Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

Abstracts for the 2018 NAEMSP Scientific Assembly

To cite this article: (2018) Abstracts for the 2018 NAEMSP Scientific Assembly, Prehospital Emergency Care, 22:1, 101-150, DOI: 10.1080/10903127.2017.1377791 To link to this article: https://doi.org/10.1080/10903127.2017.1377791

Published online: 05 Oct 2017.

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ABSTRACTS FOR THE 2018 NAEMSP SCIENTIFIC ASSEMBLY

45%, 39%, and 33% with airway placement at culture of “scoop and swoop” for OOHCA care. Oral Presentation 5, 10, 15, 20, 25, and 30 minutes, respectively. Additional studies are needed to identify any For non-shockable rhythms, the probability subgroup of OOHCA that may benefit by trans- Abstracts (1–30) of ROSC was 43%, 40%, 35%, 30%, 25%, and port for care at a hospital. 20% at the same airway intervals. Conclusions: EMS advanced airway placement for OHCA 3. Prehospital Delivery of Death has a time-dependent association with ROSC. Notifications Associated with Higher 1. Timing of Advanced Airway Placement Early advanced airway placement is associated Rates of Occupational Burnout Among after Out-Of-Hospital Cardiac Arrest: with increased ROSC, regardless of initial EMS Professionals cardiac rhythm. Earlier Is Better Remle Crowe, Rebecca Cash, Madison Rivard, Justin Benoit, Jason McMullan, Henry Wang, 2. EMS Agencies with High Rates of Field Abraham Campos, Brian Clemency, Robert Changchun Xie, Peixin Xu, Kimberly Hart, Termination of Cardiac Arrest Care Also Swor, Eric Ernest, Ashish Panchal, The National Christopher Lindsell, University of Cincinnati Have High Rates of Survival Registry of Emergency Medical Technicians Category of Submission: Cardiac Category of Submission: Operations, Qual- John Summers, Christopher Berry, Anne ity, Safety, Systems, Disaster Background: Advanced airways (e.g., Knorr, Mark Olaf, Douglas Kupas, Geisinger endotracheal tubes, supraglottic airways) Health System Category of Submission: Background: EMS professionals often under- are frequently placed by Emergency Medical Cardiac take the difficult task of notifying families Services (EMS) in patients with out-of-hospital when a death occurs in the prehospital setting. cardiac arrest (OHCA). However, the opti- Background: The relationship between field However, many do not receive related training, mal timing of advanced airway placement termination of resuscitation (FTOR) and sur- which may exacerbate the associated stress. during the sequence of resuscitation events vival from cardiac arrest is unknown. We The emotional strain that accompanies death is unknown. We hypothesized that earlier hypothesized that EMS agencies with more fre- notifications has been linked to burnout in advanced airway placement would be asso- quent FTOR would be more likely to opti- other healthcare settings, yet this has not ciated with increased probability of return of mize resuscitative efforts on scene and would been examined in EMS. Our objective was to spontaneous circulation (ROSC). Methods: also have better patient outcomes. Methods: assess the relationship between death noti- This secondary analysis of ROC PRIMED study The Cardiac Arrest Registry to Enhance Sur- fication, training and work-related burnout data included adult, non-traumatic, OHCA vival (CARES) identified out-of-hospital car- among EMS professionals. We hypothesized patients with advanced airway placement by diac arrests (OOHCAs) occurring from 2013 to that after controlling for training, delivering EMS prior to ROSC. Patients were excluded 2016. A priori, EMS agencies were included if death notifications would be associated with if EMS witnessed the arrest or arrest time they submitted at least 80 cases during this higher odds of burnout. Methods: We analyzed was unknown. The primary exposure vari- period. Subsequently, agencies were divided data from a cross-sectional electronic survey able was time from EMS arrival to advanced into quartiles based upon FTOR frequency. The administered in April 2017. A sample size airway placement. The outcome variable was top and bottom quartiles were identified as high calculation approximated that 1,300 responses ROSC. A Cox proportional hazards model (HFTAs) and low field termination agencies were needed to make estimates with 95% was constructed to estimate the probability of (LFTAs). Generalized estimating equation mod- confidence. Assuming an 11% response rate ROSC as a function of the time to advanced els were used to compare HFTAs and LFTAs. from previous work, we randomly selected airway placement using non-linear penalized Results: Seventy agencies were classified as 19,330 nationally-certified EMS professionals. splines. The Cox model was stratified by initial HFTAs (treating 31,486 OOHCA patients) and Inclusion criteria consisted of EMTs or higher, cardiac rhythm, accounted for resuscitation 70 agencies were classified as LFTAs (treating practicing in non-military settings. We assessed duration, and adjusted for Utstein variables 27,314 OOHCA patients). FTOR was performed burnout using the validated Copenhagen including age, sex, bystander interventions, on 51.6% HFTA patients and on 7.1% of LFTA Burnout Inventory and providers self-reported and EMS response time. Patients were right patients. The mean patient age was 62.1 years training and the number of adult death noti- and 61.2% were male. HFTAs were more likely fications delivered in the past 12 months. We censored at time of hospital arrival or EMS = termination of resuscitation. Results: A total to have patients with a shockable rhythm (OR conducted multivariable logistic regression 1.16, 95%CI 1.1–1.3, p = .003) and who received modelling using confounders selected a priori of 7,547 OHCA patients were evaluated. Mean = age was 67 years (standard deviation 15), bystander CPR (OR 1.52, 95%CI 1.3–1.7, from previous research: certification level, expe- p < .001) than LFTAs. HFTAs had higher pro- rience, agency type, and call volume. We used 69% were male, 38% had an initial shockable = rhythm, and 49% received bystander CPR. portions of ROSC (35.4% vs. 26.4%, OR 1.38, the Hosmer-Lemeshow goodness-of-fit test to 95%CI 1.2–1.6), survival to discharge (12.5% vs. assess model calibration. Results: We received Median EMS response time was 6 minutes = (interquartile range 4–7). Time from EMS 8.5% OR 1.46, 95%CI 1.3–1.7), and favor- 2,333/19,330 responses (response rate:12.1%) able neurologic outcome in survivors (86.7% vs. and 1,514 (65%) met inclusion criteria. Over arrival to advanced airway placement was = = 0–5 minutes (12%), 5–10 (36%), 10–15 (29%), 77.9%, OR 1.84, 95%CI 1.4–2.4) than LFTAs, half (53%, n 780) delivered at least one > all p < .001; These results remained signifi- death notification in the past 12 months, while 15–20 (14%), 20–25 (5%), 25–30 (2%), and 30 = (2%). Median time from EMS arrival to ROSC cant after controlling for patient characteris- one-third (32%, n 468) exhibited burnout. was 19 minutes (interquartile range 14–25). tics like age, shockable rhythm, and bystander A step-wise increase in burnout prevalence Time to advanced airway placement was CPR. When compared to LFTAs, HFTAs spent was noted as number of death notifications greater time at the scene before patient trans- increased. The prevalence of burnout was 23%, significantly associated with ROSC based on < the Cox model. For initial shockable rhythms, port (25 min vs. 16 min, 95%CI 6.3–9.0, p .001) 36%, and 51% for those who delivered 0, 1–5, the probability of ROSC was 59%, 55%, 51%, and were more likely to administer drugs to and 6 or more death notifications, respectively. patients (92.0% vs. 86.7%, 95%CI 1.0–2.1, p = After adjustment, delivering one or more death .04). Conclusions: EMS agencies with the high- notifications was associated with 47% greater est rates of FTOR also have higher rates of odds of burnout (OR:1.47, 95%CI:1.12–1.94). ROSC, survival, and good neurologic outcome. Meanwhile, training was associated with PREHOSPITAL EMERGENCY CARE 2018;22:101–150 HFTAs spend more time on scene before patient reduced odds of burnout (OR:0.60, 95%CI transport, suggesting they may not have a 0.47–0.77). Conclusions: After adjustment for doi: 10.1080/10903127.2017.1377791

101 102 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

provider characteristics including experience, Background: Along with out-of-hospital car- Suicide was defined based on ICD-10 E-Codes. delivering death notifications was associated diac arrest (OHCA), opioid abuse and over- The proportionate mortality ratios (PMRs) for with higher odds of burnout, while training dose (OD) have become major public health suicide were compared between the groups, was protective. Important limitations include problems in the US. While opioid-related after adjusting for age, sex, race, and ethnic- response bias, recall bias and the cross-sectional deaths have increased in the US, recent tem- ity. Results: There were a total of 349,793 GP nature of this evaluation. Prospective work is poral and regional trends in the proportion of deaths (all causes) of which 7,775 (2.2%) were needed to explore the underlying causes of this OHCAs related to overdose (OD-OHCA) are by suicide. EMT death total was 1,205 EMT– relationship. largely unknown and may impact treatment 63 (5.2%) by suicide. Demographics of suicide: strategies and outcomes. Objective: To assess Mean age: GP–48.7 yrs; EMT - 43.4 yrs (p = 4. Incivility among Nationally Certified trends in incidence, process of care, and out- 0.023); Male: GP–77.3%; EMT–88.8% (p = 0.029); Ems Professionals Is Linked to comes of OD-OHCAs compared to presumed White non-Hispanic: GP–80.0%; EMT–73.0% Workforce-Reducing Factors cardiac etiology arrests (C-OHCA). Methods: (p = 0.166). The crude odds ratio (OR) for EMT Statewide observational study utilizing an suicide was 2.43 (95%CI = 1.88–3.13) compared Rebecca Cash, Remle Crowe, Kim White- Utstein-style database, along with detailed to the GP. The adjusted OR (aOR) for EMT sui- Mills, Madison Rivard, Ashish Panchal, The review of EMS first care reports linked with hos- cide was 1.39 (95%CI = 1.06–1.82) compared to National Registry of Emergency Medical Techni- pital records and vital statistics data between the GP. The top three mechanisms of suicide cians Category of Submission: Operations, 2010 and 2015. The proportion and 95% Con- among EMTs and the GP in Arizona, respec- Quality, Safety, Systems, Disaster fidence Intervals were calculated to compare tively, were firearm (67% vs. 57%), suffocation Background: Incivility is defined as nega- the rate of arrests between OD-OHCAs vs. C- (24% vs. 21%), and poisoning (9.5% vs. 17%). tive interpersonal acts that violate norms for OHCAs. Multivariate logistic regression was Conclusions: In this statewide analysis, EMTs social interaction, ranging from breaches of carried out to compare survival between the in Arizona had a significantly higher propor- etiquette to outright harassment. In other two groups. Results: There were a total of tional mortality ratio of deaths due to suicide healthcare settings, incivility has been linked 21,658 confirmed OHCAs during the study compared to the general population, even after to negative individual and organizational period. After excluding non-C-OHCAs/non- controlling for age, sex, race, and ethnicity. This effects, although scant literature exists con- OD-OHCAs, 18,988 cases remained. Overall, is the first study that we are aware of to com- cerning incivility in the unique, high-stress 18,001 (94.8%) of arrests were C-OHCA and 987 pare EMT suicide completions with the general EMS setting. Our objective was to describe the (5.2%) were OD-OHCA. There was a signifi- public. Hopefully this information will increase association between incivility and stress, career cant increase in the proportion of OD-OHCAs awareness and spur studies to elucidate under- = satisfaction, turnover intentions, and work- between 2010, 4.6% (95% CI 3.8–5.4) and lying causes and evaluate the effectiveness of = place absence among EMS professionals. We 2015, 6.4% (95% CI 5.7–7.3). Mean age for interventions. hypothesized that exposure to incivility would OD-OHCA was 38.8 yrs compared to 64.2 yrs < be linked to poorer personal and occupational for C-OHCA (p 0.0001) and location of OD- 7. Assessment of the Rapid Arterial well-being. Methods: Based on a sample size OHCAarrests was more likely residential 66.6% Occlusion Evaluation (Race) Scale in < calculation, 38,000 nationally-certified EMS vs. 54.0% (p 0.0001). Shockable rhythm was Real-World Practice for Prediction of professionals received an electronic ques- present in 7.0% of OD-OHCAs vs. 22.6% of C- Large Vessel Occlusion and Reducing Time < tionnaire. Incivility was measured using an OHCAs (p 0.0001). Bystander CPR was per- to Thrombectomy EMS-adapted Workplace Incivility Scale (WIS). formed in 49.4% of OD-OHCAs vs. 48.3% of < Stress was measured using the depression anx- C-OHCAs (p 0.5231). Overall survival to dis- Peter Antevy, Brijesh Mehta, Ashutosh Jad- iety and stress scale (DASS). Satisfaction was charge in the OD-OHCA group was 18.6% vs. hav, Joy Sessa, Randy Katz, Hoang Duong, < measured using a 4-point Likert scale and high 11.9% in the C-OHCA group (p 0.0001). After Andrey Lima, Gina Dimartini, Lakota self-reported workplace absence was classified risk adjustment, there was an aOR of 2.0 (1.6– Woodall, Ryan McTaggart, Ronil Chandra, as missing 10 or more days of work in the previ- 2.5) for survival to hospital discharge in the OD- Thabele Leslie-Mazwi, Joshua Hirsch, Albert ous 12 months. Non-military, practicing EMTs OHCA group compared to the C-OHCA group. Yoo, Tudor Jovin, Raul Nogueira, Memorial or higher were included in the analysis. Mul- Conclusions: This statewide study found a sig- Healthcare System Category of Submission: tivariable logistic regression was conducted nificant upward trend in the proportion of OD- Medical using a priori selected covariates based on OHCAs as well as differences in population demographics and epidemiology. Given the Background: Prehospital identification of directed acyclic graphs to obtain adjusted odds potential large vessel occlusion (LVO) stroke ratios and 95% confidence intervals (OR, 95% varying etiology, location, and age, it is surpris- ing that the bystander CPR rates were nearly patients may lead to faster triage and treat- CI) to examine the association between expe- ment. We examined whether the Rapid Arterial riencing incivility and the outcomes of interest. identical. It is likely that regional variations in OD-OHCAs exist and emergency medical sys- Occlusion Evaluation (RACE) scale can be Results: A total of 3,741 EMS professionals reliably implemented in a real-world setting responded (response rate = 10.3%), with 2,815 tems should track data to optimize their preven- tion and resuscitation efforts. with multiple EMS agencies and lead to rapid (75%) meeting inclusion criteria. Most were treatment. Methods: A prospective study was male (70%) and white, non-Hispanic (87%) performed at a high volume comprehensive 6. Death by Suicide: The EMS Profession with 54% certified at the EMT level. Incivility stroke center. In the first phase, eight EMS Compared to the General Public was experienced at least once per week by agencies were educated on use of the RACE 47% of respondents. Exposure to incivility was scale using an online training video. All EMS associated with greater odds of dissatisfaction Bentley Bobrow, Micah Panczyk, Robyn Blust, Paula Brazil, Taylor George, Vatsal stroke alerts were recorded. When EMS RACE with EMS (4.70, 3.48–6.35), dissatisfaction score was 5 or higher, the neurocath lab team with a main EMS job (6.68, 4.99–8.93), dissat- Chikani, Chengcheng Hu, Daniel Spaite, Arizona Department of Health Services Category was alerted prior to EMS arrival as part of a isfaction with immediate supervisors (11.04, parallel workflow. Upon emergency depart- 8.21–14.85), increased stress (5.31, 4.04–6.98), of Submission: Operations, Quality, Safety, Systems, Disaster ment arrival, the following characteristics were intent to leave one’s job or the EMS profession tracked: NIHSS score, RACE score, CT findings, in the next 12 months (3.99, 3.17–5.02 and 3.55, Background: EMS professionals face high lev- presence of LVO and workflow time metrics. 2.48–5.09, respectively), and workplace absence els of chronic physical/emotional stress and Results: During the study period (January 2016 (1.38, 1.06–1.81). Conclusions: About half of Post Traumatic Stress Disorder related to pre- to June 2017), RACE score was provided for 797 nationally-certified EMS professionals were hospital care. Suicide has been linked to other of 1498 EMS stroke alerts (53%). Higher pre- exposed to regular incivility. Exposure to inci- first responder professions, such as law enforce- hospital RACE scores correlated with NIHSS vility was associated with workforce reducing ment, presumably related to multiple chronic scores. LVO was found in 13% of patients with factors such as career dissatisfaction, stress, stressors. While high-profile anecdotal EMT an available RACE score. A RACE score of 5 turnover intentions, and workplace absence. suicide cases and national survey data on sui- or higher was able to identify 64% of all LVO Further research is needed to understand cidal ideation/attempts have received much patients (sensitivity: 64%; specificity: 72%; how organizational climate and interpersonal attention, there is a paucity of data on EMT PPV: 30%; NPV: 93%; accuracy: 71%; Youden’s behaviors in the workplace affect individual suicide completions. We sought to determine index). However, of the 260 patients with RACE employees and EMS workforce stability. the statewide proportionate mortality ratios of score 5 or higher, only 68 patients (26%) were 5. Statewide Trends in Out-of-Hospital suicide completions among EMTs compared to found to have LVO while 29 patients (11%) had Cardiac Arrest Related to Drug Overdose the general public (GP) in Arizona. Methods: ICH; among 499 patients with RACE score less Observational study of adults (ࣙ18 yrs; 1/2009– than 5, LVO was present in 38 patients (8%). Samuel Beger, Gabriella Smith, Vatsal 12/2015. The Arizona Vital Statistics Infor- When an EMS stroke alert with high RACE Chikani, Daniel Spaite, Samuel Keim, Terry mation Management System-Electronic Death score triggered early alert of the neurocath lab Mullins, Taylor George, Bentley Bobrow, Uni- Registry was queried with manual review team, median door to groin puncture time for versity of Arizona College of Medicine – Phoenix of decedent occupation free-text fields. These thrombectomy was 68 minutes compared to Category of Submission: Student, Resident, data were compared to the non-EMT cohort 91 minutes for cases with sequential work- Fellow aggregate of all other occupations combined. flow. Conclusions: The RACE scale can be NAEMSP 2018 ANNUAL MEETING ABSTRACTS 103

