This study was conducted to evaluate the reliability of the COHb measurements from the Nonin versus the Rad-57 device.

Methods: Firefighters undergoing standard fire rehabilitation were enrolled and had a DCI sensor (no light shield) with Rad-57 Pulse CO-Oximeter utilized in keeping with standard use of the product. On the opposite hand a Nonin 8330AA CO-Met fingertip sensor with prototype handheld oximeter was applied to the index, middle, or ring finger. Subject demographics were collected along with the COHb, peripheral oxygen saturation, and pulse rate values from the oximeters. Observations from the EMS personnel operating the two systems were also collected.

Results and Discussion: 114 measurements on 43 firefighters (42 male, age 36 ± 10 years, one smoker). Longer fire events resulted in multiple rehabilitations and measurements for a single firefighter. The Nonin CO-Met system reported readings for COHb on 97% of attempted measurements compared to 88% for the Rad-57. EMS personnel noted that the Nonin device displayed readings faster than the Rad-57, with a majority of blank readings on the Rad-57 occurring during a nighttime fire with an ambient temp of 18°F. The Rad-57 manual notes that ambient light can interfere with its COHb readings. Light shields were not used with the Rad-57 device, which may have contributed to the reading errors during daytime events. Per the manufacturer, the Nonin device did not require a light shield. 

Conclusion: These results suggest the Nonin CO-Met noninvasive oximetry system delivers reliability in a fire rehabilitation environment. The ongoing study will continue to expand on these results, adding subjects and observers. Further work is still needed to verify the accuracy of the new Nonin device in clinical use.

Likelihood of Bystander CPR in Pediatric Cardiac Arrest

Author: Lee Van Vleet, MHS, NRP

Associate Authors: Bradley Baggett, BS, NRP, FP-C; April Elmore, NRP; Michael Ross, BS, NRP, CCEMTP; Melisa Martin, EdD(c), Paramedic

Introduction: From 2014 to 2015, over 7,000 pediatric patients experienced out-of-hospital cardiac arrest (OHCA). However, only 10.7% of these children survived to hospital discharge. Layperson cardiopulmonary resuscitation (CPR) has been shown to markedly improve out-of-hospital cardiac arrest outcomes in the adult population. Bystanders are not, however, always willing to perform CPR on adults before trained responders arrive, especially in impoverished areas and among minority populations. There is a lack of such data regarding the likelihood of bystanders to perform CPR on pediatric patients. 

Objective: To determine the incidence of layperson CPR in witnessed pediatric cardiac arrest and demographic factors that may impact the likelihood of layperson efforts.

Method: We conducted a retrospective observational study of pediatric patients less than 18 years of age who experienced witnessed OHCA from January 1, 2017–December 31, 2017. Inclusionary criteria consisted of patients identified as experiencing witnessed cardiac arrest prior to the arrival of emergency medical services personnel. Descriptive statistics and multivariate logistic regression were used to analyze the incidence of and influence upon performance of layperson CPR. 

Results: A total of 269 patients met inclusionary criteria, of whom 69.5% (160) were Caucasian, 39.4% (163) were male, and 42.8% (115) received layperson CPR. Of the patients receiving layperson CPR, 54.8% (63) were male and 45.2% (52) were female. Compared to males, female OHCA victims were more likely to receive layperson CPR (OR 2.05, p=0.04). Gender was the only factor that showed a statistically significant (p=0.048) difference in the likelihood of bystanders to perform CPR, with females 2.05 times more likely than males to receive layperson CPR. There was no difference in age, weight, race, and cardiac arrest etiology regarding performance of layperson CPR.

Conclusion: The percentage of pediatric OHCA patients receiving bystander CPR is unacceptably low, and bystanders appear to exhibit a bias toward providing CPR to pediatric females. Further public initiatives are needed to increase bystander CPR and to decrease bystander bias.

Paramedic Team Emotional Intelligence and Its Impact on Performance During Simulation Training

Author: Hannah McGowan, BS

Associate Authors: Yasmin Graham, BS; Gary B. Williams, Jr., BS, NRP; J. Lee Jenkins, MD, MS, FACEP; Helena Mentis, PhD; Andrea Kleinsmith, PhD

Introduction: Emotional intelligence (EI) has been shown to play an important role in team functioning and can impact performance. While much of the research has focused on team EI in an office setting or a lab setting with an experimentally defined task, less work has considered EI in a more complex real-world context, such as paramedic simulation training. 

Objective: To evaluate the EI of paramedic trainee teams during simulation training and the impact EI may have on simulation performance.

Methods: Paramedic trainees in their fourth year of the paramedic track at University of Maryland, Baltimore County were participants. Data was collected during the emergency response simulations carried out in the Field and Clinical Experience course as part of the curriculum. Each simulation day comprised 6–8 simulations carried out by one team that consisted of four trainees (n=10 teams). Trainees alternated between the roles of team lead, partner, and support crew. At the end of each simulation day, trainees completed the Work Group Emotional Intelligence Profile (short version) which measures EI in terms of awareness and management of one’s own and others’ emotions, yielding four subscales. Team performance was evaluated by course instructors as bad, moderate, good, and excellent for the categories: patient care, crew interaction, and timing throughout the call. 

Results: A Kruskal-Wallis H test did not reveal significant differences in EI between teams (p=0.113). Wilcoxon signed ranks analysis of EI within teams demonstrated that teams were better at managing their own emotions than managing teammates’ emotions (p=0.0049), as well as being aware of their own emotions (p=0.0005) and being aware of teammates’ emotions (p=0.001). Linear regression was employed to assess the relationship between EI and performance. Results indicated team EI was moderately correlated with crew interaction (r=0.468) and patient care (r=0.404).

Conclusion: In the complex context of simulation training, EI within paramedic trainee teams had a moderate impact on team performance with respect to patient care and crew interaction. However, further analysis is necessary to draw more concrete conclusions. As a next step, the electrodermal activity of each participant—also recorded during each simulation—will be examined.

An Epidemiology of Pediatric Suicide Attempts

Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic

Associate Authors: Helen E. Tripp, MA, LPCA, Paramedic; Emily A. Burchette, BS, NRP; David A. Stallings, MHS, NRP; Michael W. Hubble, PhD, MBA, NRP

Introduction: Suicide is the second-leading cause of death for individuals between the ages of 10–24, and it is estimated that 2 million adolescents attempt suicide each year. While there is literature describing epidemiological factors associated with pediatric suicidality, little is known about the presentation of this population in a prehospital setting. 

Objective: To describe epidemiological and patient-related factors of a nationwide population of prehospital pediatric suicide attempts. 

Methods: This was a retrospective epidemiological study performed using nationwide data from ESO Solutions from January 1, 2017–December 31, 2017. The database contains prehospital patient care records for over five million EMS responses from more than 900 agencies across the U.S. and encompasses a broad range of practice settings from urban to rural. All patients who had an EMS provider primary impression of suicide attempt were included, and descriptive statistics were utilized to describe the sample. A licensed professional counselor associate (LPCA) categorized chief complaints into 26 subgroupings. 

Results: A total of 2,698 patients met inclusionary criteria, of whom 65.2% (n=1,759) were female and 26% (n=702) were minorities. Suicide attempts accounted for approximately 1% of the overall sample from the data set. Mean age was 15.5 ± .05 years with a range of 6–18. Patients identified as prepubescent (<13 years) accounted for 15.3% (n=413) of the sample. Average EMS response time was 11.75 ±33.36 minutes, and 457 (16.9%) attempts had a traumatic component. Suicidal ideations without actual attempt were the highest subgrouping (n=990; 36.7%), followed by nonspecific suicide attempt (n=414; 15.3%), overdose (n=390; 14.5%), lacerations (n=172; 6.4%), and depressive symptoms (n=101; 3.75%). Upon EMS arrival, 5 patients were observed to be in cardiac arrest. Of these, resuscitation was attempted on 2, and 1 achieved ROSC. Twelve patients were intubated.

Conclusions: Pediatric suicide is a significant cause of premature death, especially among adolescents. Our study shows the prepubescent population is at risk. EMS data does not accurately describe the methods used to attempt or complete suicide and more research is needed to further define suicidality in EMS pediatric patient cohorts.

Validation of Proposed Criteria for Withholding Resuscitative Efforts in Out-of-Hospital Cardiac Arrest

Author: Sabrina Vlk, MS, LP, CCRC

Associate Authors: Veer Vithalani, MD, FACEP, FAEMS; Dwayne Howerton, RN, LP

Background: In 2018 Shibahashi, Sugiyama, and Hamabe proposed a new set of criteria for withholding resuscitative efforts for patients in out-of-hospital cardiac arrest (OHCA). Using their all-Japan registry, they found that patients who were 73 years of age or older and suffered an unwitnessed, unshockable OHCA were significantly likely to have an unfavorable neurologic outcome, including death. This study aims to validate the proposed criteria using previously collected data on OHCA in a large, urban-suburban EMS system in the United States.

Methods: A retrospective review was performed on all completed cardiac arrest data for this system within the Cardiac Arrest Registry to Enhance Survival (CARES) from 2013 through 2018. The data was analyzed using the proposed criteria: age 73 years or more, unwitnessed, and unshockable initial rhythm. Neurologic outcome was quantified through Cerebral Performance Category (CPC) scores; unfavorable neurologic outcome was qualified as a CPC of 3, 4, or 5.

Results: There were a total of 4,532 cardiac arrests in the inclusion period. Of these, 863 (19%) met the proposed criteria. Eleven (1.3%) survived to discharge, with only 2 (0.2%) of those patients having a favorable neurologic outcome. This represents a PPV of 99.8% (99% CI, 99.3%–100%), specificity of 99.3% (99% CI, 98.0%–100%), PLR of 29.4 (99% CI, 4.8–181), and OR of 36.7.

