12 research outputs found
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Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score
Introduction: There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol.Methods: We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of “stroke/TIA,” “CVA,” or “neurological problem” were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score’s metrics were evaluated as a surrogate marker for a successful EMS triage protocol.Results: We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%.Conclusion: In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols
The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval
Introduction: A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time.Methods: The MDO was implemented on November 11, 2013. A senior EMS paramedic was assigned to the position and was placed in the fire communication bureau from 9 a.m. to 9 p.m., seven days a week. We defined the pre-intervention period as August 2013 - October 2013 and the post-intervention period as December 2013 - February 2014. We also compared the post-intervention period to the “seasonal match control” one year earlier to adjust for seasonal variation in EMS volume. The MDO was tasked with the prospective management of city EMS resources through intensive monitoring of unit availability and hospital ED traffic. The MDO could suggest alternative transport destinations in the event of ED crowding. We collected and analyzed data from BCFD computer-aided dispatch (CAD) system for the following: ambulance response times, ambulance at-hospital interval, hospital diversion and alert status, and “suppression wait time” (defined as the total time suppression units remained on scene until ambulance arrival). The data analysis used a pre/post intervention design to examine the MDO impact on the BCFD EMS system.Results: There were a total of 15,567 EMS calls during the pre-intervention period, 13,921 in the post-intervention period and 14,699 in the seasonal match control period one year earlier. The average at-hospital time decreased by 1.35 minutes from pre- to post-intervention periods and 4.53 minutes from the pre- to seasonal match control, representing a statistically significant decrease in this interval. There was also a statistically significant decrease in hospital alert time (approximately 1,700 hour decrease pre- to post-intervention periods) and suppression wait time (less than one minute decrease from pre- to post- and pre- to seasonal match control periods). The decrease in ambulance response time was not statistically significant.Conclusion: Proactive deployment of a designated MDO was associated with a small, contemporaneous reduction in at-hospital time within an urban EMS jurisdiction. This project emphasized the importance of better communication between EMS systems and area hospitals as well as uniform reporting of variables for future iterations of this and similar projects. [West J Emerg Med. 2016;17(5)662-668.]