successfully implemented across EMS agencies Category of Submission: Operations, Quality, in three mid-sized cities. EMS providers were and results in faster door to groin puncture Safety, Systems, Disaster interviewed to obtain patient demographics times. While a RACE score of 5 or higher is and presence or absence of each FTDS criteria. associated with greater likelihood of LVO, there Background: Understanding motivations for Children were considered to need a TC if they are a significant number of false positives. Fur- exiting the workforce is important to improve met a published consensus definition. Outcome ther refinement of prehospital stroke severity recruitment and retention of EMS profession- data was obtained through structured hospital scales is warranted to improve the accuracy of als. Factors influencing the choice to leave record review. The over- and under-triage rates this approach. EMS have not been explored by provider level. and positive likelihood ratios (+LR) were cal- Our objective was to describe and compare culated using traditional and age-specific cut the most important factors in the decision 8. Effecting Neurologically-Intact points for the physiologic step, as well as for to leave EMS among EMTs and . systolic blood pressure (SBP), and respiratory Survival for Children with As education requirements and practice set- Out-of-Hospital Cardiac Arrest rate (RR). Results: EMS and outcome data were tings vary between EMTs and paramedics, we available for 9,484 children. 2% of all patients Paul Pepe, Paul Banerjee, Amninder Singh, hypothesized that reasons for leaving EMS needed the resources of a TC. 11% of patients Latha Ganti, University of Texas Southwest- differed by certification level. Methods:This met the physiologic step when traditional cut ern Medical Center Category of Submission: was a cross-sectional analysis of an electronic points were used and 23% when age-specific Pediatric questionnaire deployed in June 2017 to all cut points were used. Using the traditional nationally-certified EMTs and paramedics who physiologic criteria, 46% of children needing a Background: EMS crews commonly limit on- did not renew National EMS Certification dur- TC would have been under-triaged and 10% scene care for pediatric out-of-hospital cardiac ing the 2016–2017 recertification period end- over-triaged (+LR 5.44, 95%CI 4.75–6.24). Using arrest (POHCA) patients, typically attempt- ing on March 31, 2017. Since National EMS the age-specific physiologic criteria, 40% would ing to provide treatment while transporting. Certification is not required to renew a license have been under-triaged and 22% would have Hypothesis: Neurologically-intact survival in all states, participants were asked if they been over-triaged (+LR 2.69, 95%CI 2.40–3.01). for children can be improved by deferring were currently practicing in EMS. Inclusion The traditional RR cut point had a +LR of 3.12 transport and prioritizing on-site care using criteria consisted of those who reported not (95%CI 2.39–4.07). The age-specific RR cut point strategies that expedite on-scene drug delivery working in EMS. Z-tests of proportion with had a +LR of 1.86 (95%CI 1.56–2.22). The tra- and intubation with tightly-controlled ventila- a Bonferroni adjustment for multiple compar- ditional SBP had a +LR of 5.28 (95%CI 3.35– tion. Methods: Data for all consecutive POHCA isons were used to evaluate differences in 8.34). The age-specific SBP had a +LR of 6.10 cases between January 1, 2012 and April 30, reasons for leaving EMS between EMTs and (95%CI 3.54–10.00). EMS did not obtain RR in 2017 were collected prospectively (compre- paramedics. Results: We received 4,793/51,344 16% and SBP in 28% of cases. Conclusions:The = hensive Utstein-style registry). In 2014, new responses (response rate 10%) and 2,703 met accuracy of the physiologic step of the FTDS is = training prioritized on-scene resuscitation inclusion criteria. Most were EMTs (85%, n not improved by using age-specific criteria. The = strategies (Phase I) that expedited drug deliv- 2,291) and 15% were paramedics (n 412). rate of under-triage is decreased while the rate ery and intubation with controlled ventilation For EMTs, the most commonly selected rea- of over-triage is increased. (e.g., rates ∼6/min). In 2016, techniques to son for leaving EMS was the pursuit of further dose/prepare drugs while responding were education (22%), while paramedics most com- monly cited a desire for better pay and ben- introduced (Phase II). Neuro-intact survival 11. Comparative Effectiveness of efits (20%). There was more than a two-fold in 2012–13 (Phase 0, pre-changes) were then Antiarrhythmics for Out-of-Hospital increase in the proportion of paramedics that compared to Phase I and II outcomes. Through- Cardiac Arrest: A Systematic Review and selected illness/injury/disability compared to out the study, protocols followed the 2010 Network Meta-Analysis American Heart Association guidelines. No EMTs (13% vs. 6%, p < 0.001). Three times other relevant modifications were made as many paramedics selected stress/burnout Shelley McLeod, Romina Brignardello- < system-wise. The modified training included compared to EMTs (9% vs. 3%, p 0.001). Petersen, Andrew Worster, John You, Alla psychological and skills-enhancing tools to Only 5% of EMTs listed retirement as the most Iansavichene, Gordon Guyatt, Sheldon provide greater confidence in providing on- important factor for leaving EMS compared Cheskes, Schwartz/Reisman < scene care. Results: EMS crews managed 143 to 14% of paramedics (p 0.001). Exclud- Institute, University of Toronto Category of consecutive POHCA cases over the 5.33-year ing those who left for retirement, 68% of Submission: Cardiac study period throughout which the majority EMTs stated they intended to return to EMS, of children continued to present in asystole, compared to 32% of paramedics (p < 0.001). Background: The objective of this systematic including those resuscitated. In resuscitated Conclusions: Important factors related to leav- review, direct pairwise meta-analysis and patients, the interval from vehicle arrival on- ing EMS differed by provider level. Of concern, network meta-analysis (NMA) was to assess scene to the first epinephrine administration fell a larger proportion of paramedics reported the use of antiarrhythmic drugs for patients from 16.5 minutes (2012–2013) to 7.3 minutes illness/injury/disability or stress/burnout as experiencing out-of-hospital cardiac arrest (Phase I) and 5.0 minutes (Phase II). Children their primary reason for leaving the profes- (OHCA). Methods: Electronic searches of received intubation and intraosseous insertion sion compared to EMTs. Additionally, fewer Medline, EMBASE, and Cochrane Central in much greater frequency on-scene in Phase I paramedics reported an intention to return to Register of Controlled Trials were conducted and II with no other significant differences in EMS. Limitations include potential response and reference lists were hand-searched. terms of age, sex, etiology, response intervals, bias and confounding. Randomized controlled trials (RCTs) inves- or sequence of drug infusions. Rates of survival tigating the use of antiarrhythmic agents to hospital discharge with intact neurological administered during resuscitation for adult (ࣙ 18 years) patients suffering non-traumatic status did improve immediately: 23.2% (13/56) 10. Do Age Appropriate Vital Sign Cut OHCA were included. Two reviewers inde- in Phase I and 34.7% (17/49) in Phase II versus Points Improve the Predictive Ability of pendently screened abstracts, assessed risk 0 of 38 for the pre-change calendar years of the Physiologic Criteria of the Field < of bias of the included studies, and extracted 2012–2013 (p 0.0001; 2-tailed Fisher’s exact Triage Decision Scheme for Identifying data for the following outcomes: return of test). By 2017, the mean time to epinephrine Children Who Need the Resources of a spontaneous circulation (ROSC), survival to administration had fallen to 2 minutes for Trauma Center resuscitated patients and 3.33 minutes for all hospital admission, survival to hospital dis- patients. Conclusions: Although a historically- E. Brooke Lerner, Jeremy Cushman, Mohamed charge and survival to hospital discharge with controlled study, the sudden appearance of Badawy, Amy Drendel, Courtney Jones, good neurologic status. Direct and indirect neuro-intact survivors following the renewed Manish Shah, David Gourlay, Medical College evidence were combined in a NMA using a focus upon on-scene care was profound, imme- of Wisconsin Category of Submission: Trauma frequentist approach with fixed-effects models diate and sustained. Beyond skills-enhancing and reported as relative risks (RR) with 95% strategies, physiologically-driven techniques Background: Prior research found the Field confidence intervals (CIs). For each pairwise and supportive encouragement from leader- Triage Decision Scheme’s (FTDS) physiologic comparison, the certainty of direct, indirect, ship, pre-arrival psychological and clinical step is a moderate predictor of pediatric trauma and network evidence was assessed using the tools were also likely contributors to the center (TC) need. Predictive ability could be GRADE approach. Results: 8 RCTs involving observed outcomes. hindered by the current use of adult values 4,464 patients were combined to compare when defining abnormal vital signs. Our objec- the effectiveness of five antiarrhythmic agents tive was to determine the accuracy of the FTDS (amiodarone, bretylium, lidocaine, magnesium, 9. Motivations for Exiting the EMS physiologic step when traditional cut points and sotalol) and placebo administered during Profession Differ between EMTS and are compared to age-specific cut points for resuscitation following OHCA. Lidocaine Paramedics identifying children needing TC resources. was associated with a statistically significant Madison Rivard, Remle Crowe, Rebecca Cash, Methods: A prospective study of all injured increase in ROSC compared to placebo (1.15; ࣘ Jeremy Miller, Ashish Panchal, The National children 15 years, regardless of severity, trans- 95% CI: 1.03–1.28) and was also superior to Registry of Emergency Medical Technicians ported by EMS to pediatric TC was conducted bretylium (1.61; 95% CI: 1.00–2.60) for ROSC. 104 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