Conclusions: When tested using an unrelated population set, this study validated the proposed criteria’s ability to accurately identify OHCA patients likely to suffer neurologic devastation or death. Though differences in system design between Japan and the United States warrant further large-scale derivation/validation studies, this study highlights a significant opportunity to risk-stratify OHCA patients while maximizing resources on those who may benefit.

Reference: Shibahashi K, Sugiyama K, Hamabe Y. A potential termination of resuscitation rule for EMS to implement in the field for out-of-hospital cardiac arrest: An observational cohort study. Resuscitation, 2018; 130: 28–32. 

The Doctor Is In? Patient Acuity and Its Influence on Paramedic Utilization in the Emergency Department

Author: Jackson Deziel, PhD, MPA, NRP

Associate Authors: Eryn Dixon, EMT; Joshua Guthrie, EMT; Madison Benton, EMT

Introduction: In recent decades hospital emergency departments have increasingly diverged from the traditional medical provider model. Once the sole province of physicians, patients are now attended to by physician assistants, nurse practitioners, and even EMT/paramedics. Given their unique skill set, EMT/paramedics have the capacity to make significant contributions to patient care in the emergency department setting. However, the question remains: Which patients are these providers treating? 

Objective: To explore provider assignments in the emergency department given differing patient acuities. 

Methods: The analysis examined a nationally representative sample of deidentified emergency department patient encounters from 2011 through 2016, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Triage (acuity) levels followed the standard five-point Emergency Severity Index scale. Multivariate logistic regression analyses were adjusted for the weighted data set and controlled for potential confounders. Likelihoods of medical practitioner consultation were analyzed by presenting acuity level. 

Results: Drawing from the NHAMCS data set, 69,820 emergency department records were analyzed, weighted to represent 350.7 million estimated patient encounters. Patients triaged as “immediate” were 14 times more likely to be cared for by an EMT/paramedic (OR 14.63, p<0.000). Patients triaged as “emergent” were nearly five times more likely to be cared for by an EMT/paramedic (OR 4.80, p<0.000). Patients triaged as “urgent” were also more likely to be cared for by an EMT/paramedic (OR 2.59, p<0.000). Patients attended to by an EMT/paramedic spent more time in the emergency department (B=24.28, p<0.000) and received more total diagnostic services (B=1.55, p<0.000). Findings show that higher-acuity patients were increasingly more likely to see a physician (attending, consultant, or resident) and less likely to see a nurse practitioner or physician assistant. 

Conclusion: In the emergency department, hospitals appear to be utilizing EMT/paramedics for higher-acuity patients. This application of provider expertise profits from the EMT/paramedic’s training and general comfort in a fast-paced emergent setting. With the relatively recent addition of EMT/paramedics into emergency departments, there has been a broad fear of relegation to “minor care” or “fast-track” areas (i.e., low-acuity patient populations). This study, however, suggests the opposite: EMT/paramedics are being reserved for the sickest of patients.

New Documentation Mnemonic and Rubric Substantially Improved Documentation Performance

Author: Douglas Randell, BS, NRP

Associate Author: Michelle Mayer, BA, NRP

Background: Emergency medical services (EMS) documentation is essential for recording patient care, billing, and quality improvement and patient outcomes. Documentation techniques vary, and few tools exist to provide feedback to EMS professionals regarding their documentation processes and performance. 

Objective: The objective was to evaluate the performance of a newly developed mnemonic for documentation, an accompanying evaluation rubric, and to improve compliance with documentation of patient care report elements.

Methods: A descriptive method was used based on the development of a mnemonic as a method for improving the process of recording patient care. An evaluation rubric was developed in conjunction with the mnemonic to assess documentation performance. Scores greater than 80% were deemed ‘passing’ and scores greater than or equal to 95% were classified as ‘high achievers’ out of 100%. Training was conducted at a fire-based EMS agency in the fall of 2017. Beginning January 1, 2018, a team of quality improvement personnel randomly reviewed one run report per employee per shift. The analysis was from January 1 to December 31, 2018.

Definition: DOCUMENT

• Dispatch/demographics/distance
• On-scene assessment
• Chief complaint
• You (U) say what?
• My eyes
• Examination
• And (N) the verdict is…
• Treatment and transport and decisions

Results: In October 2016 a retrospective analysis was conducted using the rubric (instrument). The review was conducted prior to the implementation of the instrument, training, or evaluation. Forty-three percent of patient care reports were reviewed in October 2016 (n=122) using the rubric. Reports above the passing score (greater than or equal to 80% compliance) were 48%. Reports in the ‘high achievers’ category (greater than or equal to 95% compliance) was 0%. 

After implementation of the instrument, 37% (n=1,482) of patient care reports were reviewed. The reports with a passing score ranged from 85% in January 2018 to 98% in December 2018. Reports in the ‘high achievers’ category ranged from 16% in January 2018 to 71% in December 2018. 

Conclusion: Substantial improvement in the documentation of key patient care record elements was noted following implementation of the newly developed mnemonic DOCUMENT and associated objective evaluation rubric. Future work is needed to assess the generalizability of these findings at other EMS agencies. 

The Kids Are All Right: A Multiyear Statewide Analysis of Pediatric Nontransport

Author: Eryn Dixon, EMT

Associate Authors: Joshua Guthrie, EMT; Madison Benton, EMT; Jackson Deziel, PhD, MPA, NRP; Evelyn Wilson, EdD, MHS, NRP

Introduction: In the world of emergency medical services, refusals of care and/or transport are relatively common. For those aged 18 years or greater, it is his/her right to refuse treatment and/or transport. Minors, however, are not allowed this autonomous decision. In situations such as these, a responsible adult is charged with the choice to continue or stop medical care. 

Objective: This study explores differences in nontransport among pediatric age ranges. 

Methods: This retrospective study captured all 9-1-1 ambulance requests in the state of Virginia for the years 2009 through 2013. Pediatric patients were isolated and then classified into Infant (0–1 years), toddler (2–5 years), child (6–10 years), tween (11–12 years), teen (13–16 years), and pre-adult (>16 years). Multivariate logistic regressions with time-fixed effects were utilized. Control variables included patient sex, race, EMS organizational ownership type, and EMS employment structure (paid, volunteer, or mixed). 

Results: Of all 9-1-1 requests during this time period, 288,120 pediatric patients were analyzed. Overall, 19.9% of all pediatric calls resulted in a refusal, and 3.2% resulted in a determination of “no treatment required.” Compared to refusal and no-treatment rates in adults (11% and 1.7%, respectively), pediatric patients were more likely to have a refusal issued (OR 1.98, p<0.000) and were more likely to be classified as “no treatment required” (OR 2.06, p<0.000). Logistic regression analyses showed increased patient age was positively associated with patient refusal (OR 1.058, p<0.000) and negatively associated with “no treatment required” (OR 0.883, p<0.000). When analyzed by age group, infants were 33% less likely to have a refusal issued (OR 0.667, p<0.000), but three times more likely to be classified as “no treatment required” (OR 3.136, p<0.000). 

Conclusion: Younger patients were more likely to receive no treatment, while older pediatric patients were more likely to have a refusal issued. Several factors may be in play, but the “scared new parent” may account for the higher likelihood of no-treatment 9-1-1 calls, while older teenagers might be allowed a bit more autonomy and input regarding their medical care. Previous research also highlights that providers are generally uncomfortable with pediatric patients and may influence the decisions of guardians.

The Effects of a Recent Emergency Department Visit on Acuity Classification and Diagnostic Service Provision

Author: Joshua Guthrie, EMT

Associate Authors: Eryn Dixon, EMT; Madison Benton, EMT; Jackson Deziel, PhD, MPA, NRP; Susan Braithwaite, EdD, NRP

Introduction: Return visits to the emergency department are a significant problem in the field of emergency medicine. Some studies suggest that patients often feel as if their original diagnosis was not correct or ineffective, and many times these patients are right. Additionally, a large number of return visits can be attributed to poor discharge instructions or a lack of understanding by the patient about their condition and treatment. The perceived ideas of convenience and speed also play a role in patient’s choosing to return to the emergency department versus a primary care provider. Yet little research has explored the effects of a recent visit on the services rendered.

Methods: The analysis examined a nationally representative sample of deidentified emergency department patient encounters from 2011 through 2016, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Multivariate linear and logistic regression analyses were adjusted for this weighted data set and controlled for potential confounders. The provision of diagnostic services, length of visit, and patient acuity were explored for patients presenting to the emergency department within 72 hours of a previous visit. 

Results: Drawing from the NHAMCS data set, 62,699 emergency department records were analyzed, weighted to represent 313.9 million estimated emergency department patient encounters. Findings suggest that patients who had been seen in the emergency department in the prior 72 hours were less likely to be classified as “emergent” (OR 0.864, p=0.006) and more likely to be classified as “nonurgent” (OR 1.139, p<0.000). Additionally, these patients received fewer total diagnostic services (B=[-0.462], p<0.000). There was no significant difference in length of visit. 

Conclusions: Patients who present to the emergency department within 72 hours of their previous visit are much more likely to be triaged as low-acuity and subsequently receive fewer diagnostic tests. These patients, however, do not appear to be expedited through the department. Many reasons contribute to return visits, among them inadequate discharge education and lack of primary care access. This study highlights that return visits are largely low-acuity and do not require extensive diagnostic testing. 

