9 results
EMS Responses for Pediatric Behavioral Health Emergencies in the United States: A 4-Year Descriptive Evaluation
- Lori L. Boland, Morgan K. Anderson, Jonathan R. Powell, Michael T. Patock, Ashish R. Panchal
-
- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue 6 / December 2023
- Published online by Cambridge University Press:
- 30 November 2023, pp. 784-791
- Print publication:
- December 2023
-
- Article
-
- You have access Access
- Open access
- HTML
- Export citation
-
Background:
The occurrence of behavioral health emergencies (BHEs) in children is increasing in the United States, with patient presentations to Emergency Medical Services (EMS) behaving similarly. However, detailed evaluations of EMS encounters for pediatric BHEs at the national level have not been reported.
Methods:This was a secondary analysis of a national convenience sample of EMS electronic patient care records (ePCRs) collected from January 1, 2018 through December 31, 2021. Inclusion criteria were all EMS activations documented as 9-1-1 responses involving patients < 18 years of age with a primary or secondary provider impression of a BHE. Patient demographics, incident characteristics, and clinical variables including administration of sedation medications, use of physical restraint, and transport status were examined overall and by calendar year.
Results:A total of 1,079,406 pediatric EMS encounters were present in the dataset, of which 102,014 (9.5%) had behavioral health provider impressions. Just over one-half of BHEs occurred in females (56.2%), and 68.1% occurred in patients aged 14-17 years. Telecommunicators managing the 9-1-1 calls for these events reported non-BHE patient complaints in 34.7%. Patients were transported by EMS 68.9% of the time, while treatment and/or transport by EMS was refused in 12.5%. Prehospital clinicians administered sedation medications in 1.9% of encounters and applied physical restraints in 1.7%. Naloxone was administered for overdose rescue in 1.5% of encounters.
Conclusion:Approximately one in ten pediatric EMS encounters occurring in the United States involve a BHE, and the majority of pediatric BHEs attended by EMS result in transport of the child. Use of sedation medications and physical restraints by prehospital clinicians in these events is rare. National EMS data from a variety of sources should continue to be examined to monitor trends in EMS encounters for BHEs in children.
Consensus Standard for Evidence Integration into EMS Education and High-Stakes Testing
- Christopher B. Gage, Mark Terry, Kim D. McKenna, Jonathan R. Powell, Megan Hollern, Matt Ozanich, Christopher T. Richards, Christian Martin-Gill, Ashish R. Panchal
-
- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue 3 / June 2023
- Published online by Cambridge University Press:
- 04 May 2023, pp. 338-344
- Print publication:
- June 2023
-
- Article
-
- You have access Access
- Open access
- HTML
- Export citation
-
Background:
Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation.
Objective:The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments.
Methods:The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator.
Results:In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources.
Conclusion:The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.
Administrative and Educational Characteristics of Paramedic Programs in the United States
- Matthew T. Ball, Jonathan R. Powell, Lisa Collard, Doug K. York, Ashish R. Panchal
-
- Journal:
- Prehospital and Disaster Medicine / Volume 37 / Issue 2 / April 2022
- Published online by Cambridge University Press:
- 02 February 2022, pp. 152-156
- Print publication:
- April 2022
-
- Article
- Export citation
-
Introduction:
Paramedics are a vital component of the Emergency Medical Services (EMS) workforce and the United States health care system. The continued provision of high-quality care demands constantly improving education at accredited institutions. To date, only limited characteristics of paramedic education in the United States have been documented and studied in the literature. The objective of this study was to describe the educational infrastructure of accredited paramedic programs in the United States in 2018.
Methods:This is a retrospective, cross-sectional evaluation of the 2018 paramedic program annual report from The Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP; Rowlett, Texas USA). The dataset includes detailed program metrics. Additionally, questions concerning program characteristics, demographics, and resources were asked as part of the evaluation. Resource availability was assessed via the Resource Assessment Matrix (RAM) with a benchmark of 80%. Included in the analysis are all paramedic programs with students enrolled. Descriptive statistics were calculated (median, [interquartile range/IQR]).
Results:A total of 677 programs submitted data (100% response rate). Of these, 626 met inclusion criteria, totaling 17,422 students. Program annual enrollment varied greatly from one to 362 with most programs having small sizes (18 students [IQR 12-30]). Program duration was 12 months [IQR 12-16] with total hours of instruction being approximately 1,174 [IQR 1069-1304], 19% of which were dedicated to clinical experience. Full-time faculty sizes were small (two faculty members [IQR 1-3]) with most programs (80%) having annual operating budgets below USD$500,000. For programs with an annual budget below USD$100,000 (34% of programs), annual enrollment was approximately 14 students [IQR 9-21]. Degrees conferred by programs included certificates (90%), associate degrees (55%), and bachelor’s degree (2%). Simulation access was assessed with nearly all (100%) programs reporting simple task trainers and 84% of programs investing in advanced simulation manikins. Seventy-eight percent of programs met the RAM benchmark.