When compared to placebo, both amiodarone 13. Effectiveness of Prehospital escalating threats of violence during EMS calls. (1.18; 95% CI: 1.08–1.30) and lidocaine (1.18; Hypertonic Saline for Hypotensive We hypothesized that providers with greater 95% CI: 1.07–1.30) were associated with a Patients: A Systematic Review and EMS experience and training would be more statistically significant increase in survival to Meta-Analysis likely to escape threatening situations. Meth- hospital admission (certainty of the evidence ods: EMS providers of a large county-based sys- was high). However, no antiarrhythmic was Ian Blanchard, Armghan Ahmad, Karen Tang, tem participated in specially-developed patient statistically more effective than placebo for Paul Ronksley, Diane Lorenzetti, Gerald care simulations. Each scenario escalated survival to hospital discharge or neurologically Lazarenko, Eddy Lang, Christopher Doig, H threats of violence so that providers should intact survival, and no antiarrhythmic was Stelfox, Alberta Health Services/University of Cal- escape the scene for safety. Trained evaluators convincingly superior to any other for any gary Category of Submission: Professional recorded performance per provider on 51 outcome (certainty of the evidence was low standardized data elements including time, de- Background: The optimal prehospital fluid or very low). Conclusions: Amiodarone and escalation attempts, and escape. Our primary for the treatment of hypotension is unknown. lidocaine were the only agents associated with outcome was whether the provider escaped Hypertonic fluids, meaning that the composi- improved survival to hospital admission in before the scenario ended. Our secondary tion of solutes is higher to that of the human the NMA. For the outcomes most important outcome was whether a provider made an ade- body, may increase circulatory volume and to patients, survival to hospital discharge and quate de-escalation attempt. Descriptive statis- mute the pro-inflammatory response of the neurologically intact survival, no antiarrhyth- tics and univariable odds ratios (OR, 95%CI, body to injury and illness. The purpose of this mic was convincingly superior to any other or p-value) were calculated. Results: We evalu- study was to determine whether in patients to placebo. ated 272 EMS providers as individual members presenting with hypotension in the prehospi- of two-person crews, with <3% missing data. tal setting (population), the administration of Overall, 55% (n = 145/263) made an adequate 12. Emergency Medical Services Provider hypertonic saline (intervention), compared to de-escalation attempt and 55% (n = 147/268) Perspectives on Pediatric Calls: A an isotonic fluid (control), improves survival to escaped the unsafe scene. Of those who did not Qualitative Study hospital discharge (outcome). Methods:Inthis escape, nearly half (44%, n = 53/120) also did PROSPERO registered review, searches were Jessica Jeruzal, Lori Boland, Monica Frazer, not make an adequate de-escalation attempt. conducted in Medline, Embase, CINAHL, and Jonathan Kamrud, Russell Myers, Charles EMS experience (p = 0.31) and military back- CENTRAL from the date of database inception Lick, Andrew Stevens, Allina Health Emer- ground (p = 0.39) were not associated with to November, 2016, and included all languages. gency Medical Services Category of Submission: odds of de-escalation. A two-fold increase in Two reviewers independently selected random- Cardiac odds of adequately attempting de-escalation ized control trials of hypotensive human par- was observed for providers with Crisis Inter- ticipants administered hypertonic saline in the Background: Previous survey results in our vention Training (CIT) (2.13, 1.15–3.93, p = prehospital setting. The comparison was iso- service indicate that 9-1-1 response 0.02). As experience increased, a stepwise tonic fluid, which included normal saline, and to incidents involving children are particularly decrease in the proportion of providers that near isotonic fluids such as Ringer’s Lactate. distressing for emergency medical services escaped was noted (p-trend = 0.01). Providers Assessment of study quality was done using (EMS) clinicians. This qualitative study was with 20-plus years of EMS experience had 64% the Cochrane Collaborations’ risk of bias tool conducted to increase understanding about the lower odds of escaping (0.36, 0.17–0.76, p < and a fixed effect meta-analysis was conducted difficulties of responding to pediatric calls and 0.01; referent:<5 years experience). Providers to determine the pooled relative risk of sur- obtain information about how organizations with military experience (0.38, 0.18–0.84, p = vival to hospital discharge. Secondary out- can better support EMS providers in managing 0.02) or CIT (0.37, 0.20–0.67, p < 0.01) also had comes were reported for fluid requirements, potentially difficult calls. Methods: Paramedics reduced odds of escaping. Conclusions:Nearly multi-organ failure, adverse events, length of and emergency medical technicians from a sin- half of EMS providers failed to escape a sim- hospital stay, long term survival and disabil- gle U.S. ambulance service were invited to par- ulated scene with threat of physical violence. ity. Results: Of the 1,160 non-duplicate cita- ticipate in focus groups about responding to 9- Experienced providers and those with military tions screened, 38 articles underwent full-text 1-1 calls involving pediatric patients. A total of or CIT training had lower odds of escaping. review, and five trials were included in the 17 providers from both rural and metro service Limitations include that these results were systematic review. All studies administered a regions participated in six focus groups held in obtained in a training environment. Future fixed 250 mL dose of 7.5% hypertonic saline, community meeting spaces. A semistructured research should focus on developing training except one that administered 300 mL. Two stud- focus group guide was used to explore: (1) to improve recognition of failed de-escalation ies used normal saline, two Ringer’s Lactate, elements that make pediatric calls difficult, (2) and the need to escape an unsafe scene. pre-arrival preparation practices, (3) experi- and one Ringer’s Acetate as control. Routine ences with coping after difficult pediatric calls, care co-interventions included isotonic fluids 15. Performance Characteristics of the and (4) perspectives about follow-up resources and colloids. Five studies were included in the Modified Rapid Arterial Occlusion and support. Focus groups were audio recorded meta-analysis (n = 1,162 injured patients) with Evaluation Scale (MRACE) To Predict and transcripts were analyzed using standard minimal statistical heterogeneity (I2 = 0%). The Large Vessel Occlusion coding, memoing and content analysis meth- pooled relative risk of survival to hospital dis- ods in qualitative analysis software (NVivo). charge with hypertonic saline was 1.02 times Hinnah Siddiqui, Denisse Sequeira, Mar- Results: Responses about elements that make that of patients who received isotonic fluids cus Robinson, Christian Martin-Gill, Francis pediatric calls difficult were organized into (95% CI: 0.95,1.10). There were no consistent Guyette, Department of Emergency Medicine, Uni- the following themes: (1) the social value of statistically significant differences in secondary versity of Pittsburgh School of Medicine Category children, (2) clinical difficulty of pediatric calls, outcomes. Conclusions: There was no signifi- of Submission: Student, Resident, Fellow (3) type or nature of the call, (4) interactions cant difference in important clinical outcomes with parents, and (5) location/scene chal- for hypotensive injured patients administered Background: Stroke is a leading cause of dis- lenges. With regard to pre-arrival preparation, hypertonic saline compared to isotonic fluid in ability in the United States. The most debilitat- participants often cited mentally reviewing the prehospital setting. Hypertonic saline can- ing strokes are caused by large vessel occlusion protocols, equipment location and dosages, not be recommended for use in prehospital clin- (LVO), and patient outcomes are improved and discussing assignment of on-scene tasks ical practice for the management of hypotensive through delivery of time-sensitive endovascu- with their partner. The use of retrospective call injured patients based on the available data. lar therapies at comprehensive stroke centers reviews among peers was highlighted across (CSC). The Rapid Arterial Occlusion Evaluation the topic areas as a high-value, commonly used 14. Are EMS Provider Characteristics (RACE) scale can identify patients with LVO method for coping with difficult pediatric calls Associated with Appropriate Responses and facilitate triage to CSCs, with published that also serves as a learning or preparation during Violent Encounters? sensitivity of 68% and specificity of 85% at score ࣙ tool. Suggestions for additional supportive Donald Garner, Mallory DeLuca, Remle of 5. We aimed to demonstrate the implemen- resources included: increasing opportunities Crowe, Rebecca Cash, Madison Rivard, tation feasibility and performance of prehospi- for external feedback (e.g., from hospital-based Jefferson Williams, Ashish Panchal, Jose tal mRACE scale, which does not assume the staff); additional, more frequent pediatric clin- Cabanas, Wake County EMS Category of laterality of aphasia and agnosia symptoms, to ical training; institutionalization of structured Submission: Professional identify LVO. Methods: The mRACE scale was recovery time after difficult calls; and improved implemented in 12 EMS agencies, scoring both storage and labeling of pediatric equipment. Background: Violence against Emergency aphasia and agnosia regardless of laterality Conclusions: This study provides qualitative Medical Services (EMS) providers is increasing. of symptoms to improve the ease of training data about the difficulties of responding to Little is known regarding providers’ response and capture of atypical symptoms. Training pediatric calls and resources needed to support during threatening encounters. Recognition consisted of a didactic presentation with both clinicians. Findings from this study will be and management of threatening situations is video and hands-on demonstrations of patient used to guide EMS leadership in designing key to provider and patient safety. Our objec- scenarios. A step-by-step scoring guided and implementing institutional initiatives to tive was to evaluate the association between paramedics through the exam. mRACE data enhance wellbeing among EMS clinicians. provider characteristics and response to were collected prospectively and documented NAEMSP 2018 ANNUAL MEETING ABSTRACTS 105