Current and Potential Community Paramedic Call Volume in the NEMSIS Database

Author: Avery Dorgan, MPH, NREMT

Associate Author: Joyce A. O’Connor, DrPH, MA, RD

Introduction: Though overall use of emergency departments has increased in recent years, there are interventions that could curb the currently observed overcrowding. One promising intervention is the implementation and scale-up of community paramedicine.

Methods: Using data from the National EMS Information System database, 2017 emergency calls with a community paramedic response were analyzed for call, patient, and payment characteristics. The most frequent dispatch categories were then used to assess the total number of calls in the data set that could potentially be averted through the scale-up of community paramedicine.

Results: Table 1 shows the distribution and demographics of current and potential community paramedicine calls. Analysis of the 3,862 calls with a community paramedic response showed the most frequent dispatch categories were “no other appropriate choice” (23%), “sick person” (12.4%), and “well-person check” (11.5%). Of the total 8.9 million calls in 2017, 1.9 million fit those categories and could potentially be averted. 

Table 1. Comparative demographic results between community paramedic subpopulation and all calls that could be handled by community paramedics

Discussion: Though the National Registry of EMTs does not recognize community paramedic as a level of care, providers are operating at that care level. As paramedics currently respond to most community paramedicine-eligible calls, paramedics may be able to address these calls before they elevate to the emergent level and help triage services, lowering the current EMS system call volume and allowing the system to better prepare for more urgent calls. 

Conclusion: By formalizing the community paramedic role through uniform policies, procedures, standards, and training programs to ensure level of care, nearly 2 million calls could be handled in the community.

A Pediatric Medication Dosing Support Tool Increases Rates and Safety of Medication Delivery

Author: David Miramontes, MD, FACEP, FAEMS, NREMT

Associate Authors: Bailey Devereaux, MPH; Michael Stringfellow, EMT-P; David A. Wampler, PhD, LP, FAEMS

Background: Pediatric patients represent 13% of all EMS transports, and only approximately 10% of pediatric patients transported are critically ill or injured requiring parenteral medication administration. This low exposure rate of critically ill children increases the risk of medication administration errors. Medication administration is further complicated by a weight-based schema. Technology support that addresses medication-dosing errors in pediatric care holds the potential to significantly increase pediatric patient safety. The goal of this study was to evaluate the medication dosing error rates before and after deployment of the Handtevy age-based system in a large metropolitan fire-based EMS system.

Methods: This was an interrupted time series comparing three months (Q1 2016) prior to the deployment of a pediatric dosing support tool (period 1) with the three months (Q1 2018) following full implementation (period 2). Criteria: All pediatric patients (≤13 years old) treated for pain or seizure. Medication dosing errors were defined as greater than 10% medication deviation from the correct mg/kg dose. Descriptive statistics and chi square were used to compare periods 1 and 2.

Results: A total of 133 pediatric patients were enrolled in this study, 51 in period 1 and 82 in period 2. Mean age was 8 ± 3 years for period 1 and 6 ± 4 in period 2 (p=0.003). The observed error rate was greater than expected, 72% and 82% for fentanyl and midazolam, respectively for period 1. Ninety percent of the errors were by underdosing patients. Error rates for period two were 41% and 36% for fentanyl and midazolam, respectively, with 69% being underdosing (p<0.001). 

Conclusions: Post deployment of the Handtevy pediatric drug dosing support application was correlated with a younger cohort and 61% increase in the overall rate of pediatric patients receiving pain or antiepileptic medications. Using a very conservative definition of a doing error (10% over or under ideal dosage per kg), the intervention resulted in a 42% reduction in overall dosing error. 

Evaluating the Utility of Initial Prehospital Shock Index and Modified Shock Index to Predict Hospital Sepsis and Septic Shock Diagnosis

Author: Antonio Fernandez, PhD, NRP, FAHA

Associate Authors: Ryan Schroeder; Remle P. Crowe, PhD, NREMT; J. Brent Myers, MD, MPH; Scott Bourn, PhD, RN

Introduction: Early recognition and initiation of treatment for suspected sepsis patients is important to reduce morbidity and mortality. Shock index (SI) and modified shock index (MSI) can be readily obtained in the prehospital setting and may be useful predictors of sepsis; however, their predictive value for sepsis and septic shock has not been tested for use by EMS. 

Objective: To evaluate SI and MSI in the prehospital setting as predictors of hospital sepsis diagnosis. 

Methods: This retrospective analysis used linked prehospital and hospital patient care records for January 1, 2018–December 31, 2018 from the large national health data exchange research database maintained by ESO. All medical emergency EMS responses with linked hospital data were included. Patients under 18 and those with traumatic injuries were excluded. Any sepsis diagnosis was defined by hospital ICD-10 codes A40, A41, R65.20, and R65.21, and septic shock was restricted to R65.21 only. SI was calculated by dividing initial heart rate by systolic blood pressure. MSI was calculated by dividing initial heart rate by mean arterial pressure. Based on previous research, elevated SI was defined as greater than 1.0, and elevated MSI was greater than 1.3. Four multivariable logistic regression models were created to separately evaluate SI and MSI as predictors of sepsis and septic shock, controlling for patient age, gender, race/ethnicity, community size, and census region. 

Results: This analysis included 325,558 patients. The median age was 60 (IQR 43–75), 53% were female, 69% were white (non-Hispanic), and 94% were in urban communities. Five percent (16,881) were diagnosed with sepsis. Of these, 19% had septic shock (3,144). Over a fivefold increase in odds of any sepsis diagnosis was noted for patients with an elevated initial SI (AOR 5.30, 95% CI, 5.08–5.52) or MSI (AOR 5.42, 95% CI, 5.21–5.64). Approximately a ninefold increase in odds of septic shock was observed for patients with an elevated SI (AOR 9.05, 95% CI, 8.32–9.85) or MSI (AOR 8.61, 95% CI, 7.92–9.36). 

Conclusion: Our findings suggest elevated initial prehospital SI and MSI are both strong predictors of hospital sepsis diagnosis and stronger predictors of septic shock.

Effects of Paramedic Tenure on the Accuracy of Prehospital Stroke Identification

Author: Justin Brines, BS, NRP

Associate Author: Jackson Deziel, PhD, MPA, NRP

Introduction: Stroke is the fifth-leading cause of death in the United States and the No. 1 cause of disability, affecting approximately 795,000 people per year. Reliable identification of stroke in the field by prehospital personnel expedites delivery of acute stroke therapy. While the National Institutes of Health (NIH) scale is comprehensive, it is difficult to perform in the prehospital environment, and abbreviated scales are much more common. Provider experience, however, may factor into the correct identification of stroke.

Objective: To determine if years of prehospital experience affect the accuracy of stroke identification.
Methods: A systematic review was conducted of data from a suburban EMS agency answering approximately 34,000 calls per year with access to a Level 1 trauma center and a certified stroke center. All patients determined to be having a stroke by paramedics between January 1, 2013 and December 31, 2017 were included in the analysis. There were no exclusions based on age, sex, race, or comorbidities. ICD-10 diagnostic codes were collected for each patient. Multivariate logistic regression with robust standard errors was utilized.

Results: A total of 621 patients were included in the data analysis. Of the patients identified by the paramedic as having a stroke, 51% were subsequently admitted to the hospital for stroke, while 49% were not determined to be suffering from an acute stroke. For each additional year of experience, the paramedic was 6.5% more likely to correctly identify stroke (OR 1.065, p=0.112). It was also found that paramedics were more likely to correctly diagnose stroke in male patients (OR 1.020, p=0.045) and less likely to correctly diagnose stroke in female patients for each additional year of experience (OR 0.982, p=0.046). 

Conclusions: This study may suggest that paramedics with more tenure are more accurate at recognizing stroke in the prehospital setting. Additionally, a disparity appears to exist between male and female patients. Patients included in this study appear to have been overtriaged by paramedics. While there is an acceptable level of overtriage related to stroke, it should be noted that this may lead to alarm fatigue and overuse of scarce resources.

Attitudes of EMS Stakeholders in Barbados: A Convergent Parallel Mixed-Methods Study

Author: Hezedean Smith, DM(c), CFO, CEMSO, FACPE, CPM, EF/ESO, MIFireE, CHSE, PMD

Objective: To examine the attitudes of accident and emergency (A&E) doctors, prehospital EMS providers, and A&E nurses based on the tripartite model of attitudes theory. How do the attitudes of EMS stakeholders in Barbados align with the attributes of the EMS Agenda for the Future?

Design and Methods: A convergent parallel mixed-methods design was used. Beliefs, affect, and behavior measures were used as dependent and independent variables. Stakeholders were examined collectively and separately. Sampling was purposeful (n=105). Semi-structured interviews and a four-part survey were used to answer eight research questions. Inferential statistical methods were applied using SPSS. NVivo was used to code qualitative information collected.

Results: A confidence interval of 0.95 was used to report findings. A significant regression model based on beliefs and behaviors was identified for prehospital EMS providers (F[1,63]=9.278, p=0.003), with an R2 of .130. A significant regression model based on affect and beliefs was identified for A&E doctors (F[1,27]=5.896, p=0.022), with an R2 of 0.179; prehospital EMS providers (F[1, 62]=10.931, p=0.002), with an R2 of 0.150; and A&E nurses (F[1, 9]=7.318, p=0.024), with an R2 of 0.448. Eight themes emerged from the research.

Conclusions: EMS legislation, regulation, and medical direction are important in the English-speaking Caribbean, as they address a strategic priority of the Caribbean community. A 2050 EMS Agenda for the Caribbean is suggested to strengthen prehospital EMS and serve as a future model for out-of-hospital care in the region.