Conclusion:Most paramedic educational programs in the United States have small annual enrollments with low numbers of dedicated faculty and confer certificates and associate degrees. Nearly one-quarter of paramedic educational programs are not adequately resourced. This study is limited by self-reported data to the national accreditation agency. Future work is needed to identify program characteristics that are associated with high performance.
Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport
- Casey Patrick, Brad Ward, Jordan Anderson, Joe Fioretti, Kelly Rogers Keene, Carri Oubre, Rebecca E. Cash, Ashish R. Panchal, Robert Dickson
-
- Journal:
- Prehospital and Disaster Medicine / Volume 35 / Issue 5 / October 2020
- Published online by Cambridge University Press:
- 23 July 2020, pp. 495-500
- Print publication:
- October 2020
-
- Article
- Export citation
-
Background:
The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency.
Methods:This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record.
Results:Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals.
Conclusion:These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.
Differences in Cardiovascular Health Metrics in Emergency Medical Technicians Compared to Paramedics: A Cross-Sectional Study of Emergency Medical Services Professionals
- Rebecca E. Cash, Remle P. Crowe, Julie K. Bower, Randi E. Foraker, Ashish R. Panchal
-
- Journal:
- Prehospital and Disaster Medicine / Volume 34 / Issue 3 / June 2019
- Published online by Cambridge University Press:
- 29 April 2019, pp. 288-296
- Print publication:
- June 2019
-
- Article
- Export citation
-
Background:
Emergency Medical Services (EMS) professionals face high physical demands in high-stress settings; however, the prevalence of cardiovascular health (CVH) risk factors in this health care workforce has not been explored. The primary objective of this study was to compare the distribution of CVH and its individual components between a sample of emergency medical technicians (EMTs) and paramedics. The secondary objective was to identify associations between demographic and employment characteristics with ideal CVH in EMS professionals.
Methods:A cross-sectional survey based on the American Heart Association’s (AHA; Dallas, Texas USA) Life’s Simple 7 (LS7) was administered to nationally-certified EMTs and paramedics. The LS7 components were scored according to previously described cut points (ideal = 2; intermediate = 1; poor = 0). A composite CVH score (0-10) was calculated from the component scores, excluding cholesterol and blood glucose due to missing data. Multivariable logistic regression was used to estimate odds ratios (OR; 95% CI) for demographic and employment characteristics associated with optimal CVH (≥7 points).
Results:There were 24,708 respondents that were currently practicing and included. More EMTs achieved optimal CVH (n = 4,889; 48.8%) compared to paramedics (n = 4,338; 40.6%). Factors associated with higher odds of optimal CVH included: higher education level (eg, college graduate or more: OR = 2.26; 95% CI, 1.97-2.59); higher personal income (OR = 1.26; 95% CI, 1.17-1.37); and working in an urban versus rural area (OR = 1.31; 95% CI, 1.23-1.40). Paramedic certification level (OR = 0.84; 95% CI, 0.78-0.91), older age (eg, 50 years or older: OR = 0.65; 95% CI, 0.58-0.73), male sex (OR = 0.54; 95% CI, 0.50-0.56), working for a non-fire-based agency (eg, private service: OR = 0.68; 95% CI, 0.62-0.74), and providing medical transport service (OR = 0.81; 95% CI, 0.69-0.94) were associated with lower odds of optimal CVH.
Conclusions:Several EMS-related characteristics were associated with lower odds of optimal CVH. Future studies should focus on better understanding the CVH and metabolic risk profiles for EMS professionals and their association with incident cardiovascular disease (CVD), major cardiac events, and occupational mortality.
Cash RE, Crowe RP, Bower JK, Foraker RE, Panchal AR. Differences in cardiovascular health metrics in emergency medical technicians compared to paramedics: a crosssectional study of Emergency Medical Services professionals. Prehosp Disaster Med. 2019;34(3):288–296.
Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States
- Daniel M. Buckland, Remle P. Crowe, Rebecca E. Cash, Stephen Gondek, Patrick Maluso, Sarah Sirajuddin, E. Reed Smith, Paul Dangerfield, Geoff Shapiro, Christopher Wanka, Ashish R. Panchal, Babak Sarani
-
- Journal:
- Prehospital and Disaster Medicine / Volume 33 / Issue 1 / February 2018
- Published online by Cambridge University Press:
- 21 December 2017, pp. 23-28
- Print publication:
- February 2018
-
- Article
-
- You have access Access
- HTML
- Export citation
-
Background
Use of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States.
MethodsA cross-sectional survey of NRPs was performed. The electronic questionnaire assessed paramedic training, authorization, use, and perceptions of ketamine. Included in the analysis were completed surveys of paramedics who held one or more state paramedic credentials, indicated “patient care provider” as their primary role, and worked in non-military settings. Descriptive statistics were calculated.
ResultsA total of 14,739 responses were obtained (response rate=23%), of which 10,737 (73%) met inclusion criteria and constituted the study cohort. Over one-half (53%) of paramedics reported learning about ketamine during their initial paramedic training. Meanwhile, 42% reported seeking ketamine-related education on their own. Of all respondents, only 33% (3,421/10,737) were authorized by protocol to use ketamine. Most commonly authorized uses included pain management (55%), rapid sequence intubation (RSI; 72%), and chemical restraint/sedation (72%). One-third of authorized providers (1,107/3,350) had never administered ketamine, with another 32% (1,070/3,350) having administered ketamine less than five times in their career. Ketamine was perceived to be safe and effective as the vast majority reported that they were comfortable with the use of ketamine (94%) and would, in similar situations (95%), use it again.
ConclusionThis was the first large, national survey to assess ketamine training, use, and perceptions among paramedics in the civilian prehospital setting. While training related to ketamine use was commonly reported among paramedics, few were authorized to administer the drug by their agency’s protocols. Of those authorized to use ketamine, most paramedics had limited experience administering the drug. Future research is needed to determine why the prevalence of ketamine use is low and to assess the safety and efficacy of ketamine use in the prehospital setting.
,Buckland DM ,Crowe RP ,Cash RE ,Gondek S ,Maluso P ,Sirajuddin S ,Smith ER ,Dangerfield P ,Shapiro G ,Wanka C ,Panchal AR .Sarani B Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States . Prehosp Disaster Med.2018 ;33 (1 ):23 –28 .
The Effect of Ambulance Staffing Models in a Metropolitan, Fire-Based EMS System
- Eric J. Cortez, Ashish R. Panchal, James E. Davis, David P. Keseg
-
- Journal:
- Prehospital and Disaster Medicine / Volume 32 / Issue 2 / April 2017
- Published online by Cambridge University Press:
- 18 January 2017, pp. 175-179
- Print publication:
- April 2017
-
- Article
- Export citation
-
Introduction
The staffing of ambulances with different levels of Emergency Medical Service (EMS) providers is a difficult decision with evidence being mixed on the benefit of each model.
Hypothesis/ProblemThe objective of this study was to describe a pilot program evaluating alternative staffing on two ambulances utilizing the paramedic-basic (PB) model (staffed with one paramedic and one emergency medical technician[EMT]).
MethodsThis was a retrospective study conducted from September 17, 2013 through December 31, 2013. The PB ambulances were compared to geographically matched ambulances staffed with paramedic-paramedic (PP ambulances). One PP and one PB ambulance were based at Station A; one PP and one PB ambulance were based at Station B. The primary outcome was total on-scene time. Secondary outcomes included time-to-electrocardiogram (EKG), time-to-intravenous (IV) line insertion, IV-line success rate, and percentage of protocol violations. Inclusion criteria were all patients requesting prehospital services that were attended to by these teams. Patients were excluded if they were not attended to by the study ambulance vehicles. Descriptive statistics were reported as medians and interquartile ranges (IQR). Proportions were reported with 95% confidence intervals (CI). The Mann-Whitley U test was used for significance testing (P<.05).
ResultsMedian on-scene times at Station A for the PP ambulance were shorter than the PB ambulance team (PP: 10.1 minutes, IQR 6.0-15; PB: 13.0 minutes, IQR 8.1-18; P=.01). This finding also was noted at Station B (PP: 13.5 minutes, IQR 8.5-19; PB: 14.3 minutes, IQR 9.9-20; P=.01). There were no differences between PP and PB ambulance teams at Station A or Station B in time-to-EKG, time-to-IV insertion, IV success rate, and protocol violation rates.
ConclusionIn the setting of a well-developed EMS system utilizing an all-Advanced Life Support (ALS) response, this study suggests that PB ambulance teams may function well when compared to PP ambulances. Though longer scene times were observed, differences in time to ALS interventions and protocol violation rates were not different. Hybrid ambulance teams may be an effective staffing alternative, but decisions to use this model must address clinical and operational concerns.