upon completion of the prehospital electronic (2) The pre-shock values started very low which Steve Lin, Refik Saskin, Damon Scales, Insti- health record. A project coordinator obtained may make decreases difficult to detect from a tute of Health Policy, Management and Evaluation, in-hospital data elements for those individu- floor effect; and (3) Modern bi-phasic wave- University of Toronto Category of Submission: als transported to UPMC facilities. Analysis forms may be less harmful than those previ- Student, Resident, Fellow included descriptive statistics and performance ously studied. characteristics (sensitivity, specificity, positive Background: Sepsis is a life-threatening syn- predictive value (PPV), and negative predictive 17. Epidemiology of Mortality in Patients drome caused by a dysregulated immune value (NPV). Results: From December 2015 to Transported by Emergency Medical response to infection. Early recognition and July 2017, a prehospital mRACE scale was com- Services (EMS) intervention are critical to improve patient pleted for 780 patients with suspected stroke. outcomes. In modern healthcare systems Ian Blanchard, Dan Lane, Tyler Williamson, Complete in-hospital data were available for paramedics often encounter patients with sep- Brent Hagel, Gerald Lazarenko, Ian Phelps, 517 (66%). Of these, 186 had a mRACE scale sis before other clinicians, offering an important Darren Sandbeck, Damon Scales, Eddy of ࣙ5. There were 188 (36%, CI 32–40%) cases opportunity for earlier sepsis care. The purpose Lang, Christopher Doig, Alberta Health with final diagnosis of ischemic stroke of which of this study was to estimate the incidence and Services/University of Calgary Category of 65 (12.6% CI 10–16%) had LVO. This yielded examine characteristics of patients with infec- Submission: Professional 75.3% (CI 72–79%) sensitivity, 68.6% (CI 65– tions, and sepsis transported by paramedics. Methods: A one-year cohort of all adults(> 73%) specificity, 56.3% (CI 45–67%) PPV, and Background: Outside of key conditions such = 18 years) transported by a BLS/ALS EMS 83.8% (CI 75–90%) NPV with a ROC AUC of as cardiac arrest and trauma, little is known system servicing a rural/urban population 0.76 in the identification of LVO. Conclusions: about the epidemiology of mortality of all of approximately 2 million was linked to in- Implementing the prehospital mRACE scale transported EMS patients. The purpose of this hospital administrative databases(emergency to identify patients with LVO is feasible and study was to describe characteristics of EMS department[ED] and inpatient). Infection, performs similarly to the RACE scale without patients who after transport, die in a health care and sepsis cases were classified based on need to discriminate laterality of symptoms. facility. Methods: EMS transport events over ED infectious disease diagnosis code, and Further research is necessary to determine if one year (April, 2015–2016) from a BLS/ALS an existing sepsis algorithm based on ED implementation of the mRACE scale leads to system serving an urban/rural population of diagnosis codes and EMS clinical information. increased interventions for patients with LVO approximately 2 million were linked with in- Clinical characteristics including age (years), and subsequent decreased morbidity. hospital datasets to determine overall, emer- Glasgow Coma Score (GCS)<15, tachypnea gency department (ED), and in-patient mortal- (>22/minute), and fever (> = 37.8 Celsius), 16. Effects of Failed Defibrillation ity. Medical Priority Dispatch System (MPDS) and operational factors such as prehospital Attempts on Waveform Characteristics of determinant, age in years (> = 18 years - time (minutes), transport distance from munic- the Ventricular Fibrillation adult, <=17 years - pediatric), gender, day of ipality to hospital, and high-priority Medical Electrocardiogram week, season, time (categorized in six hour Priority Dispatch System (MPDS) determinant periods), and the highest mortality MPDS (Echo/Delta) were evaluated in adults (> Jacob Thomas, David D. Salcido, Allison C. cards, clinical impressions, and ED = 18 years) and compared to patients not Koller, Matthew L. Sundermann, James J. diagnoses (International Classification of Dis- meeting sepsis criteria. Two sided t-test or dif- Menegazzi, Department of Emergency Medicine, ease v.10 - Canadian) are presented. Anal- ference of proportion were used with statistical University of Pittsburgh School of Medicine yses included two-sided t-test or chi-square significance <0.05. Results: 131,174 unique Category of Submission: Student, Resident, with alpha < 0.05. Results: A total of 239,534 adult encounters were successfully linked to Fellow EMS events resulted in 159,507 patient trans- in-hospital databases (89% linkage rate). The ports; 141,114 were included for analysis after Background: The morphology of the electro- one-year incidence of infections, and sepsis duplicate removal (89.1% linkage). Of 141,114 cardiogram (ECG) of the ventricular fibrillation were 11% and 2.1%, respectively. A minority patients, 4,269 died (3.0%; 95%CI 2.9%, 3.1%). (VF) waveform during cardiac arrest can be of all patients with infections presented with There were 724/4,269 deaths in the ED (17.0%) quantified using signal analysis (QECG). Stud- fever (18%), abnormal GCS (22%) or tachypnea and 3,545/4,269 died as in-patients (83.0%). The ies have shown that QECG measures may be (32%). Compared to other patients, adults with proportion of overall mortality by MPDS deter- predictive of defibrillation success. We sought sepsis were more likely to have an abnormal minant was Echo (24.6%), Delta (3.9%), Charlie to quantify the effect of failed rescue shocks on GCS (60% vs. 16%, p < 0.001), tachypnea (48% (3.4%), Bravo (1.1%), Alpha (2.1%), and Omega the QECG values for patients with VF in out- vs. 20%, p < 0.001), or fever (25%vs.4%, p < (1.1%). For adults the mean age of survivors of-hospital cardiac arrest (OHCA). We consid- 0.001). They were generally older(mean 75 vs. was less than non-survivors (59.2 vs. 75.8; p ered a failed shock to be one in which the ECG 60 years, p < 0.001), and more likely to have a < 0.001), but pediatric survivors were older rhythm was VF prior to and after the shock. We high priority MPDS determinant (38% vs.31%, than non-survivors (8.8 vs. 2.8; p < 0.001). hypothesized that failed rescue shocks would p < 0.001). Sepsis patients had longer prehospi- Males had increased mortality (3.3%) compared lead to worsened QECG measures. Methods: tal intervals (mean 44 vs.39 minutes, p < 0.001) to females (2.8%)(p < 0.001). Mortality did Electronic defibrillator data were taken from despite shorter transport distances(15/9.3 not change by day of week (p = 0.573), but non-traumatic, EMS-treated OHCA cases from vs.16/9.9 km/miles, p = 0.004). The in-hospital did by season with increased ED mortality the Resuscitation Outcomes Consortium (ROC) mortality rate for patients with infection in the winter (p = 0.004). The highest over- Continuous Chest Compression trial. For each was 6.8% (95%CI, 6.4–7.2), and 19% for sep- all mortality occurred with patients presenting shock, QECG values amplitude spectrum area sis (95%CI, 18–21). Conclusions: Infections between 0600–1200 hours (3.9%), and the lowest (AMSA), median slope (MS), centroid fre- and sepsis are common among paramedic- between 0000–0600 hours (2.3%)(p < 0.001). The quency (CF), and detrended fluctuation analy- transported patients, and paramedics spend a MPDS cards with the highest overall mortality sis (DFA) were calculated for the closest artifact- considerable time with these patients prior to were 9-cardiac/respiratory arrest (34.4%), 33- free 3 second gap in chest compressions prior arriving in the ED. These patients frequently interfacility transfers (7.1%), 6-breathing prob- to and after the shock. We used custom-built have altered vital signs, suggesting earlier lems (5.8%), and 28-stroke/transient ischemic MATLAB programs to perform QECG calcu- recognition may be feasible. The in-hospital attack (4.3%). The highest overall mortality lations. QECG values were compared using a mortality of these patients is significant, sup- for paramedic clinical impressions were car- paired t-test for the pre- and post-shock val- porting the need for further research into diac arrest (76.4%), respiratory arrest (18.0%), ues. Correlation coefficients were also calcu- opportunities for prehospital identification and hypovolemia/shock (11.4%), and stroke/CVA lated between the time from shock to post- intervention. shock window and the change in QECG values. (10.9%). The ED diagnoses with the highest Results: Out of 5,195 total shocks, 1,399 shocks overall mortality were related to neoplasms 19. Combined Prehospital were analyzable. 520 were the first shock. For (19.8%), circulatory system (12.4%), respira- Hypoxia-Hypotension “Depth-Duration all shocks, AMSA increased from 4.83 to 5.60 tory system (7.4%), and infections (6.0%). Con- Dose” and Mortality in Major Traumatic (p-value < 0.01). MS increased from 2.36 to clusions: Significant in-hospital mortality dif- Brain Injury 2.44 (p-value = 0.01). CF increased from 7.05 ferences were found between event, patient, to 7.16 (p-value < 0.01). DFA did not show and clinical characteristics. These data provide Daniel Spaite, Chengcheng Hu, Bentley any change: 1.28 to 1.27. For only first shocks, important foundational and hypothesis gener- Bobrow, Vatsal Chikani, Bruce Barnhart, similar results were observed. No correlation ating knowledge regarding mortality in trans- Joshua Gaither, P. David Adelson, Kurt appeared between time to post QECG mea- ported EMS patients that can be used to guide Denninghoff, Amber Rice, Chad Viscusi, surement and the change in QECG values. research and training. Duane Sherrill, Samuel Keim, University of Arizona Category of Submission: Trauma Conclusions: For all the QECG measures except 18. Epidemiology of Infections And Sepsis for DFA, a slight improvement in value was in a Large, Canadian Emergency Medical Background: Our previous work has shown observed. While statistically significant, these Services (EMS) System that the depth-duration doses of prehospi- changes may not be physiologically or clinically tal hypoxia (SpO2 < 90%) and hypotension meaningful. Possible explanations include: (1) Daniel Lane, Ian Blanchard, Gerald [SBP < 90 mmHg], separately, are strongly asso- These may be a result of the CPR delivered in Lazarenko, Christopher Oleynick, Laurie ciated with mortality in Traumatic Brain Injury between the shock and the post-shock QECG; Morrison, Hannah Wunsch, Sheldon Cheskes, (TBI). However, hypoxia and hypotension are 106 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

obviously not mutually exclusive. Hence, the experienced post-intubation hypotension. 22. Prevalence of Mortality Due to next logical step in evaluating the influence Patient factors independently associated with Rebound Toxicity after “Treat and of the “dose” of these physiological anoma- hypotension were age (adjusted odds ratio Release” Practices in Prehospital Opiate lies in TBI is to identify the combined risk. (aOR) 1.03, 95%CI 1.02–1.04), female gender Overdose Care: A Systematic Review and Methods: We evaluated major TBI cases (aOR 1.40, 95%CI 1.06–1.85), lower SBP (aOR Meta-Analysis (moderate/severe) enrolled in the EPIC Study 0.96, 95%CI 0.96–0.97), higher heart rate (aOR (NIH-1R01NS071049) before TBI guideline 1.01, 95%CI 1.00–1.01) and lower SpO2 (OR Jennifer Greene, Brent Deveau, Justine Dol, implementation (N = 16,711; 1/07–9/14). 0.97, 95%CI 0.95–0.98). Paralysis with rocuro- Micheal Butler, Dalhousie University Category Definitions: hypoxia dose-SpO2 depth < nium (aOR 1.83, 95%CI 1.26–2.67) compared to of Submission: Medical 90% integrated over time (min); hypotension succinylcholine was associated with increased Background: Death from fentanyl overdose dose-SBP < 90 mmHg integrated over time. odds of post-intubation hypotension while pre- was declared a public health crisis in Canada Both dose variables were then transformed intubation treatment with lidocaine (aOR 0.70, in 2015. Traditionally, patients who have over- to achieve approximate normality. Logistic 95%CI 0.52–0.94), post-intubation treatment dosed on opiates that are managed by emer- regression was used to determine the associa- with fentanyl (aOR 0.23, 95%CI 0.18–0.30) and gency medical services (EMS) are treated with tion between odds of death and nonparametric post intubation administration of normal saline the opiate antagonist naloxone, provided venti- functions of the (transformed) hypoxia and (aOR 0.30, 95%CI 0.10–0.88) were associated latory support and subsequently transported to hypotension doses. The combined fitted effects with a decreased occurrence of post-intubation hospital. However, certain EMS agencies have of both hypoxia and hypotension then yielded hypotension. Conclusions: In trauma patients allowed paramedics who have reversed an opi- the dose score. Results: After exclusions [age undergoing critical care transport, multiple ate overdose to refuse transport, if the patient <10 (6.8%), transfers (28.4%), SBP >200 (2.1%), patient factors and modifiable treatments has the capacity to do so. The safety of this missing SBP/SpO2/time (12.8%), only one including administration of rocuronium for practice has not been examined by a systematic recorded SBP or SpO2 (8.3%),] 6682 cases intubation were independently associated review. Therefore, our intent is to examine the remained (median age = 40; male = 70%). with hypotension. Additional investigation is available literature to determine the prevalence Mortality increases consistently across the needed to confirm this effect and identify other of mortality and serious adverse events within quartiles (Q) of unadjusted dose score (No patient and treatment factors associated with 48 hours of EMS treat and release due to sus- hypoxia or hypotension-5.6%; Q1–16.5%; Q2– post-intubation hypotension. In the interim, pected rebound opiate toxicity after naloxone 20.8%; Q3–35.8%; Q4–43.2%). In the adjusted current protocols and clinical practice should administration. Methods: A systematic search model, the mortality increase is remarkably be reviewed. was preformed on May 11, 2017 in PubMed, monotonic (indeed, nearly linear) with increas- Cochrane Central, Embase, and CIHAL using ing dose score. Across the entire range of 21. Prehospital Lactate: A Severity search strategies developed with the aide of a dose, an increase of one standard deviation of Indicator in Early Sepsis Management health sciences librarian. No search limits were adjusted dose score is associated with a 63% applied. Included studies were hand searched. increased odds of death (aOR = 1.63) among Kurt Isenberger, Aaron Burnett, Jeffrey Two authors conducted the screening, selec- patients with either hypoxia or hypotension or Anderson, Adam Mayer, Sandi Wewerka, tion and data extraction process. Discrepan- both. This result is strongly supported by the Joseph Pasquarella, Ralph Frascone, Regions cies were resolved via discussion. A modified highly significant, monotonically-increasing Hospital Category of Submission: Medical QUIPs tool was used to evaluate risk of bias. relationship between the separate hypoxia Analysis for prevalence of outcomes were pre- and hypotension doses and their adjusted Background: Serum lactate levels can rapidly formed. Results: A total of 1,401 records were death rates. Conclusions: Both hypoxia and dictate clinical awareness of shock and prompt screened after duplicate removal. Eighteen full hypotension depth/duration appear to have intervention in sepsis. Collecting serum lac- text studies were reviewed with eight selected a profound and additive influence on TBI tate levels is restricted to the hospital setting. for inclusion. Included studies had a low risk mortality. The influence of hypoxia and The objective of this study was to investi- of bias. The prevalence of mortality within hypotension on outcome (both separately and gate whether a prehospital lactate value (PL) 48 hours was so infrequent that it could not combined) appears to be far more complex improves time to intervention upon ED arrival. be quantitatively meta-analyzed. There were than the current literature reflects (only being We hypothesized that EMS communication of 4/4912 (0.00081%) total reported deaths of sus- assessed dichotomously as present or not). a PL value to the ED physician would result in pected rebound etiology from included patients Future TBI studies should account for both the improved time to antibiotics and an in-hospital acrossallstudies.Onlyonestudyreportedon depth and duration of prehospital hypoxia and lactate (IL) order. Methods: This prospective, adverse events of patients released on scene. hypotension. observational study included patients with a This study found no incidence of adverse events prehospital impression of infection based on from their sample of 71 released patients. Con- 20. Association Between Induction and SIRS criteria. A POCT PL was collected by clusions: Mortality or serious adverse events in Sedation Agents and Post Intubation paramedics prior to ED arrival, and reported the included studies due to suspected rebound Hypotension in Trauma Patients during presentation. ED metrics were collected toxicity in patients released on scene post EMS and compared to a previously collected con- Frederick Brown, Francis Guyette, Christian treatment with naloxone was rare. Despite lim- trol group (CG) of patients presenting with- Martin-Gill, Jonathan Elmer, Department of ited studies, the prevalence rate was so low that out a PL but who met early sepsis criteria. Cox Emergency Medicine, University of Pittsburgh we concluded that this practice may be safe in regression models were used to estimate hazard School of Medicine Category of Submission: terms of mortality and may be considered an ratios (HRs) with 95% confidence intervals (CIs) Trauma alternative of traditional transport. Additional for time to physician order for an antibiotic or prospective studies need to be preformed to in-hospital lactate test. Results: Study patients Background: Medications used for rapid strengthen knowledge around adverse events. sequence intubation and post-induction seda- (age 60–96) included 170 with PL measures and tion may cause hypotension, resulting in 269 controls. The PL group was older on aver- < 23. Prehospital qSOFA Score as Predictor secondary injury and worse outcomes after age (mean age, 69 vs. 54; p 0.001), and was of Sepsis and Mortality Eileen Shu, Crystal trauma. We identified patient and treatment more likely to have expired in the hospital (10% = Ives Tallman, Megann Young, William Frye, characteristics associated with post-intubation vs 5%; p 0.027). An antibiotic was ordered Leyla Farshidpour, Danielle Campagne, hypotension. Methods: We retrospectively for 104 prehospital lactate patients (61%) and UCSF-Fresno; Department of Emergency Medicine reviewed charts from consecutive patients 216 controls (80%). In a Cox model adjusted Category of Submission: Medical undergoing transport between January 2001 for age and gender, the CG had a nearly two- and June 2016 by STAT MedEvac, a multistate fold faster rate of time to antibiotic order (HR Background: The quick Sequential [Sepsis- = critical care transport service with >10,000 1.93; 95% CI: 1.50, 2.48), relative to prehos- related] Organ Failure Assessment (qSOFA) missions per year. We identified adult trauma pital lactate patients. Among the PL patients, score was proposed in 2016 as a rapid way patients intubated by a flight crew member. The time to antibiotic order did not differ by PL to identify adult patients with suspected infec- > ࣘ = primary outcome was early post-intubation ( 2 vs. 2 mmol/L, p 0.545). Time to IL tions who are likely to have poor outcomes. A hypotension, defined as a systolic blood pres- order did not significantly differ between CG 2017 study showed that qSOFA was correlated > = sure (SBP) <90 mmHg within 15 minutes and patients with PL 2 mmol/L (p 0.811), with hospital admission, ICU admission, hospi- of intubation. We used logistic regression to but time to IL order was twice as slow for tal length of stay, and inpatient mortality. How- ࣘ = identify predictors of post-intubation hypoten- patients with PL 2 mmol/L (vs. CG, HR ever, to our knowledge, the ability of the qSOFA sion. Results: During the study period, 4701 0.47; 95% CI: 0.33, 0.68). Conclusions:Inthis score to predict patient outcomes has not been adult trauma patients were intubated and small study, the availability of PL value did evaluated in the prehospital setting. We hypoth- transported. Mean age was 44 years, 26% were not improve time to antibiotics. Patients with esize that prehospital qSOFA scores are corre- female, mean pre-induction heart rate was a normal PL had a prolonged time to antibi- lated with up-triage (change to a higher acu- 99 bpm (SD 25), SBP was 137 mmHG (SD 32), otics compared to the CG, and a higher death ity triage zone in the emergency department), SpO2 was 96% (IQR 95, 100), and respiratory rate. A larger study is required to validate these presence of sepsis, ICU admission, and in- rate was 18 (SD 7). A total of 14% of patients results. hospital mortality. Methods: We conducted a NAEMSP 2018 ANNUAL MEETING ABSTRACTS 107