Road Traffic Accident Related Fatalities in Addis Ababa City, Ethiopia: An Analysis of Police Reports 2013–2014

Author: Anteneh Kebede Sebsbie, BSN, MSN

Associate Authors: Temesgen Beyene, MD, Assistant Professor; Haimanot Geremew, Assistant Professor

Background: The increase in access and number of transportations pose a great challenge in the individual’s daily activity ranging from minor injuries to death. The nation also suffers from loss of productive citizens.

Objectives: To assess the magnitude and factors contributing to the mortality related to road traffic accidents in Addis Ababa, Ethiopia.

Methodology: Data from the Addis Ababa Police Commission, Traffic Police Department was collected from the checklist of information by the police officer at the scene. Data were entered to SPSS version 16.00. Results were generated from the SPSS and presented to the department of emergency medicine. The results were made available to concerned bodies (Addis Ababa Traffic Police Department, Federal Ministry of Health Ethiopia, and Federal Ministry of Transport).

Results: Overall there were 2,372 recorded road traffic accidents in Addis Ababa during the study period. Of these, 382 (16.1%) were fatal. Among all fatalities the majority were male 279 (73.03%), the ratio of male/female was 3:1, and pedestrians accounted for 321 deaths (84.0%). Fatal accidents were more prevalent on isled roads 262 (60.7%) and involved especially commercial cars. More than half of fatalities (205, 53.8%) occurred due to failure to give the right of way for pedestrians. 

Conclusion: The majority of affected victims were vulnerable road users and pedestrians. Many victims died at the scene instantaneously. These findings can serve as a basis for healthcare professionals and policymakers to create preventive measures for traffic accidents. 

Impact of Pediatric Age Groups on Prehospital Intubation Success

Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic

Associate Authors: A. Watkins, BS, EMT; K. Collopy, BA, NRP, FP-C, CMTE; J. Hoover, EMT; J. Tuttle, MHS, NRP

Introduction: Current studies indicate that first-pass success rates for endotracheal intubation (ETI) range from 66% to 91%. Additional studies suggest that basic airway management with a bag-valve mask produces better outcomes in out-of-hospital cardiac arrest (OHCA) than advanced airway management with ETI. Additional data demonstrates decreased success with repetitive prehospital intubation attempts. However, there are limited data evaluating intubation success among pediatric age groups. 

Objective: This study sought to evaluate whether prehospital overall ETI success varied based on patient age.

Methods: This is an IRB-approved retrospective analysis of pediatric ETI from January 1, 2017–December 31, 2017. Data were collected from all pediatric records in the ESO database. All patients aged less than 18 years with an ETI attempt were included. Patients were divided into 6 age groups: neonate (age 0–30 days), infant (31–364 days), toddler (1–3 years), preschool (4–6 years), school-age (7–12 years), and adolescent (13–17 years). A logistic regression was performed to evaluate the influence of patient age on overall ETI success while controlling for patient age, sex, minority status, and receipt of paralytic agents. 

Results: A total of 553 patients were included in the analysis, of which most were male (n=331; 59.9%) and Caucasian (n=384; 69.4%). Adolescents were the most commonly intubated age group (n=164; 29.66%), followed by infants (n=160; 28.93%), toddlers (n=82; 14.82%), school-aged children (n=60; 10.84%), preschoolers (n=45; 8.13%), and neonates (n=42; 7.59%). Compared to adolescents, neonates (OR 0.404; p=0.014) and those patients not receiving paralytics were less likely to obtain overall ETI success (OR 0.404; p=0.049). Neither sex nor minority status were statistically significant predictors of ETI success. 

Conclusions: Compared with adolescents, prehospital professionals are 60% less likely to successfully intubate neonates. In addition, patients are 60% less likely to be successfully intubated when paralytic agents are not used. Further research is necessary to evaluate if provider experience and training influence pediatric patient intubation success rates. 

Treatment Equity Among Pediatric Diabetic Patients in the Prehospital Setting

Author: Lee Van Vleet, MHS, NRP

Associate Authors: Bradley Baggett, BS, NRP; April Elmore, NRP; Michael Ross, BS, NRP; Melisa McNeil, EdD(c), EMT-P

Introduction: Current research indicates the adult population demonstrates higher tendencies of poor glycemic control based on race, ethnicity, and socioeconomic status. Assuming a similar tendency in the pediatric population, it is important to identify any disparities in the prehospital treatment of this underexamined population. 

Objective: To identify disparity in prehospital treatment of pediatric diabetic emergencies.

Method: A retrospective observational study of pediatric diabetic emergencies was conducted using national ESO reporting data from January 1, 2017–December 31, 2017. Inclusionary criteria consisted of patients whose lowest blood glucose level (BGL) was less than 70 mg/dL and had a total Glasgow coma score of 14 or less and a primary impression that may have been related to BGL abnormalities. A multivariate logistic regression was used to calculate the odds ratio for hypoglycemic treatment (D10, D25, D50, glucagon, and/or oral glucose) while controlling for age, weight, gender, minority status, and primary impression.

Results: A total of 251 patients met our inclusionary criteria, of whom 58.2% (146) were Caucasian and 51.8% (130) were male. A total of 36.7% (92) patients received an included treatment modality, and 63.3% (159) patients were not treated. A primary impression of altered level of consciousness was statistically significant (OR 8.05, p=0.029) regarding the treatment of prehospital pediatric hypoglycemia. Age, weight, gender, and minority status revealed no statistically significant influence on treatment.

Conclusion: This study identified no discernable disparity in treatment of prehospital pediatric diabetic patients when examined by age in years, weight, gender, or minority status. Further study is indicated to identify factors affecting the likelihood for treatment in the primary impression of altered mental status in pediatric prehospital patients.

Lifesaving Policy Solutions for EMS Motor Vehicle Collisions

Author: Jeffrey Rollman MPH, NRP

Associate Author: Michael Kaduce, MPS, NRP

Background: Emergency medical services (EMS) providers are first responders to motor vehicle collisions and other emergencies, transporting these patients to definitive care. Despite their critical role in society, transportation-related injuries and fatalities among EMS providers range from two to five times the general worker population. The majority of these fatal collisions involve the use of lights and sirens.

Objectives: The primary objective is to better understand the incidence and severity of EMS motor vehicle collisions. A secondary objective is to analyze potential policy interventions that address the problem of motor vehicle collisions. 

Methods: First, a literature review was conducted in order to synthesize current knowledge surrounding the statistics and epidemiology of this issue. Then policy solutions were explored that can address the problem of motor vehicle collisions in EMS. Finally a recommendation was proposed that incorporates regulatory and fiscal realities. 

Results: Lights and sirens usage quadruples the risk of motor vehicle fatality and injury. Research demonstrates that lights and sirens are almost always unnecessary and generally do not improve patient outcomes. EMS provider fatalities are on par with or higher than police, firefighters, and other public safety personnel. Fatal ambulance crashes disproportionately occur on rural roads and among volunteer EMS providers. Engineering controls are necessary given the lack of any federal ambulance safety equipment or chassis mandates. Administrative controls, through improved training and driving policies, may enhance EMS driving behavior. Safety culture is also an important mediator to address, as research demonstrates that EMS agencies with strong safety cultures have much lower injury and fatality rates. Personal accountability for seat belt usage and distracted driving may lead to a decrease in collisions without regulatory control.

Conclusions: Sufficient evidence is available to suggest that significant reductions in lights and sirens usage can lead to dramatic reductions in EMS motor vehicle collisions without negatively impacting health outcomes, yet this risky practice largely continues. Ambulance collisions are also underreported, which means the incidence is likely even higher. Simple regulatory changes to address lights and sirens utilization could yield positive benefits without any apparent unintended consequences.

Exhaustion and Disengagement in Emergency Responders: Measuring Burnout Using the Oldenburg Burnout Inventory Tool

Author: Morgan Anderson, MPH

Intro/Background: Employee burnout, which ultimately can lead to staff turnovers, is a commonly heard problem within the emergency responder industry. There are few tools available to measure the extent of the issue and gain insight into specific themes related to exhaustion, disengagement, and burnout. There has been minimal research done on burnout within this population.

Purpose: To evaluate burnout in an emergency responder population utilizing the Oldenburg Burnout Inventory (OLBI) tool and identify what portion of the population have scores indicative of burnout.

Methods: This retrospective study gathered data from the CrewCare mobile app, an anonymous mental health app for first responders. Respondents were located in the United States and were individuals working in emergency medical services, fire, and law enforcement. Self-reported respondent data was acquired from February 2018 to May 2019. The OLBI questions were analyzed and scored. Each question received a score between 1 and 4 points depending on the answer. Exhaustion and disengagement scores were indicative of burnout based on a study by Peterson, et al. (2008). In order to receive a burnout score, respondents had to have answered all 16 questions. Points were totaled and divided by 8 in each section (Exhaustion and Disengagement). Burnout was indicated by a score of 2.25 or more for exhaustion and 2.10 or more for disengagement.

Results: There were 1,254 respondents that participated in the OLBI tool, and 1,195 (95%) answered all 16 questions. The average exhaustion score was 2.60 ± 0.49, and the mean disengagement score was 2.42 ± 0.4. Of those that answered all 16 questions, mean scores for exhaustion were 2.81 ± 0.35 and disengagement was 2.62 ± 0.37. Almost three-quarters (72%) of the study population had scores indicative of burnout. 

Conclusion: This study confirms there is an epidemic of exhaustion, disengagement, and burnout within the emergency response industry. Efforts should continue to focus on providing support and wellness programs to combat burnout, which can lead to high staff turnover.