,Cortez EJ ,Panchal AR ,Davis JE .Keseg DP The Effect of Ambulance Staffing Models in a Metropolitan, Fire-Based EMS System . Prehosp Disaster Med.2017 ;32 (2 ):175 –179 .
Creation and Validation of a Novel Mobile Simulation Laboratory for High Fidelity, Prehospital, Difficult Airway Simulation
- Jason J. Bischof, Ashish R. Panchal, Geoffrey I. Finnegan, Thomas E. Terndrup
-
- Journal:
- Prehospital and Disaster Medicine / Volume 31 / Issue 5 / October 2016
- Published online by Cambridge University Press:
- 17 August 2016, pp. 465-470
- Print publication:
- October 2016
-
- Article
- Export citation
-
Introduction
Endotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI.
Hypothesis/ProblemThe availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance.
MethodsThe MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis.
ResultsNineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts.
ConclusionsThe MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers.
,Bischof JJ ,Panchal AR ,Finnegan GI .Terndrup TE Creation and Validation of a Novel Mobile Simulation Laboratory for High Fidelity, Prehospital, Difficult Airway Simulation . Prehosp Disaster Med.2016 ;31 (5 ):465 –470 .
Clinical Outcomes in Cardiac Arrest Patients Following Prehospital Treatment with Therapeutic Hypothermia
- Eric Cortez, Ashish R. Panchal, James Davis, Paul Zeeb, David P. Keseg
-
- Journal:
- Prehospital and Disaster Medicine / Volume 30 / Issue 5 / October 2015
- Published online by Cambridge University Press:
- 12 August 2015, pp. 452-456
- Print publication:
- October 2015
-
- Article
- Export citation
-
Introduction
Recent studies have brought to question the efficacy of the use of prehospital therapeutic hypothermia for victims of out-of-hospital cardiac arrest (OHCA). Though guidelines recommend therapeutic hypothermia as a critical link in the chain of survival, the safety of this intervention, with the possibility of minimal treatment benefit, becomes important.
Hypothesis/ProblemThis study examined prehospital therapeutic hypothermia for OHCA, its association with survival, and its complication profile in a large, metropolitan, fire-based Emergency Medical Services (EMS) system, where bystander cardiopulmonary resuscitation (CPR) and post-arrest care are in the process of being optimized.
MethodsThis evaluation was a retrospective chart review of all OHCA patients with return of spontaneous circulation (ROSC) treated with therapeutic hypothermia, from January 1, 2013 through November 30, 2013. The primary outcomes were the proportion of patients with initiation of prehospital therapeutic hypothermia with survival to hospital admission, the proportion of patients with initiation of prehospital therapeutic hypothermia with survival to hospital discharge, and the complication profile of therapeutic hypothermia in this population. The complication profile included several clinical, radiographic, and laboratory parameters. Exclusion criteria included: no prehospital therapeutic hypothermia initiation; no ROSC; and age of 17 year old or younger.
ResultsFifty-one post-cardiac arrest patients were identified that met inclusion criteria. The mean age was 61 years (SD=14.7 years), and 33 (72%) were male. The initial rhythm was ventricular fibrillation or pulseless ventricular tachycardia in 17 (37%) patients, and bystander CPR was performed in 28 (61%) patients with ROSC. Thirty-nine (85%) patients survived to hospital admission. Twenty-one patients (48%; 95% CI, 33-64) were administered vasopressors, 10 patients (24%; 95% CI, 10-37) were administered diuretics, and 19 patients (44%; 95% CI, 29-60) were administered antibiotics. Initial chest radiograph (CXR) findings were normal in 12 (29%) patients. Overall, 13 (28%; 95% CI, 15-42) study patients survived to hospital discharge.
ConclusionRecent reports have questioned the efficacy and safety of prehospital therapeutic hypothermia. In this evaluation, in the setting of unstandardized post-arrest care, 85% of the patients survived to hospital admission and 28% survived to hospital discharge, with a complication profile which was similar to that noted in other studies. This suggests that further evidence may be needed before EMS systems stop administering therapeutic hypothermia to appropriately selected patients. In less-optimized systems, therapeutic hypothermia may still be an essential link in the chain of survival.
,Cortez E ,Panchal AR ,Davis J ,Zeeb P .Keseg DP Clinical Outcomes in Cardiac Arrest Patients Following Prehospital Treatment with Therapeutic Hypothermia . Prehosp Disaster Med2015 ;30 (5 ):452 –456 .