retrospective observational study using prehos- equipment availability, controlled substance have decreased since implementation of PDR, pital ambulance vital signs to calculate qSOFA management, infrequent training, few pediatric but frequent ten-fold errors still occur. Cross scores for all adult medical patients that pre- calls, unclear definition of a treatable seizure, checks of drug doses do not occur. Errors occur sented in September 2016 to a large academic and incongruent protocol and reference tool with dilution and length-based tape use. Error emergency department in Fresno, CA. Informa- dosing. Personal barriers included fear of res- reduction strategies are needed for pediatric tion from the electronic health record (EHR) piratory depression, confusion about dosing, prehospital drug administration. was used to determine up-triage, presence of and misconceptions about preferred routes, sepsis, hospital admission, ICU admission, and febrile seizure management, and accurate 26. Training in Prehospital Death in-hospital mortality. Results: A total of 1,903 methods of weight estimation. Paramedics Notifications Linked to Improved Provider adult medical patients were transported by shared other opinions about management: Comfort and Preparation ambulance to the emergency department dur- preference for intranasal vs. intramuscular Abraham Campos, Rebecca Cash, Remle ing the study period. Of these, 151 patients medication, how transport distance affects Crowe, Madison Rivard, Brian Clemency, (7.93%) were prehospital qSOFA positive. A management, use of online medical control, Robert Swor, Ashish Panchal, Eric Ernest, positive prehospital qSOFA score was corre- and the need to manage bystanders. Providers Department of Emergency Medicine, Univer- lated with emergency department diagnosis of suggested system improvements to address sity of Nebraska Medical Center Category of infection (29.1% vs. 15.2%; p < 0.001), hos- equipment, medication, protocol, and training Submission: Student, Resident, Fellow pital admission (55.0% vs. 33.4%; p < 0.001), limitations. Conclusions: Paramedics identi- < ICU admission (9.93% vs. 2.22%; p 0.001), fied many standardized strategies EMS systems Background: Death notifications in the prehos- admission diagnosis of sepsis (19.2% vs. 3.08%; used that enabled pediatric seizure protocol pital setting are difficult situations that require < p 0.001), and in-hospital mortality (6.62% adherence, as well as numerous systems-based training. However, this training is not uni- < vs. 0.74%; p 0.001). A positive prehospi- and personal barriers to adherence. Providers formly included in initial EMS education, and tal qSOFA score was not associated with up- identified solutions to address the barriers. the proportion of providers prepared for this = triage (7.95% vs. 5.82%; p 0.291); however, it Conducting research on EMS protocol changes, task is unknown. Our objective was to describe was correlated with final triage to a high acu- policy modifications, and training that address the prevalence of death notification training by ity zone in the emergency department (35.8% the barriers identified in this study may provider level and its association with prepa- < vs. 8.96% p 0.001). Conclusions:Prehospital enhance understanding of how to optimize ration and comfort in performing this task. qSOFA is correlated with the diagnosis of infec- pediatric prehospital seizure outcomes. We hypothesized that fewer EMTs received tion and sepsis. Furthermore, it is correlated training and that training was associated with 25. Analysis of Dosing Errors Made by with poorer patient outcomes including need greater preparation and comfort. Methods:An Paramedics During Simulated Pediatric for hospital admission, ICU admission, and in- electronic questionnaire was sent to a random Patient Scenarios after Implementation of hospital mortality. However, a positive prehos- sample of 20,000 nationally-certified EMS pro- State-Wide Pediatric Drug Dosing pital qSOFA score in isolation does not appear fessionals in April 2017. Participants reported Reference to be more useful than the current triage pro- death notification training received during ini- cess in the emergency department to identify John Hoyle, Glenn Ekblad, Tracy Hover, Bill tial or continuing education and adult death patients who should be triaged to a high acuity Fales, Richard Lammers, Dena Smith, Western notifications performed in the past 12 months. zone in the absence of other patient factors. Michigan University, Homer Stryker, MD School of Level of comfort and preparation in deliver- ing adult death notifications was rated using 24. Prehospital Provider Attitudes and Medicine Category of Submission: Pediatric a 4-point scale. Inclusion criteria were prac- Beliefs Regarding Pediatric Seizure Background: Medication errors occur at a ticing, non-military EMTs or higher. Certifica- Management: A Multicenter, Qualitative high rate for prehospital pediatric patients. tion level was grouped into advanced life sup- Study Epinephrine dose errors have been 60%. To port (ALS:paramedic/intermediate/AEMT) or John Carey, Jonathan Studnek, Lorin Browne, reduce errors, Michigan implemented a pedi- (BLS:EMT). Odds ratios (OR, Malcolm Leirmoe, Daniel Ostermayer, Tyler atric dosing reference (PDR), with doses listed 95%CI, p-value) were calculated to estimate the Miller, Diaa Alqusairi, Thomas Grawey, in milliliters, the requirement that doses be association between training and provider com- Stephanie Schroter, E. Brooke Lerner, Manish drawn into a smaller syringe from a pre-loaded fort and preparation. Results: There were 2,333 Shah, Baylor College of Medicine, Pediatrics, syringe using a stop cock and dilution of drugs responses (12% response rate), and 1,514(65%) Section of Emergency Medicine Category of to standard concentrations. The purpose of met inclusion criteria. Most respondents had Submission: Pediatric this study was to evaluate the prevalence performed at least one adult death notification of medication errors by paramedics treating in the past year (ALS: 87%, BLS: 78%, p < 0.001). Background: Seizures have the potential to pediatric patients after the implementation of a Equal proportions of ALS and BLS (51% ver- cause significant morbidity and mortality, state-wide PDR. Methods: 8 EMS agencies com- sus 52%, p = 0.58) respondents received death and are a common reason EMS are requested pleted 2 validated, pediatric scenarios: infant notification training during an initial course, for a child. A pediatric prehospital seizure seizing and infant cardiac arrest. Agencies were however fewer BLS respondents received addi- evidence-based guideline (EBG) was published private, public, not for profit, for profit, urban, tional training (BLS: 30% versus ALS: 44%, p < and has been implemented as protocol in rural, fire-based, and third service. Simulations 0.001). A larger proportion of BLS respondents multiple EMS systems. Knowledge trans- took place in a simulation center or mobile did not receive any death notification training lation and protocol adherence in medicine simulation unit. EMS crews used their regular (BLS: 40%, ALS: 32%, p = 0.005). Over one-third can be incomplete. In EMS, systems-based equipment with sham drugs and were required (34%) of those without training had performed factors and providers’ attitudes and beliefs to carry out all the steps to administer a drug an adult death notification in the past year. may contribute to incomplete knowledge dose. Two evaluators scored crew performance After controlling for certification level, training translation. The purpose of this study was via direct observation and video review. A dose was associated with increased odds of reporting to identify EMS provider-reported attitudes, error was defined as > = 20% difference com- greater comfort (2.20, 1.77–2.75, p < 0.001) and beliefs, barriers, and enablers to adhering to pared to the weight-appropriate dose. Descrip- preparation (6.05, 4.73–7.74, p < 0.001) in per- EBG-derived seizure protocols in multiple tive statistics were utilized. Results: 80 simula- forming death notifications. Conclusions:Most EMS systems. Methods: This was a qualitative tions have been completed and initial analysis respondents delivered a death notification in study utilizing 30-minute semi-structured has been conducted using descriptive statistics. the past year; however, one-third of these EMS interviews of paramedics who recently trans- The majority of crews were EMTP/EMTP. In providers had not received training. Training ported actively seizing 0–17 year olds in two cardiac arrest scenarios, 8/20 (40%; 95% CI was associated with greater comfort and prepa- different urban EMS systems. Interviewers 18.5%, 61.5%) epinephrine doses were incor- ration in delivering death notifications. Limita- explored the providers’ decision-making dur- rect. In 0/20 doses, there was no cross check of tions include recall bias attributed to self-report. ing their recent case and regarding seizures the drug volume prior to administration. There Future work should focus on barriers to receiv- in general. Two investigators used NVivo were 6, ten-fold overdoses and one, ten-fold ing death notification training. software, the grounded theory approach, underdose. In seizure scenarios, 5/11(45%; and constant comparison to independently 95% CI 16%, 74.9%) benzodiazepine doses 27. Reduction in Cervical Spine analyze transcribed interview recordings until were incorrect (2 underdoses, 3 overdoses); 2/9 Immobilization Is Not Associated with thematic saturation was reached. Results: (22%; 95% CI 0%, 49.4%) drug dilutions were Missed Injuries Several overarching themes emerged from the incorrect resulting in large dosing errors. In Jennifer Gibson Chambers, Michael O’Brien, 32 paramedics that were interviewed. Enablers 1/10 cases (10%; 95% CI 0%, 28.6%) the crew Brian Clemency, University at Buffalo Category included dosing/protocol references, training, was unable to dilute D50 to D25. Unrecognized of Submission: Student, Resident, Fellow provider knowledge about preferred routes, air bubbles were frequently entrained in the predefined provider roles, options to use dif- administration syringe resulting in underdoses. Background: Previous studies have demon- ferent routes, online medical control, multiple In 11/20 (55%) of cases there was an error using strated EMS providers can correctly deter- crews on scene, and physical accessibility of the length-based tape for weight determina- mine which patients have a cervical spine medication on scene. Systems barriers included tion. Conclusions: Epinephrine dose errors injuries and patients arriving at the emergency 108 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