A Randomized Control Equivalence Study of Emergency Medical Services Use of Inhaled Isopropyl Alcohol Versus Ondansetron for Treatment of Prehospital Nausea

Author: David Miramontes, MD, FACEP, FAEMS, NREMT

Associate Authors: Michael Stringfellow, EMT-P; Jacob Watson, MD(c); David A. Wampler, PhD, LP, FAEMS

Background: Nausea is a common symptom encountered in the emergency medical services (EMS) environment that is often treated with oral or intravenous antiemetic medications, most commonly ondansetron or promethazine. Intravenous medications are beyond the scope of most basic life support (BLS) EMS providers. Isopropyl alcohol (IPA) has long been used to relieve postoperative nausea and was recently shown to be effective in the emergency department. Isopropyl-saturated pads are ubiquitous in ambulances, even at the BLS level.

Purpose: This study compared standard practice intravascular ondansetron (OND) with inhaled IPA for the relief of prehospital nausea.

Methods: This was a prospective open-label randomized controlled equivalence trial comparing 4.0 mg ondansetron given IV with inhaled IPA. Inclusion: Adult EMS patients complaining of nausea rating scale of 5 or greater, with the cognitive ability to consent. Exclusion: minors, prisoners, pregnancy, impaired mental status, or significant upper respiratory infection. After consent, a sealed black box is opened; contents include either three large 70% IPA pads or 4.0 mg of ondansetron and syringe. Ondansetron is administered by standard-practice IV, IPA pads are opened and handed to the patient to self-administer as needed by sniffing through the nares. Nausea rating is monitored before and every 2 minutes after administration up to 10 minutes. Time was stopped at 10 minutes or arrival to the hospital.

Results: Over an 18-month trial, 51 subjects were recruited. Their initial nausea mean rating was 7.5 (95% CI, 6.7–8.2; n=28) and 7.9 (95% CI, 7.3–8.4; n=23) for the IPA and ondansetron groups (p=0.4), respectively. There was no difference in the percent of subjects who reported at least some relief of nausea: 86% in the IPA group versus 91% in the ondansetron group (p=0.08). Final nausea mean rating was IPA 4.3 (95% CI, 3.1–5.5) and ondansetron 3.5 (95% CI, 2.3–4.8; p=0.4). There were also no differences between groups at each of the two-minute intervals.

Conclusion: Inhaled IPA was similarly effective at relieving nausea as the standard-practice intravascular ondansetron in the undifferentiated EMS nausea patient. Additional research needs to be done to validate use of IPA by BLS personnel in the critically ill patient.

Death and Disability Meetings at the London’s Air Ambulance: Debrief, Case Review, and Beyond

Author: Tsz Lun Ernest Wong, Medical Student

Associate Author: Danë Goodsman, PhD

Introduction: London’s Air Ambulance (LAA) is an advanced emergency medicine service operating for the population of London. The team offers highly specialized trauma care to seriously ill patients in the prehospital environment. Alongside their innovative medical practices, the team has developed a variety of management processes to support their work. One such is the “death and disability” meetings (D&D) introduced to foster individual and team learning through discussions of patient cases. D&D in this form does not have much presence in the literature; therefore this study serves to describe D&D and its functions as used by the LAA and prehospital medicine.

Methods: The study used an ethnographic approach and observed a total of eight D&Ds, followed up with four interviews with LAA clinicians (doctors and paramedics). These were conducted between April and June 2019. The collected data was analyzed using a grounded theory approach with the aid of Nvivo 12 software.

Results: D&Ds are regular consultant-led meetings, attended by LAA clinicians and various other professionals and medical students. Selected cases are reviewed and chosen generally in relation to both specific interest and who is present. The process of discussion follows a similar structure for each: i.e., everyone introduces themselves, including role and background; the case is then outlined from the paperwork on file, and the clinicians who attended the case give a moment-by-moment account of their involvement. The consultant-chair facilitates discussion and draws out, if needed, specific areas of interest. For each case key learning points and action points are identified and documented.

The key functions of D&D include debriefing, case-based learning, review of clinical decisions made by the attending team, review of the diagnostic tool or intervention, review of clinical documentation, and support of staff welfare.

Conclusion: Death and disability meetings provide an open and nonjudgmental environment for clinicians to reflect and discuss their cases. These meetings serve an important role in education, clinical governance, and supporting staff welfare in the LAA. From the observations it was demonstrated that D&D is integral to LAA’s processes to improve and deliver care of the highest possible standard.

Influence of Intercompression Cycle Rest Period Duration on CPR Quality

Author: Daniel Wesley, MHS, NRP

Associate Authors: Jackson D. Déziel, PhD, NRP; Michael W. Hubble, PhD, NRP

Introduction: Cardiopulmonary resuscitation (CPR) has been the keystone of cardiac arrest care since its creation in the early 1900s. CPR quality, however, decreases drastically, in some cases over 60%, in just a few minutes. Limited research has investigated rest periods that providers may need in order to provide another full and effective two minutes of CPR following their previous cycle.

Objective: To explore whether rest periods of varying durations influence provider fatigue and CPR compression quality. 

Methods: Participants volunteered their time, were active prehospital providers, and were tasked with performing four continuous two-minute cycles of CPR compressions. Participants were randomly assigned to one of four groups. Each group had a specified rest period between cycles: two, four, six, or eight minutes. Chest compression rate, depth, hand placement, and recoil were recorded by proprietary CPR manikins. Following each CPR cycle, the participant also self-reported his/her fatigue level on a 0–10 scale. Linear regression models utilizing robust standard errors were estimated and controlled for the participant’s age, sex, years of EMS experience, level of EMS certification, and BMI. 

Results: Sixty-two volunteers participated and were equally split among the four rest duration groups. Using the two-minute rest duration group as the referent, there were no statistically significant differences in compression rate, depth, hand placement, or recoil among groups. There was, however, a statistically significant difference in self-reported fatigue among the groups. Following the fourth compression cycle, participants in the eight-minute rest group reported a fatigue level nearly  three points lower than the two-minute rest group (β=[-2.94], p<0.000). The six-minute (β=[-1.75], p=0.013) and four-minute (β=[-1.48], p=0.037) rest groups also reported lower fatigue after four cycles. 

Conclusions: Previous research has shown that compressor rotation is an important contributor to CPR quality. Although a two-minute cycle is now the standard, there are no recommendations on the length of rest between cycles for each provider. Using rest duration as a proxy for the number of available providers, this study may suggest that increasing the number of responders decreases fatigue but does not improve the quality of CPR compressions. 

A Descriptive Assessment of EMS Encounters for Patients Experiencing Behavioral Health Emergencies

Author: Lee Van Vleet, MHS, NRP

Associate Authors: Brooke Burton, NRP, FACPE; Remle Crowe, PhD, NREMT; David Page, PhD(c); Henry Wang, MD, MS

Introduction: Behavioral health emergencies (BHE) comprise a considerable proportion of patients receiving care by emergency medical services (EMS). However, only limited data describe the characteristics and outcomes of this population. 

Objective: To describe characteristics of EMS patients experiencing BHE.

Method: This retrospective observational study of patients experiencing BHE was conducted using a large national EMS research data set maintained by ESO. A subset of encounters in this database participate in the ESO health data exchange, linking hospital outcome data to the prehospital record. The study period spanned January 1 through December 31, 2018. Inclusion criteria consisted of 9-1-1 responses for adult patients (older than 18 years) with a documented EMS provider primary or secondary impression of a behavioral or psychiatric etiology transported to the ED. Substance abuse and overdose were specifically excluded. We analyzed the data using descriptive statistics.

Results: The data set included 7,574,879 responses from 1,289 EMS agencies, of which 5,970,280 (79%) were 9-1-1 responses. BHE was present in 213,410 (4%). We excluded 21,901 (10%) with patient age less than 18. Of the remaining 191,509 encounters, there were 146,124 (76%) transports by EMS. Median age was 41 (IQR 29–56), 51% were male, 69% were white (non-Hispanic) and 25% were black (non-Hispanic). Hospital outcome data was available for 15,500 encounters (11%). Of these, 51% (7,948) were discharged home in 24 hours or less.

Conclusion: The majority of adult patients with a BHE encountered by EMS were transported to the hospital. More than half of patients transported to the ED for BHE were discharged home within 24 hours. Further study may identify opportunities for the alternative care of BHE patients. Limitations to this study include a lack of universal definition for BHE and the inability to track the same patient over separate EMS encounters.

The Epidemiology of EMS-Witnessed Cardiac Arrest in a U.S. Patient Cohort

Author: David Wampler, PhD, LP, FAEMS

Associate Authors: Roland Tenley, EMT-P; Remle Crowe, PhD, NREMT; Jeffrey Jarvis, MD, MS, EMT-P

Introduction: Out-of-hospital cardiac arrest is fatal without immediate aggressive intervention. Arrests witnessed by EMS personnel are associated with more favorable neurological outcomes, likely because of earlier resuscitation. It is also possible that, if signs of impending arrest are recognized early, some arrests may be avoided. The goal of this study was to describe the epidemiology of EMS-witnessed cardiac arrests.

Methods: This retrospective analysis was conducted using deidentified patient care records from a large national research database maintained by ESO. All adult (18 years and older) arrests from 2018 were included. Descriptive statistics were calculated to describe patient demographics, arrest characteristics, and presence of return of spontaneous circulation (ROSC). 