department via EMS without a cervical collar (CFA) using a polychoric correlation matrix for were under-triaged to the non-trauma centers rarely have serious cervical spine injuries. In ordinal data. We used prior SOPS thresholds the most frequently cited reasons by EMS was a recent study, we demonstrated that imple- to assess fit (0.90), factor-loadings (0.4), and patient request (61.4%) and proximity of the mentation of a spinal motion restriction (SMR) factor variances (0.5). We assessed domain non-trauma center (13.7%). Conclusions:EMS protocol was associated with decreased cervi- reliability and validity using Cronbach’s alpha provider destination decisions are influenced cal collar use. We sought to determine if this (cutoff:0.6) and Pearson’s correlation coeffi- by mechanism of injury, but a substantial pro- decrease was associated with an increase in cients (r; cutoff:0.3). Results: We randomly split portion of patients who meet the physiologic serious cervical injuries among patients trans- 23,765 responses into equally-sized calibration and anatomic criteria of FTDS were under- ported without cervical collars. Methods:This and validation datasets. The CFA supported triaged. Both under- and over-triage appear to was a secondary analysis of a retrospective the 11-domain model with a comparative fit be heavily influenced by patient preference. chart review of patients transported by a sin- index = 0.94, exceeding the 0.90 threshold. gle large, commercial EMS agency with a dis- Item factor-loadings all exceeded 0.4 (range: 30. Does Mechanism of Injury Predict patch for motor vehicle collision to one of three 0.51–0.98). Three domains exhibited factor Trauma Center Need for Children? E. hospitals. EMS and hospital data were reviewed variances below the 0.5 threshold: staffing, Brooke Lerner, Mohamed Badawy, Jeremy for all calls during a 6-month period before communication about incidents, and handoffs. Cushman, Amy Drendel, Courtney Jones, (January–June 2015) and a 6-month period after Cronbach’s alpha was above 0.6 for all domains Manish Shah, David Gourlay, Medical College (January–June 2016) the protocol change. Fisher (range:0.65–0.88). Predictive validity was sup- of Wisconsin Category of Submission: exact test was used for statistical comparisons ported as all domain composite scores were Pediatric between time periods. Cervical spine injuries correlated with the outcome variables of overall Background: To determine if the Mechanism identified on CT were considered serious if safety rating (r = 0.44–0.72) and frequency of of Injury step of the Field Triage Decision the patient required operative intervention, dis- event reporting (r = 0.31–0.48). Results from Scheme (FTDS) is accurate for identifying chil- charge in an immobilization collar or cervical the validation dataset confirmed the presented dren who need the resources of a trauma cen- spine injuries present in patients who died as calibration results. Conclusions: Overall, the ter (TC). Methods: EMS providers transporting a result of traumatic injuries. Results:There EMS-adapted tool demonstrated adequate psy- any injured child ࣘ15 years, regardless of sever- were 1,614 patient records identified, 819 under chometric properties, and the reliability and ity, to a pediatric TC in three midsized commu- the immobilization protocol and 796 under the validity of the tool were consistent with exist- nities over 3 years were interviewed. Collected SMR protocol. Cervical collar use decreased ing SOPS instruments. Important limitations data included EMS observed physiologic con- from 66.8% to 59.3% (p = 0.002). There was include potential response bias and the inabil- dition, suspected anatomic injuries, and mech- no significant difference between time periods ity to aggregate data at the agency level. Future anism. Patients were considered to need a in proportion of male patients, average age, work should focus on agency-level data testing. TC if they met a consensus-based definition. or subtype of motor vehicle accident. No sig- Data were analyzed with descriptive statistics nificant change was observed in the rate of 29. Explaining Disparities in Field Triage including positive likelihood ratios (+LR) and CT cervical spine imaging (51.0% before and of Older Adults: Factors that Influence 95% confidence intervals (95%CI). Results:A 52.5% after, p = 0.55). Serious cervical spine EMS Destination Decisions AND Reasons total of 9,484 provider interviews were con- injuries were identified in 2.2% before and 2.4% for Over- and Under-Triage ducted and linked to hospital data to obtain of imaged patients after SMR (p = 0.99). All Courtney Jones, Jeremy Cushman, Julius patient outcome. Of those, 215 (2.3%) needed patients with serious cervical spine injury were Cheng, Martina Anto-Ocrah, Nancy Wood, a TC. A total of 1,485 enrolled patients were placed in cervical collars by EMS providers, a Heather Lenhardt, Molly McCann, Suzanne excluded from further analysis because they sensitivity of 100%. The specificity was 14.0% Gillespie, Ann Dozier, Jeffrey Bazar- met the physiologic or anatomic steps of the before and 18.7% after SMR (p = 0.10). Conclu- ian, Manish Shah, University of Rochester, FTDS. Of the remaining 7,999 cases, 61 needed sions: Despite decreased use of cervical collars School of Medicine and Dentistry Category of a TC. The mechanisms sustained by the remain- under the SMR protocol, there were no motor Submission: Trauma ing cases were 35.5% fall (15 needed TC), 28.5% vehicle accident patients with serious cervical motor vehicle crash (MVC) (26 needed TC), fractures transported without a cervical collar Background: The Field Triage Decision Scheme 7.1% struck by a vehicle (8 needed TC), 0.2% in either period. These findings may not gener- (FTDS) is designed to identify severely injured motorcycle crash (MCC) (none needed TC), alize to other mechanisms of injury. patients and guide EMS providers’ selection of and 28.8% had a mechanism not on the FTDS a destination hospital, but a minimal amount 28. Psychometric Properties of a Survey on (12 needed TC). Among those who fell greater is known regarding the real-world application + Patient Safety Culture (SOPS)-Based Tool than 10 feet, 2 needed a TC ( LR 2.67; 95%CI: of these criteria. We aimed to identify the fac- for EMS 0.73–9.79). Among those in a MVC, 42 were tors that influence EMS destination decisions, reported to have been ejected and none needed Remle Crowe, Rebecca Cash, Madison the extent to which EMS decisions align with a TC. While 63 had reported intrusion >12 Rivard, William Gilmore, Alex Christgen, the FTDS, and explore EMS provider-identified inches and 1 needed a TC (+LR 1.40; 95%CI: Tina Hilmas, Lee Varner, Amy Vogelsmeier, reasons for over- and under-triage of older 0.20–9.69). There were 34 reported as having Ashish Panchal, The National Registry of adults. Methods: We conducted a prospective a death in the same vehicle, and 2 needed Emergency Medical Technicians Category of multi-center study, encompassing all four hos- aTC(+LR 5.41; 95%CI: 1.37–21.00). Conclu- Submission: Operations, Quality, Safety, pitals within a county, one of which was a ver- sions: Over a quarter of the children who need Systems, Disaster ified Level I trauma center which serves anine the resources of a TC are not identified in the county region of over one million people. We physiologic or anatomic steps of FTDS. The Background: Measuring and improving orga- enrolled all older adults aged 55 or older who mechanism of injury step of the FTDS does nizational safety culture has been linked to sustained an injury of any severity and were not include over a quarter of the mechanisms positive safety outcomes in EMS, yet few eval- transported by EMS. Research staff adminis- experienced by children transported by EMS uation tools exist for this unique setting. The tered a standardized interview-based survey for injury. Use of the mechanism step does not Agency for Healthcare Research and Quality’s with the patient’s EMS provider. FTDS criteria appear to greatly enhance identification of chil- (AHRQ) Surveys on Patient Safety Culture was used as the gold standard to assess pat- dren who need a TC. More work is needed to (SOPS) are widely used to assess safety culture terns of destination decisions and adherence to improve the identification of children who a in various healthcare settings and results are protocol. We used descriptive statistics to char- need the resources of a TC. included in a national comparative database acterize the study sample and used chi-square to allow for benchmarking; however, there tests to assess factors that influenced destina- is no SOPS instrument specific for EMS. Our tion decisions and agreement between EMS Poster Presentation objective was to evaluate the psychometric decisions and the FTDS. Proportions were used properties of an EMS-adapted tool based on to quantify reasons for under- and over-triage. Abstracts (31–206) existing SOPS domains. We hypothesized that Results: Data from 4,295 patients were ana- the reliability and validity of the EMS tool lyzed. The median age was 75 years and 59% would be similar to existing SOPS instruments. were female. Using the FDTS as a gold standard 31. Appropriate Needle Length for Methods: We developed and cognitively tested for destination decisions, 1,584 patients (43.8%) Emergent Pediatric Needle Thoracostomy a 37-item instrument adapting 10 domains from were over-triaged and 285 (42.0%) were under- Utilizing Computed Tomography the SOPS instruments and one new domain triaged. There were only 2 patients (2%) who Maria Mandt, Kathleen Adelgais, Kari Hayes, capturing the unique EMS aspect of communi- met the mechanism of injury criteria who were Fred Severyn, Children’s Hospital Colorado cation while enroute to a call. We administered under-triaged, compared to 154 (41.1%) and 141 Category of Submission: Pediatric an electronic survey to all 332,584 nationally- (47.2%) who met the physiologic and anatomic certified EMS professionals. Analysis inclusion criteria who were under-triaged, respectively. Background: Needle thoracostomy is a life- criteria consisted of EMTs or higher practicing Of those who were over-triaged to the trauma saving procedure. Advanced Trauma Life in non-military settings. We evaluated domain center, the most frequently cited reason by Support guidelines recommend insertion of structure using confirmatory factor analysis EMS was patient request (60.5%). Of those who a 5 cm, 14-gauge needle for pneumothorax NAEMSP 2018 ANNUAL MEETING ABSTRACTS 109