Results: The data set included 7,574,879 responses from 1,289 distinct agencies. There were 70,746 (<1%) records with documented cardiac arrest. Of these, 62,750 (89%) records were from 9-1-1 responses. Records for 2,207 (4%) patients under 18 were excluded, leaving 60,543 in the analysis population. Of the emergency responses for documented cardiac arrests among adult patients, EMS witnessed 8,014 (13%). Among EMS-witnessed cardiac arrest patients, median age was 65 (IQR 53–76), 71% were white (non-Hispanic), and 60% were male. Presumed etiology of EMS-witnessed arrests included cardiac (54%), followed by respiratory (25%), trauma (12%), and drug overdose (2%). Initial arrest rhythm was shockable in 21% of witnessed arrests, while PEA or asystole was documented in 73% of cases. Common locations where EMS-witnessed cardiac arrests occurred included residences (70%), streets/highways (10%), and nursing homes/assisted living centers (8%). Circulation was restored in 43% of cases. 

Conclusion: In this large national EMS registry data set, EMS witnessed less than 15% of documented cardiac arrests during emergency responses. Most of these EMS-witnessed arrests occurred at a residence, and half of EMS-witnessed arrests occurred in patients younger than 65. About one-fifth presented with an initial shockable rhythm. For all EMS-witnessed cardiac arrests, less than one-half experienced restored circulation.

The Impact of Race and Ethnicity on Prehospital Pain Management: Examining Disparities in a Hispanic Majority State

Author: Madison Schaeffer, MS, MPH

Associate Authors: Sahaj S. Khalsa, BS, NRP, NM I/C; Charles Becvarik, EMT-P, EMD; Edward T. Oliphant, BA, NRP

Introduction: Previous research has found significant differences in patient care associated with race/ethnicity. However, little research has been conducted in the prehospital environment. We examined prehospital patient care records in New Mexico, a state where Hispanic individuals represent more than half of the population and where provider demographics match the general population. Additionally this research compares care provided to patients with more objective indications for treatment (respiratory distress and hypoglycemia) versus more subjective indications for treatment (pain). 

Methods: We performed a retrospective cohort study using New Mexico EMS Tracking and Reporting System data from the New Mexico Department of Health Epidemiology and Response Division Emergency Medical Systems Bureau for patient care records entered between January 1, 2015 and December 31, 2017. We identified patients presenting with indicators of respiratory distress (n=2,722) (hypoxia, tachycardia and tachypnea), hypoglycemia (low blood glucose level, n=905), and (primary or secondary complaint of pain, n=52,220). We assessed whether patients had received appropriate treatment for those conditions based on state treatment guidelines. We then analyzed cases for all three complaints to identify differences in the rate of appropriate treatment associated with patient race/ethnicity.

Results: We found no significant difference in treatment rates for respiratory distress and hypoglycemia across races and ethnicities in this study population. In contrast, we found the rate of pain medication administration was significantly less in American Indian and black populations. White patients were 1.07 times more likely to receive pain medication compared to Hispanic patients (95% CI, 1.01–1.12), 1.28 times more likely than American Indian patients (95% CI, 1.20–1.38), and 1.66 times more likely than black patients (95% CI, 1.41–1.97).

Conclusion: This research suggests minority patients are less likely to receive prehospital pain medication compared to white patients. Additionally, we found disparities are reduced in Hispanic populations in the majority Hispanic state of New Mexico compared to Hispanics in the national population. This shows a need for services to systemically examine their patient care for such disparities and improve provider education. 

Evaluation of a Novel Point-of-Care Neuromonitoring Device (AlphaStroke) to Detect Large Vessel Occlusion in Suspected Acute Stroke Patients

Author: Matthew Kesinger, MS

Associate Authors: Madeleine Wilcox, PhD; Liam Berti, BS; Andrew Maza, BS; Frank Peacock, MD

Study Objectives: Several prehospital stroke scales have been developed to provide quick and accurate triage to facilitate timely treatment. This study evaluated a portable, experimental electroencephalogram (EEG) device (AlphaStroke, Forest Devices, Pittsburgh, Penn.) using artificial intelligence (AI) as a potential tool for detection of acute stroke and large vessel occlusion (LVO) among patients with neurological deficits. Both device performance and feasibility in the emergent setting were assessed. 

Methods: This observational study enrolled a convenience sample of emergency department (ED) patients evaluated for suspected stroke within 24 hours of symptom onset. LVO status was determined by local neuroradiologists blinded to AlphaStroke’s output. LVO was defined as an acute occlusion of the any of the following arteries: ICA/MCA (M1 or M2)/vertebral/ basilar. Controls were neurologically normal subjects (NIHSS=0). 

Results: From May 2018 to June 2019, eight urban US stroke centers enrolled 100 subjects being evaluated for stroke. The study also enrolled 113 controls. In subjects with acute neurologic deficits, 26 had LVOs (26%). Device performance for detecting stroke and LVO is shown in Table 1. There were no severe adverse events related to use of the device. 

Table 1: AlphaStroke Performance for Identification of LVO

Predicted:

• True positives, 52; false positives, 17
• False negatives, 6; true negatives, 113    
• Sensitivity=92%, positive predictive value=46%, positive likelihood ratio, 6.17
• Specificity=85%, negative predictive value=99%, negative likelihood ratio, 0.09

Conclusion: The AlphaStroke device performed well in identifying LVO in patients presenting with suspected stroke. The performance of the AlphaStroke device in the acute setting indicates it may be able to support prehospital decision-making when triaging suspected stroke subjects. Additional studies with larger sample sizes are needed to validate this study’s findings.

 

EDUCATIONAL ABSTRACTS

In partnership with the National Association of EMS Educators, these are the educational abstracts presented at NAEMSE Educator Symposium in Ft. Worth on July 31–August 5, 2019.

Paramedic Student Performance on the Paramedic Readiness Exam 4 (PRE4) Improves With Exposure to Higher-Acuity Patients

Author: Dale Edwards, EdD

Associate Authors: Hezedean Smith; Lindsay Eakes; Charles Foat; C.E. Casey; Katie Grondahl; Jackson Déziel; Ron Lawler

Introduction: Paramedic program directors struggle with balancing limited time available in clinical and field learning experiences with accomplishing required objectives and allowing for a broad exposure to differing patient types. The purpose of this study was to examine how the students’ exposure to perceived high-acuity patients relates to cognitive performance.

Methods: A retrospective review of 554,546 student records from Fisdap was conducted from 2014 to 2018. Participants were included in this analysis if they completed a first attempt at the PRE4 and had completed clinical and field patient contacts prior to their exam attempt. The outcome variable was pass/fail on the PRE4. The dichotomized pass/fail was determined by Angoff standard-setting. The cut score for the PRE4 is 73%, with a 97% positive predictive value for passing the NREMT paramedic examination. The primary independent variable was exposure to patients by perceived criticality as a proxy for patient acuity.

Results: A logistic regression model estimated the likelihood of passing the PRE4 was 1.07 (95% CI, 1.02–1.12, p=0.003) for perceived red criticality when compared to all other levels of criticality. Further analysis explored the differences observed between this association in the clinical and field settings. The likelihood of passing the PRE4 was 1.18 (95% CI, 1.17–1.19, p=0.000) for perceived red criticality patients in the field setting, and the likelihood of passing the PRE4 was 0.84 (95% CI, 0.83–0.85, p=0.000) for perceived red criticality patients in the clinical setting.

Conclusions: This study suggests there is a positive correlation between exposure to high-acuity patients in field placements and performance on the PRE4. Conversely, this study suggests a negative correlation between exposure to high-acuity patients in clinical placements and performance on the PRE4. These findings suggest paramedic programs should place greater emphasis on field placements with reduced emphasis on clinical placements for paramedic students.

Effective EMT Education: Brick or Click

Author: Michael Kaduce, MPS, NRP

Associate Author: Jeffery Rollman, MPH, NRP

Introduction: The advent of online education has opened the door to novel training options. However, it is unclear if online programs can match the success of their traditional counterparts. Though many online/hybrid emergency medical technician (EMT) and paramedic courses exist nationwide, little empirical data exists to support program effectiveness.

Objective: Evaluate whether online/hybrid EMT education is as effective as traditional in-class EMT education.

Methods: A 12-month retrospective review of both online/hybrid and traditional EMT education began in August 2017. Both classes totaled 182 hours of training, including 24 hours of ambulance ride-along and the same textbook, based on the U.S. Department of Transportation EMT curriculum, grading policy, exams, and policy manual. All the traditional students’ hours were in person, while hybrid students completed didactic education (54 hours) in an online synchronous format with 52 hours of in-person skills labs. Both courses were evaluated for completion and NREMT certification exam passage rates. Course completion was defined as students who completed all course requirements among those who took the first exam. Pearson’s chi-square tests of proportions were performed to quantify differences in outcomes between the two independent samples of EMT course types.

Results: In total 1,062 students enrolled in the EMT courses (521 hybrid, 541 traditional), and 991 students took the first course exam (473 hybrid, 518 traditional). Among those who took the first exam, no significant difference was found in course completion rates (71.9% hybrid, 76.8% traditional, p=0.077). No significant differences were found in first-attempt NREMT passage rates (98.2% hybrid, 98.8% traditional, p=0.54) or within 3 attempts (98.5% hybrid, 98.8% traditional, p=0.75). Student demographics were unavailable so data could not be adjusted for student-level characteristics.

Conclusions: Similar outcomes in completion and NREMT passage rates suggest the hybrid course prepares students for the NREMT exam as well as the traditional course. Further research is necessary to understand which student-level factors are associated with attrition, retention, and success in hybrid online EMT education.

Does Your Address Make the Grade?

Author: Lydia Hamel, BS

Associate Authors: Justin Hunter, MPA, PhD(c), NRP, FP-C; Christopher Goenner, MHS, NRP, NCEE; Kathleen O’Connor, MPP, NRP; Tom Fentress, MBA, NRP, PI, CFI; Adisack Nhouyvanisvong, PhD; Ashley Procum, BA; Sahaj Khalsa, BS, NRP, NM I/C; Alan Batt, MSc, PhD(c), CCP

Introduction: There are several factors that can affect a student’s academic performance. These include family and peer support, previous education, and socioeconomic status (SES). Research indicates that students of lower SES are educationally disadvantaged. This study sought to examine the relationship between paramedic student academic performance and county-level SES indicators.