decompression. High-risk complications can had a change in pad position (anterior-anterior So Yeon Kong, Sang Do Shin, Kyoung Jun arise if utilizing an inappropriate needle size. to anterior-posterior) after 3 or more consecu- Song, Tae Han Kim, Gwan Jin Park, Depart- No study exists evaluating appropriate needle tive shocks. Termination of rVF was defined as ment of Emergency Medicine, Seoul National length in pediatric patients. Utilizing com- the absence of VF after a vector change or stan- University Hospital Category of Submission: puted tomography (CT), we determined the dard defibrillation during the next rhythm anal- Cardiac needle length required to access the pleural ysis. Results: There were 372 OOHCA, with 25 cavity in children matched to BroselowTM (6.7%) patients meeting our definition of rVF. Of Background: It was reported most bystander Pediatric Emergency Tape color. Methods: these, 16 (64.0%) patients (median age 62 years, CPR does not meet high quality CPR criteria, Three investigators reviewed chest CTs of 81.3% male) had vector change after a median strongly implying an urgent need for new children < 13 years of age obtained between (IQR) of 3 (3.0–4.0) paramedic defibrillation strategies to assist in the delivery of quality 2010–2015. Patient exclusions included those attempts. Median (IQR) time to vector change bystander CPR. The aim of this randomized with a chest wall mass, muscle disease, pectus defibrillation was 8.8 (7.1–11.1) minutes. Eight trial was to assess the effectiveness of instruc- deformity, anasarca, prior open thoracotomy, (50%) patients had termination of rVF after the tor’s real-time, objective feedback during CPR inadequate imaging, or missing height docu- first vector change shock, 6 (37.5%) had prehos- training compared to a conventional feedback mentation. We established four groups based pital return of spontaneous circulation (ROSC) in terms of trainee’s CPR quality. Methods: TM and 5 (31.3%) patients survived to hospital dis- We performed a cluster randomized trial of upon Broselow color as determined by community CPR training at Nowon District recorded height. Investigators, trained by a charge. Of the 9 rVF patients who did not have vector change, median age was 63 years and Health Center in Seoul. CPR training classes pediatric board-certified radiologist, obtained were randomized into either intervention standardized CT measurements of chest wall 88.9% were male. The median (IQR) number of defibrillations within this group was 5 (4.5– (instructor’s objective real-time feedback thickness at four points: right/left second based on Laerdal QCPR Classroom) or control intercostal space at the midclavicular line 7.0). All patients remained in VF after the fourth defibrillation. Prehospital ROSC was achieved (conventional feedback) group. Laerdal QCPR (ICS-MCL) and right/left fourth intercostal Classroom software is a real-time feedback space in the anterior axillary line (ICS-AAL). in 3 (33.3%) patients. Three patients (33.3%) survived to hospital discharge. Conclusions: device, which monitors quality of real-time Our outcome was the median chest wall thick- CPR performances of multiple trainees simulta- ness and interquartile ranges (IQR) for each This is preliminary evidence that vector change defibrillation in patients with rVF may result neously. During each training session, trainees Broselow grouping and anatomic site. Results: performed a total of five CPR. The primary To date, 225 chest CTs have been reviewed. in VF termination. A randomized controlled trial is warranted to test whether or not vector outcome was the total score, which is an Median patient age was 5 years and 52.4% were overall measure of chest compression quality. male. Children measuring Broselow Gray/Pink change has a role in the termination of rVF. < Generalized linear mixed models were used ( 68 cm), had a median chest wall thickness 33. Benchmarking EMS Compass Stroke to analyze the outcome data from baseline to at the right ICS-MCL of 1.5 cm (IQR 1.3 cm, Performance Measures Using a Large fifth CPR session, accounting for both cluster- 1.9 cm), left ICS-MCL 1.6 cm (IQR 1.5 cm, 2 cm), National Dataset and individual-level covariates. Results:A right ICS-AAL 1.7 cm (IQR 1.5 cm, 1.9 cm), left total of 77 training sessions (1,894 trainees) ICS-AAL 1.6 cm (IQR 1.4 cm, 2.2 cm). Children Jeffrey Jarvis, Dustin Barton, Lauren Sager, were randomized into 37 intervention (996 measuring Broselow Red/Purple (68.1–90 cm): Nick Nudell, Williamson County EMS trainees) and 40 control (898 trainees) groups. right ICS-MCL 1.8 cm (IQR 1.5 cm, 1.9 cm), left Category of Submission: Operations, At baseline, both groups had equal overall CPR ICS-MCL 2 cm (IQR 1.7 cm, 2.1 cm), right ICS- Quality, Safety, Systems, Disaster quality scores (78 in both groups). During the AAL 1.8 cm (IQR 1.6 cm, 2.2 cm), left ICS-AAL course of the training, QCPR feedback signif- Background: Prehospital stroke alerts have 1.6 cm (IQR 1.3 cm, 2 cm). Children measuring icantly increased trainees’ overall quality of been promoted as a means of facilitating rapid Broselow Yellow/White (90.1–115 cm): right CPR performance compared with conventional ED treatment of acute strokes. These alerts are ICS-MCL 2.1 cm (IQR 1.5 cm, 2.3 cm), left feedback (p < 0.01). In terms of changes from dependent upon the performance of validated ICS-MCL 1.9 cm (IQR 1.6 cm, 2.3 cm), right ICS- baseline to last session, trainees in the interven- stroke screening tools and assessment of blood AAL 1.8 cm (IQR 1.7 cm, 2.1 cm), left ICS-AAL tion group demonstrated significant improve- glucose to eliminate a common stroke mimic. 1.7 cm (IQR 1.5 cm, 2.1 cm). Children measur- ments on overall quality of CPR compared with > EMS Compass has identified several perfor- ing Broselow Blue/Orange/Green ( 115.1 cm): those in the control group (QCPR feedback mance measures on this topic. No work has right ICS-MCL 2.4 cm (IQR 2.1 cm, 2.9 cm), = 11.64 (95% CI 9.75–13.53) ; Conventional been done to calculate a national performance left ICS-MCL 2.4 cm (IQR 2.1 cm, 2.9 cm), feedback = 6.96 (5.16–8.76); p < 0.001). A sta- benchmark for these measures. These bench- right ICS-AAL 2.1 cm (IQR 1.7 cm, 2.9 cm), tistically significant difference between the two marks would be useful in system improvement left ICS-AAL 2.1 cm (IQR 1.6 cm, 2.9 cm). groups was observed for change in compres- efforts. We sought to describe national perfor- Conclusions: Median chest wall thickness sion depth from baseline to fifth CPR session < mance on these measures for the first time. varies little by height or location in children with a mean change of 4.51 mm in the interven- Methods: Using anonymous data from 9-4-1 13 years of age. The standard 5-cm needle is tion group and 2.72 mm in the control group (p consenting agencies in a large commercial EMS twice the chest wall thickness of most children. < 0.001). Conclusions: Considering the rate of electronic health record (ESO Solutions), we chest compression, we did not observe a statis- identified records of patients felt to have acute 32. Descriptive Analysis of Defibrillation tically significant different between two groups strokes who were transported from the scene Vector Change for Prehospital (p = 0.06). In this prospective randomize of a 9-1-1 call. From these records, we calcu- Refractory Ventricular Fibrillation trial, instructor’s objective real-time feedback lated the proportion of all patients who had a resulted in improved overall CPR quality. Matthew Davis, Andrew Schappert, Jay stroke screen and blood glucose documented. Loosley, Kristine VanAarsen,Shelley McLeod, For each of these measures, we also calculated 35. Confirming the Safety and Feasibility Sheldon Cheskes, Department of Medicine, Divi- the 95% confidence interval. Results: Over a 6 of a Bundled Resuscitation Technique sion of Emergency Medicine, Western University 1/2-year periods, we identified 168,854 patients Involving a Head-Up/Torso-Up Category of Submission: Cardiac with 9-1-1 calls who had an impression of acute Mechanical Chest Compression Technique stroke. Of these, 88,751 patients or 52.6% (52.3– for Cardiopulmonary Resuscitation Background: Patients in ventricular fibrilla- 52.8%) had a stroke scale documented. Addi- tion (VF) who do not respond to standard tionally, 140,294 patients, or 83.1% (82.9–83.3%) Paul Pepe, Kenneth Scheppke, Peter Antevy, Advanced Cardiac Life Support treatments are had a blood glucose documented. Conclusions: Daniel Millstone, Charles Coyle, Craig Pru- deemed to be in refractory VF (rVF). The ideal In this study, we calculate the first national sansky, Sebastian Garay, Johanna Moore, Uni- prehospital treatment for patients with rVF benchmarks of two important clinical perfor- versity of Texas Southwestern Medical Center remains unknown. Double sequential external mance measures on stroke care described by Category of Submission: Operations, Qual- defibrillation (DSED) has been proposed asa EMS Compass. Importantly,there was poor per- ity, Safety, Systems, Disaster viable option for patients in rVF. Although the formance of stroke screens with only 52.6% mechanism by which DSED terminates rVF of all 9-1-1 calls for stroke having them doc- Background: Strategies to lower intracranial remains unknown, one theory is that the change umented. At 83.1%, agencies performed bet- pressure (ICP) and improve cerebral/systemic in defibrillation vector that occurs may con- ter with blood glucose documentation. These perfusion during CPR have become a recent tribute. Our objective was to describe clinical results provide initial benchmarks and provide focus for resuscitation researchers. One experi- outcomes for patients presenting in rVF dur- a starting point for improvement of both the mental method to lower ICP has been to elevate ing out-of-hospital cardiac arrest (OOHCA) for measures, documentation systems, and clinical the head/chest during CPR combined with the those who underwent vector change defibril- performance. use of devices to enhance venous return to the lation, compared to those who received stan- thorax. The purpose of this study was to evalu- dard treatment. Methods: This was a retro- 34. Effect of Instructor’s Real-Time ate both the safety and clinical feasibility of such spective chart review of adult (ࣙ18 years) Feedback During Layperson a bundled technique that includes mechani- patients presenting in rVF during OOHCA over Cardiopulmonary Resuscitation Training cal CPR devices used at an angle. Methods: 15 months beginning in March 2016. Patients on Quality of Cpr Performances: A The EMS system catchment (pop. 1.4 million) who underwent vector change defibrillation Prospective Cluster Randomized Trial is geographically expansive with broad ethnic 110 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

diversity, extremes of age and socioeconomics tions but effective EZ-IO insertion could still be Background: The purpose of this study was and low frequency of bystander CPR. Through achieved. Insertion times (25 secs SD 3.46 vs. to determine rates of prenotification in a large an established Utstein-style registry, all out- 34.38 secs SD 4.17 p = 0.0002) were statistically urban setting among patients suspected by EMS of-hospital cardiac arrest (OOHCA) cases (all longer with wearing CBRN PPE. However, of having had an acute stroke and to deter- rhythms) were followed over 3.5 years (Jan- focus group discussion stated that it would mine factors associated with appropriate preno- uary 1, 2014 through June 30, 2017; n =2,285). take significantly longer to achieve intravenous tification. Methods: This was a retrospective EMS crews were previously using the Lucas© (IV) access and that IO was an effective and cohort study of all patients with a discharge device and impedance threshold device (ITD), faster option compared to IV during a CBRN diagnosis of CVA, TIA or intracranial hemor- but, after April 1, 2015, they also: (1) applied O2 incident. Conclusions: Intraosseous access can rhage who arrived by EMS between January 1 while deferring positive-pressure ventilation be effectively and promptly achieved while and December 31, 2015 at three urban hospitals. and ITD application several minutes; (2) raised wearing CBRN PPE. IO access took an addi- Patients transferred from another acute care the backboard ∼20° (head/torso-up) following tional 9.4 seconds while wearing CBRN PPE facility were excluded. “Get with the Guide- ITD application; and (3) solidified a pit-crew which can provide fast and efficient vascular lines” data was matched to data from the pre- approach for device application. With neuro- access during a CBRN incident. hospital care reports. Appropriate prehospital intact discharge data not available until 2015, notification was defined by any reference inthe “short-term” survival (sustained resuscitation EMS narrative or hospital record to advanced 37. Reprioritization of 9-1-1 Emergency by EMS to hospital admission) was used for notification of the patient’s arrival. Logistic Medical Calls Using Historical Clinical consistent comparisons. Quarterly reports were regressions were used to determine factors that Data run to identify any periodic variations or incre- may have been important for EMS prenotifica- mental effects during protocol transition (in Veer Vithalani, Sabrina Vlk, Steven Davis, tion and whether prenotification was associated Quarter 2, 2015). Results: There were no com- Neal Richmond, Office of the ; with higher rates of tPA administration. Analy- plications/difficulties in using the head/torso- MedStar Mobile Healthcare Category of Submis- sis was done using the R-statistical computing = up position (n 1,319). Of 806 consecutive sion: Operations, Quality, Safety, Systems, software. Results: During the study period, 379 OOHCA cases attended between January 1, Disaster patients presented via EMS; 126 arrived within 2014 and March 31, 2015, quarterly (all-rhythm) 3.5 hours of their last known normal (LKN). survival rates remained constant (mean 17.87%, Background: Emergency Medical Services EMS suspected a CVA in 107 (85%). Prenotifi- range 15–20%) but rose steadily during the (EMS) systems often utilize a structured cation was given in 52 of 107 instances (49%). transition period with an ensuing sustained approach to 9-1-1 call-taking and emergency Shorter EMS LKN times were associated with doubling (35.18%; range 30–40%) for the next medical dispatch (EMD). One such system, increased rates of prenotification (p < 0.01). two years (July 1, 2015 through June 30, 2017). Medical Priority Dispatch System (MPDS), Prenotification was more likely in patients with Outcomes improved across subgroups while categorizes 9-1-1 calls into EMD codes based on higher NIHSS (p = 0.01). For the elements of response intervals, indications for initiating problem and severity, with response priorities the Cincinnati Prehospital Stroke Scale (CPSS), CPR and bystander CPR rates were unchanged. and resources determined at the local level prenotification was 24% higher in patients with EMS resuscitation rates in 2016 and 2017 were through a predetermined response matrix. slurred speech (p = 0.01), 24% higher with arm found to be proportional to neuro-intact dis- In this study, we propose a methodology for drift (p = 0.01), and 20% higher with facial charge. Conclusions: The head-up/torso-up utilizing historical clinical data to increase the droop (p = 0.04). In a multivariate logistic CPR bundle was not only feasible, but was asso- accuracy of 9-1-1 call prioritization of patients regression including the three components of ciated with an immediate, steady rise in EMS with time-sensitive critical illness. The primary the CPSS, slurred speech was the most influ- resuscitation rates during the transition phase objective is to increase the number of patients ential factor for prenotification (p = 0.09), fol- with a subsequent sustained doubling of sur- with time-sensitive critical illness who receive lowed by arm drift (p = 0.14), and facial droop vival chances, making a compelling case that the highest-priority response (“Priority 1”). (p = 0.56). With appropriate prenotification, this bundled technique may improve OOHCA The secondary objective is to decrease the there was a 17% increase in likelihood of receiv- outcomes in future clinical trials. number of Priority 1 responses to patients ing tPA (p = 0.06). Conclusions:Prehospital who do not have time-sensitive critical illness. providers are not consistently providing preno- 36. Intraosseous Access Use in Chemical, Methods: All 9-1-1 calls-for-service in a large tification. In our cohort, EMS prenotified theED Biological, Radiation, and Nuclear EMS system, between December 1, 2015 and in patients with more severe and recent onset Personal Protective Equipment Tim November 30, 2016, were included. Electronic symptoms. Similar to other studies showing Collins, Clinical & Medical Affairs, Teleflex patient care reports (ePCRs) were analyzed improved time interval metrics with prenotifi- Medical Category of Submission: for time-sensitive critical illness, including any cation, our study suggests that prenotification Operations, Quality, Safety, Systems, patients in cardiac or respiratory arrest or who was associated with higher rates of tPA admin- Disaster required airway management or electrical ther- istration. There may be a benefit to dedicating apy (pacing, cardioversion, or defibrillation). resources toward EMS education on the role of Background: To determine comparisons of The percentage of calls with time-sensitive prenotification in the stroke chain of survival. success rates and ease-of-use ratings in achiev- critical illness was calculated for each of the ing intraosseous access in both wearing and 382 EMD codes in the MPDS. In our proposed non-wearing of Chemical, Biological, Radia- 39. Interaction Effects of Communities response matrix, any codes which had at least and Advanced Airway Management on tion and Nuclear (CBRN) personal protective 1% of patients with time-sensitive critical illness equipment (PPE) in a cadaver model. Methods: Survival after Out-of-Hospital Cardiac were assigned a theoretical Priority 1 response. Arrest; Multi-Level Analysis Using a cross over design, eight experienced Results: Out of a total of 119,287 actual calls-for- paramedics inserted an intraosseous (IO) service, 30,123 (25.2%) were assigned a Priority Dongsun Choi, So Yeon Kong, Tae Han device (Arrow EZ-IO©) into a cadaver spec- 1 response through the current response matrix; Kim, Jeong Ho Park, Kyoung Jun Song, imen wearing their standard prehospital 1,205 (4%) of these patients had time-sensitive Young Sun Ro, Ki Ok Ahn, Sang Do Shin, clothing. The sample then crossed over and critical illness. Utilizing our proposed method- Seoul National University Hospital, Department of applied CBRN PPE and repeated IO insertions. ology, these same calls-for-service would have Emergency Medicine Category of Submission: IO insertion times were recorded and assessed resulted in 25,441 (21.3%) Priority 1 responses, Cardiac for clinical accuracy both before and after cross including 1,333 (5.2%) patients with time- over with wearing CBRN PPE. Data collection sensitive critical illness. The net result would Background: Chest compression and adequate involved the sample completing a confidential have been an overall 15.5% decrease in Priority ventilation are essential for oxygen delivery in questionnaire assessing self-perceived ease- 1 responses, and a 10.6% increase in Priority 1 out-of-hospital cardiac arrest (OHCA) patients. of-use scores for IO access measured in Likert responses to patients with time-sensitive criti- The association between prehospital advanced scales (0–10). Qualitative data was captured cal illness. Conclusions: Historical clinical data airway management (AAM) and survival out- following structured focus group interviews. may be used to increase the accuracy of call comes was inconsistent. We hypothesized that Results: The results found no statistical differ- prioritization of patients with time-sensitive differences in the application of prehospital ence between ease-of-use scores for IO access critical illness, while simultaneously increas- AAM between regions due to medical resource between wearing or non-wearing CBRN PPE. ing operational efficiency and 9-1-1 resource would have an effect on the effectiveness of No difference in determining land marking for utilization. the AAM. The aim of this study was to inves- IO insertion (M 9 vs. 8.75 p = 0.726), humeral tigate whether the effect of prehospital AAM site insertion (M 9.13 vs. 8.75 p = 0.593), 38. Kink in the Stroke Chain of Survival: Is on outcomes between regional EMS systems of administration of IO saline flush (M 9.25 vs. EMS Appropriately Prenotifying the ED of four Asian cities. Methods: We used a PAROS 8.75 p = 0.405), holding and manipulating Suspected Strokes? (Pan-asia resuscitation outcome study) registry. driver (9.13 vs. 8.75 p = 0.593), and trocar We identified patients with OHCA of pre- removal (9.25 vs. 8.75 p = 0.405). The mean Jeffrey Nusbaum, Nachiketa Gupta, Alec sumed cardiac etiology who were resuscitated ease-of-use scores were found to be lower in Glucksman, Michael Redlener, Kevin Munjal, by emergency medical services in four Asian CBRN group but not significant, focus group Mount Sinai Hospital Category of Submission: cities between 2012 and 2014. OHCA patients discussions stated that PPE had some restric- Student, Resident, Fellow were witnessed by EMS personnel and age NAEMSP 2018 ANNUAL MEETING ABSTRACTS 111