Methods: Student academic performance data from Fisdap was combined with data from the Robert Wood Johnson Foundation County Health Rankings for 2017 and U.S. Census data for counties in California, Mississippi, Louisiana, Texas, and Virginia. Multiple linear regression modeling was performed to determine the relationship between income, high school graduation rate, poverty, and food insecurity with first-attempt scores on the Fisdap Paramedic Readiness Exam (PRE), versions 3 and 4. Counties with less than five reported PRE3 or PRE4 scores were excluded. One-way analysis of variance was performed between entrance exam (EE) score and parent education level.

Results: There were 3,697 records across 151 counties (PRE3), 1,293 records across 60 counties (PRE4), and 3,607 records (EE). Results of the multiple linear regression models indicated there was a significant collective effect between income, poverty, graduation rate, food insecurity, and both PRE3 scores (F[4,143]=10.66, p<0.001, R2=0.23) and PRE4 scores (F[4,54]=4.72, p <0.01, R2=0.26). Income, graduation rate, and poverty were significant individual predictors in the PRE3 model, but only income was a significant predictor in the PRE4 model. ANOVA was statistically significant (p<0.001) for EE score and parental education. Students whose parents had a high school diploma or less had the lowest EE scores (mean 77.42, SD 9.21), while students whose parents had a graduate degree had the highest EE scores (mean 81.55, SD 8.22).

Conclusions: This study demonstrated an association between the county-level SES indicators mentioned above and paramedic student academic performance. Parental education level appears to be related to entrance exam scores. Since data were analyzed only at the county level, it remains unclear what type of relationship exists between individual SES and academic performance of paramedic students. These findings support future collection of individual student-level SES data to further explore the relationship between SES and academic performance.

Do Paramedic Students Possess Situational Awareness?

Author: Justin Hunter, MPA, PhD(c), NRP, FP-C

Background: For paramedic students to be situationally aware, they must identify a situation, interpret the situation, and then be able to predict how that information will affect future events. No empirical research has been completed that identifies whether paramedic students possess situational awareness.

Objective: To identify if paramedic students possess situational awareness.

Method: Students wore a point-of-view camera during a simulated prehospital emergency call. Descriptive statistics and thematic analyses of interviews were utilized to interpret the data derived from 12 paramedic students in the simulated prehospital environment. Statistics were derived from debriefing interviews, surveys, as well as the point-of-view cameras. The situational awareness global assessment technique (SAGAT) was used during all debriefings to help determine if students were situationally aware. 

Conclusions: The data show paramedics students do not possess full situational awareness. While the students may have been successful in these simulations with other assessment tools, they failed to recognize too many pertinent events, and of the events they did recognize, they struggled to properly interpret what those events meant or how they may affect future events. Students were not performing thorough enough assessments, which might have led to the failure to be situationally aware. Further research is needed to determine improved best practices in paramedic situational awareness education.

Evaluating the Impact of Individual Student Exam Performance on Overall Cohort Exam Performance

Author: Michael Kaduce, MPS, NRP

Associate Authors: Edward Oliphant, BA, NRP; Maritza Steele, BA; Tashi Wangmo, BA; James Dinsch, MS, NRP, CCEMT-P; Andrea Lalumia, BS, NRP; Robert Gurliacci, BPS, EMT-P

Introduction: Student performance has been documented to be dependent on size, socioeconomic status, and attendance, yet not on other classmates’ performance. This study seeks to determine if the class performance affects individual academic achievement.

Methods: A retrospective review of EMT student data in Fisdap analyzed EMT Entrance Assessment (EMTEA) and EMT Readiness Exam (ERE2 or ERE4) results to classify students based on exam performance. Scores from 164 students from December 2017 to September 2018 were analyzed from 13 student cohorts ranging from 4 to 57 students. To determine the “cohort effect,” the student’s ability (EMTEA score) and the cohort’s ability (mean cohort score) were measured. Student performance was divided into four student-groups. Cohort performance was divided into three cohort-groups. ANOVA was calculated with the dependent variable of difference score and two factors: student-group and cohort-group.

Results: The main effect of cohort-group wasn’t statistically significant (F[3,145]=2.5, p=0.088). The ability of the cohort didn’t have a significant effect on ERE scores. The main effect of student-group was statistically significant (F[3,145]=53, p<0.001). Most interesting is the lack of an interaction effect (F[5,145]=0.9, p=0.47). Students in a given student-group did not have a significant difference in performance based on cohort-group.

Conclusions: There was no significant difference in students’ performance when compared to classmates’ performance. Students who scored lowest initially showed the most improvement, independent of the cohort. Students who scored highest initially showed the least improvement, again independent of cohort.

Does Patient Age Affect a Student’s Opportunity to Be a Team Leader?

Author: John Thomas Meyer, BS, PGDip Education, CCP

Associate Authors: Adam Alford, BS, NRP; Elizabeth Todak, MS, PM; Kyra Wicklund, MPH; Kevin Loughlin; William Camarda, MS, NRP; Marilee Rosensweig, MEd, NRP; William Robertson, DHSc, NRP

Introduction: Students must act as team leads in the field to successfully graduate from their paramedic program. The team leads allow the student to develop technical skills, scene management skills, and nonclinical skills. However, there are times when the student as a team lead has the leadership role taken over by the preceptor. In previous research it was shown there was a correlation between the acuity of the patient and preceptors taking control of the call.

Objectives: To determine if the age of the pediatric patient affected the student’s ability to complete team leads; to determine if the criticality of the pediatric patient affected the student’s ability to complete team leads; to determine if the criticality and the age of the pediatric patient affected the student’s ability to complete team leads. 

Methods: The methodology for this research includes data from student field time from January 2010 to December 2018 from paramedic students with accounts in Fisdap, an Internet-based administrative database. SPSS was used to conduct a descriptive analysis and represented as chart and tables.

Results: Paramedic students were team leaders for 68% of all patient interactions. For pediatric patients the rate of the student as the team leader dropped to 38% (p<0.00). The likelihood of the paramedic student functioning as the team leader was lower as the patient’s age decreased. When patient acuity was factored in, all age groups had the same rate of team leads by the paramedic student when the patient was deemed a “green.” However, paramedic students had almost no opportunities to function as the team leader for pediatric patients with higher acuities.

Conclusions: We hypothesized that the age of the patient would also affect the likelihood of students being team leaders. Paramedic students had fewer opportunities to function as team leaders on pediatric patients, particularly in the younger age groups (infant, toddler). The results suggest paramedic students do not get opportunities to function as team leaders for pediatric patients, and even less so on high-acuity pediatric patients.

Are We Dense? Effects of Paramedic Program Length and Nondidactic Course Density on Student Summative Exam Scores

Author: Daniel Armstrong

Associate Authors: Jackson Deziel; Sarah Glass; Glen Keating; Lisa Clegg; Christopher Metsgar

Introduction: A lack of standardization among paramedic programs has long been identified as one of the most significant problems in prehospital education. One example of this lack of standardization is variance in program length and density. According to the National Emergency Medical Services Standard Curriculum, a paramedic program is estimated to take 1,000–1,200 hours to complete. These hours may be delivered over months or years, affecting program density. This study was designed to determine whether paramedic program length and density have an effect on paramedic student success.

Methods: A retrospective analysis of Fisdap educational data was conducted. A total of 3,268 paramedic student records from October 2012 to January 2019 were examined. This study used student performance on the summative Fisdap Paramedic Readiness Exam version 3 (PRE3) as the measure of student success. Elasticity functions were estimated to determine whether course length (in months) and/or course density (field and clinical hours per month) was related to performance on the PRE3 summative exam.

Results: Course length (ß=0.027, p=0.001) and course density (ß=0.032, p<0.000) were both statistically significant contributors to paramedic student success on the PRE3. Course density had a greater positive effect on student success than course length. For a 10% increase in course density, student scores on the PRE3 increased by 0.32%. Similarly, for a 10% increase in course length, student scores on the PRE3 increased by 0.27%.

Conclusion: A positive correlation exists between the length and the density of a paramedic program and scores on a summative paramedic exam. This study highlights the importance of length and concentration of a paramedic student’s educational experience.

Can a Short Survey Predict Outcomes on the NREMT Exam?

Author: Daniel Limmer, AS, LP

Associate Authors: Sandra L. Turner, RN; Robert Preshong, NRP

Hypothesis: A short survey of clinical questions and student perceptions can be used to identify student outcomes on the NREMT cognitive EMT exam.

Methods: The National Registry of Emergency Medical Technician Readiness Assessment Test (NREMT-RAT) containing two parts, perceptions of preparation and core clinical concepts, was administered to EMT students at the U.S. Army EMT training program. Clinical components of the NREMT-RAT contained multiple-choice items relating to core EMT knowledge points, including pathophysiology, airway, cardiology and resuscitation, medical emergencies, obstetrics, and trauma. Three questions in the perception of preparation and readiness section asked about the student’s EMT class, study efforts, and ability to focus. Surveys were evaluated in an attempt to identify differentiating characteristics between students who passed and failed the NREMT.

Results: The 752 students in two cohorts completed the NREMT-RAT. The NREMT pass rate for the combined cohorts was 78% (586 students). Of the students who failed the NREMT (166), 86.7% scored 7 or fewer correct. 3.8% (22) of the students who failed the NREMT scored 8 or more correct. Also, 66% (389) of the students who scored 7 or fewer correct passed the NREMT. The student’s perception of preparation varied widely from their actual NREMT results. Of those who failed the NREMT cognitive examination, 89% (147) believed they were prepared well by their EMT class, and 55% (91) thought their study was effective. In addition, 40% (66) of those who failed reported feeling able to focus during study, compared to 52% (303) of successful students.

Conclusions: The NREMT-RAT identified students who were likely to be unsuccessful on the NREMT cognitive examination but was not a predictor of exam success. This will be helpful in identifying students in need of remediation before testing as well as highlighting foundational educational concepts to be highlighted in the EMT classroom. Students’ perceptions of preparation did not correspond to actual performance on the examination.

Evaluating the Impact of Individual Student Exam Performance on Overall Cohort Exam Performance

Author: Michael Kaduce, MPS, NRP

Associate Authors: Edward Oliphant, BA, NRP; Maritza Steele, BA; Adisack Nhouyvanisvong, PhD; Andrea Lalumia, BS, NRP; Robert Gurliacci, BPS, EMT-P; James Dinsch, MS, NRP, CCEMT-P; Kenneth Kirkland, MSN, RN, NRP

Introduction: Socioeconomic status, class size, and attendance are known to affect student performance, but it is not yet known if the performance of the class as a whole affects learner success. This study seeks to determine if the class performance affects individual academic achievement.
Methods: A retrospective review of EMT student data in Fisdap analyzed EMT Entrance Assessment (EMTEA) and EMT Readiness Exam (ERE2 or ERE4) scores to evaluate changes from EMTEA to ERE when compared to classmates’ performance. Scores from 164 students from December 2017 to September 2018 were analyzed from 13 student cohorts ranging from 4 to 57 students. To determine the “cohort effect,” the student’s ability as measured by the EMTEA score and the cohort’s ability (mean cohort score) were measured. ANOVA was calculated with the dependent variable of difference score for both student and cohort groups.

Results: The ability level of the cohort did not have a statistically significant effect on the individual ERE scores (F[3,145]=2.5, p=0.088). Students who were low-performing did not get a boost by being in the high-performing cohort (F[5,145]=0.9, p=0.47).

Conclusion: There is no significant difference in EMT students’ performance when compared to classmates’ performance. Students who scored lowest initially showed the most improvement, independent of the cohort. Students who scored highest initially showed the least improvement, again independent of cohort.

Flipping Toward Success

Author: Leah Tilden, MA, AEMT

Associate Authors: Sara Walker, MS, EMT-P; Felix Marquez, BA, NRP; Mark Malonzo, EdD(c), NRP; Kelly Kohler, BA, NRP; Justin Allen, BA, EMT-P; Marissa Peterson, BA; Kevin Loughlin, PhD(c); Nancy Hoffmann, MSW

Introduction: The flipped classroom methodology is based on students gaining first exposure to new material outside of class, followed by the assimilation of that knowledge through in-class activities and discussion. Flipped classrooms are thought to enhance learning through interactive activities among instructors and peers that lead to improved outcomes. Results from a 2018 study found EMT students have higher cognitive competency in a flipped classroom setting.

Hypothesis: 1) Increasing the amount of flipped classroom methodology in an EMT classroom will increase first-time NREMT pass rates; 2) EMT students in a flipped classroom will have higher NREMT first-time pass rates versus hybrid or traditional classrooms.

Methods: Surveys were distributed to about 1,600 EMS programs across the United States that are current Fisdap users. Each individual program was asked a universal set of questions to determine if their EMT classes utilize a traditional, hybrid, or flipped classroom model. Programs were also asked to share first-time NREMT pass rates for 2017 and 2018.

Results: The survey yielded 224 responses. One hundred and seventy-eight respondents had complete data and were included in the final data set. Thirty-two states were represented in the data. Sixty-seven percent of respondents self-identified as nonflipped (hybrid and/or traditional), and 33% identified as flipped. There was a positive correlation between increased flipped methodology in an EMT classroom and first-time EMT class pass rates. EMT students in classes with flipped methodology have higher NREMT first-time pass rates than students not exposed to flipped methodology.

Conclusions: The study revealed a positive correlation between flipped classrooms and NREMT scores. Also it was determined there is a thin line distinguishing the flipped from the hybrid classroom methodology. The sample size played an intricate role in determining statistical significance. In the future the survey will be sent again to programs to achieve a higher response rate, and then data reanalyzed.

Lab Knows Best: Effects of Experiential Course Setting on EMT Student Success

Author: Daniel Armstrong

Associate Authors: Jackson Deziel; Christopher Metsgar; Lisa Clegg; Glen Keating; Sarah Glass

Introduction: According to the National Emergency Medical Services Education Standards the length of an initial Emergency Medical Technician (EMT) course is estimated to take about 150–190 hours. These hours include the four integrated phases of EMT education: didactic, laboratory, clinical, and field. The didactic phase is the most uniform, while the number of hours spent in the laboratory, clinical, and field settings shows more variability among programs. This project was designed to determine whether the number of hours spent in the laboratory, clinical, and field settings are related to EMT student success on a summative exam. Evidence from this study could be used by educators to determine the most effective training venues for a more valuable educational experience.

Methods: A retrospective analysis of Fisdap educational data was conducted. A total of 2,125 EMT student records from October 2012 to January 2019 were examined. This study used student performance on the summative Fisdap EMT Readiness Exam version 2 (ERE2) as the measure of student success. Student data were analyzed with linear regression and elasticity models to determine if the number of hours students spent in the laboratory, clinical, and field settings was related to performance on the ERE2 summative exam.

Results: Linear modeling revealed that laboratory (ß=0.027, p<0.000) and clinical (ß=0.016, p=0.024) hours had a statistically significant impact on exam performance, while the number of field hours was not statistically significant to test scores (ß=[-0.008], p=0.214). The elasticity function isolated laboratory hours as the most important contributor to EMT student success. For each 10% increase in lab hours, student scores on the summative exam increased by 0.15% (ß=0.015, p<0.000).

Conclusions: The number of hours spent in the laboratory had a statistically significant positive impact on student success and appears to be the most significant influence on EMT student success outside of the traditional didactic phase. This study highlights that assessment and skills practice in the lab may be the most beneficial for initial EMT students. 

Beyond the Lecture: Effects of Nondidactic Hours on Paramedic Student Success

Author: Daniel Armstrong

Associate Authors: Jackson Deziel; Sarah Glass; Angela Finney; Lisa Clegg; Christopher Metsgar

Introduction: According to the National Emergency Medical Services Standard Curriculum, the length for an initial paramedic course is estimated to take about 1,000–1,200 hours. The hours spent in a paramedic program span didactic, lab, clinical, and field settings. The hours spent in each of these components also varies among programs. Accreditation guidelines do not offer specific information regarding in which setting the students should concentrate their time. Despite widespread agreement on the importance of nondidactic experiences, the number of hours for each phase remains unclear and inconsistent across programs. This study was designed to explore which nondidactic setting is the most valuable for paramedic students.

Methods: A retrospective analysis of Fisdap educational data was conducted. A total of 3,268 paramedic student records from October 2012 to January 2019 were examined. This study used student performance on the summative Fisdap Paramedic Readiness Exam version 3 (PRE3) as the measure of student success. Student data were analyzed with linear regression and elasticity models to determine if the number of hours students spent in the laboratory, clinical, and field settings were related to performance on the PRE3 summative exam.

Results: Students who took the PRE3 summative exam increased their scores when they had more field (ß=0.011, p<0.000) and lab hours (ß=0.001, p=0.040), while increased clinical times appeared to have a negative impact on PRE3 scores (ß=-0.004, p=0.025). The elasticity function isolated field and laboratory hours as the most important contributor to paramedic student success. For each 10% increase in field hours, student scores on the summative exam increased by 0.33% (ß=0.033, p<0.000). Additionally, a 10% increase in lab hours yielded a PRE3 score increase of 0.08% (ß=0.008, p<0.000). Clinical hours remained negative correlated to student success (ß=[-0.011], p=0.081).

Conclusions: The number of hours spent in laboratory and the field experiences had a statistically significant positive impact on student success on a summative paramedic exam. This study highlights that assessment and skills practice in the lab and internship may be the most beneficial for initial paramedic students.

Do Team Lead Experiences of Paramedic Students Influence Critical Thinking?

Author: Kim McKenna, PhD, RN, EMT-P

Associate Authors: Patricia Tritt, MA, RN; Steven Jenison, MD, NRP; Elizabeth Robinson, MD; Jose Palma, PhD; Megan Corry, EdD, NREMT-P

Introduction: Since 2013 EMS education has had substantial changes in laboratory and team lead requirements. Previous research demonstrated a positive correlation between the number of patient contacts and critical-thinking scores (CTS) on summative and certification exams. We investigated the relationship between team leads in the lab and CTS and the number of team leads in the field and CTS.

Methods: This study used retrospective data from Fisdap between 2014 and 2019. Data points included the number of field and lab patients and team leads. Students’ logit scores were correlated to total team leads and total patient encounters.

Results: A sample of 2,623 students from the 2014–2019 PRE4 administrations were evaluated. The average PRE4 CTS was 0.65 (SD=10). There was a positive correlation between field team leads and CTS (r=0.08, p<0.01) and lab team leads and CTS (r=0.09, p<0.01). Limitations include the timing of PRE4 exam and definition of “team leads” varying by program.

Setting    Total patient (average)    Team lead (average)
Field                   13 (SD=30)                 7 (SD=15)
Lab                     92 (SD=47.7)            73 (SD=43.4)

Conclusions: These results confirm previous findings that correlate team leads to improved critical thinking performance.