under 18 years were excluded. The main expo- coaching with real-time mannequin feedback their experience with paramedic palliative sup- sure variables were AAM. The primary end- led to significant improvements in measures of port at home. Methods: The perspective of point was survival discharge and neurologic CPR quality in teams of EMS providers. families/patients registered in a provincial pal- recovery. We compared outcomes between the liative care registry in Nova Scotia and PEI AAM and non-AAM groups using multivari- 41. Influence of Patient Race on was gathered in a mixed methods approach able logistic regression with an interaction term Administration of Analgesia by Student from June 1, 2016 to August 31, 2016. Upon between AAM and four Asian cities (Osaka, Paramedics enrollment in the program, a survey was Seoul, Singapore, and Taipei), after adjusting for mailed. Six months after an episode of care Bill Lord, Sahaj Khalsa, University of the potential confounders. Results: Among 27,375 (allowing for grieving time) a semi-structured Sunshine Coast Category of Submission: patients, 16,510 patients were included in the telephone interview using a validated guide Professional final analyses. Survival discharge and neuro- was conducted. Overall satisfaction was mea- logic recovery was better in the non-AAM Background: Disparities in healthcare are asso- sured using a 5-point Likert scale. Respon- group (8.7% vs. 5.1%, 4.9% vs. 2.0%) than in ciated with factors that include social status, dent characteristics are reported descriptively. the AAM group (adjusted odds ratio [aOR] 0.58 age and race or ethnicity, with evidence show- Open ended-questions were analyzed by the- [95% confidence interval (CI)0.59–0.68]). In the ing African American individuals receive fewer matic content analysis. Results: A total of interaction model for the survival discharge, the procedures and poorer-quality medical care 225 registration surveys were distributed, 67 aORs for AAM of Osaka and Singapore was 0.43 than white individuals. Disparities in the man- (30%) were returned. Of those, 49 (73%) were (95% CI 0.35–0.52) and 0.31 (0.17–0.58), respec- agement of pain have been shown to be associ- completed by the family. For the interviews, tively. In the interaction model of Seoul and ated with race. However, there is limited data families were contact sequentially (8 declined, Taipei, the association between AAM and sur- regarding the influence of race on analgesia 22 disconnected telephones, 32 unanswered vival to discharge were statistically insignifi- provided by paramedics. As such, this study calls with two call attempts). Eighteen fam- cant (aOR 0.99 ; 95% CI 0.75–1.30) and aOR aims to investigate associations between patient ilies completed the interview. Three themes 1.04; 95% CI 0.69,1.55, respectively) . The sim- race and student paramedic management of emerged from the pre-encounter survey: regis- ilar results showed for neurologic recovery. pain, using a null hypothesis of no difference. tering meant fulfilling loved one’s care wishes, Conclusions: Regional EMS system modified Methods: This retrospective cohort study used providing peace of mind, and feeling prepared the effect of AAM on outcomes for patients with a contiguous dataset of all student paramedic for emergencies. Post-encounter, 14/18 fam- OHCA. records entered in the FISDAP Skill Tracker ilies rated the care received as “excellent,” database between January 1, 2014 to Decem- and all indicated that symptoms were helped. 40. Rapid Cycle Deliberate Practice and ber 31, 2015. Cases were extracted if aged 16 Seven families indicated that without the pro- Coaching of Specific Interventions to 100 years, the patient was alert and the gram, they would have had to be in hos- Improves Cardiopulmonary Resuscitation primary or secondary impression was trauma pital. Five themes emerged: 24/7 availability, Quality Measures in Teams of EMS (abdominal, chest, extremity, neck-back, multi) professionalism of paramedics, compassion of Providers or burns. Head injury was excluded as this paramedics, relief of symptoms, and a plea for is a contraindication to analgesia in some set- program continuation. Thematic saturation was Christopher Berry, Pamela Humphrey, tings. The primary outcome of interest was reached with minimal divergence of comments. Anthony Halupa, Stephen Taylor, Jarrett the interaction between patient race and stu- Conclusions: The model of paramedics provid- Shugars, Douglas Kupas, Geisinger Health dent paramedic administration of any analge- ing palliative support in the home resulted in System Category of Submission: Cardiac sia for cases meeting inclusion criteria. Sec- high patient/family satisfaction; registering in the program, prior to any call for assistance, Background: High-quality cardiopulmonary ondary outcomes of interest were associations provides peace of mind and a feeling of being resuscitation (CPR) skills are paramount for between age and gender and analgesia admin- prepared. Families particularly note the value good survival from cardiac arrest, but previous istration. The adjusted logged odds of patients of 24/7 availability, success in relief of symp- studies have suggested that CPR quality is often receiving any analgesic was tested with bino- toms, and the degree of compassion and profes- poor. The purpose of this study was to eval- mial logistic regression using a stepped mod- sionalism of paramedics. uate changes in the quality of EMS provider elling approach. Results: A total of 59,962 cases CPR skills using rapid cycle deliberate prac- were available for analysis; median age was 43. Amplitude Spectrum Area Changes tice (RCDP) of specific teaching interventions 50 years (IQR 39 years), 50.2% were female = during Cardiopulmonary Resuscitation with real-time feedback. Methods: A record- (n 30,077). The most common cause of trauma = after Different Durations of Untreated ing mannequin, with feedback blinded from was fall, representing 50% (n 26,053) of cases. Cardiac Arrest in a Porcine Model of participants, was used to evaluate CPR qual- 14.1% of patients received any analgesia (n = Ventricular Fibrillation with a ity metrics on 3- or 4-person teams of EMS 8,425). Caucasian patients have significantly Concurrent Acute Myocardial Infarction providers. All participants were certified EMS higher logged odds of receiving analgesia than non-Caucasian patients (p < 0.001). When anal- providers who also had previous CPR educa- Giuseppe Ristagno, Francesca Fumagalli, gesic administration is adjusted for age cate- tion and certification. CPR quality metrics were Weilun Quan, Giovanni Babini, Roberto gory and gender, African Americans have the assessed, before and after educational inter- Latini, Yongqin Li, IRCCS–Istituto di Ricerche lowest logged odds of receiving any analge- ventions, using a 5-minute resuscitation case Farmacologiche Mario Negri, Milan, Italy simulating adult cardiac arrest with ventricu- sia when compared to Caucasian patients (OR < Category of Submission: Cardiac lar fibrillation. The intervention included using 0.65, p 0.001). Conclusions: The results indi- coaching and RCDP to teach techniques of palm cate inequality in the provision of analgesia by Background: Amplitude spectrum area lift, two-person two-thumbs-up bag-mask ven- student paramedics based on patient race. This (AMSA) is a predictor of successful defib- tilation, upstroke ventilation during continuous suggests a need for education that addresses rillation (DF). In this study, we investigated compressions, and chest compressions during cognitive and affective biases that can affect the effect of high quality cardiopulmonary defibrillator charging. CPR metrics included: clinical judgements, and EMS audit of cases to resuscitation (CPR) on AMSA in relationship compression fraction, compression rate, per- identify disparities in care based on race. with the duration of untreated ventricular centage of compressions with full depth and fibrillation (VF) in a preclinical porcine model 42. Paramedics Providing Palliative Care full recoil, percentage of compressions between with a concurrent acute myocardial infarction. at Home: Patient and Family Satisfaction 100–120 per minute, ventilation rate, percentage Methods: An established model of myocardial of ventilation of adequate volume, and length Alix Carter, Judah Goldstein, Marianne Arab, infarction followed by VF and CPR was used. of longest pause. Outcomes were compared Michelle Harrison, Barbara Stewart, Mireille Forty-four pigs were subjected to different VF = through Paired Samples t-tests using bias- Lecours, Carolyn Villard, James Sullivan, durations: 8–10 minutes (short), n 14; 12 min- = corrected bootstrapping, resampling 1000 times Dalhousie University Category of Submis- utes (intermediate), n 21; and 13–15 minutes = with 95% confidence intervals. Results:The sion: Operations, Quality, Safety, Systems, (long), n 9. Continuous mechanical CPR sample consisted of 67 providers divided into Disaster (Lucas, PhysioControl) with ventilation with 18 teams. There were significant improvements oxygen and epinephrine administration (1 mg for the following metrics of CPR quality when Background: Paramedic crisis and symptom at 2 minutes of CPR) was performed for 5 min- comparing the pre- and post- intervention management for patients receiving palliative utes prior to a 150 J DF attempt. AMSA and measures: percentage of compressions between care with the goal to treat in place repre- changes in AMSA during CPR (dAMSA), in 100–120 per minute (39.5% vs. 78.5%; p = .001, sents a novel approach to care. A new clini- relationship with the duration of untreated ȵ2 = 0.60), compression fraction (78.8 vs. 92.3; cal practice guideline, additional medications, VF, coronary perfusion pressure (CPP), and p = .006, ȵ2 = 0.52), percentage with full recoil and a training program Learning Essentials epinephrine administration were evaluated. (52.7% vs. 85.6%; p = .001, ȵ2 = 0.60), percent- Approach to Palliative Care (LEAP) Mini for Results: Overall AMSA decreased from 13.7 age with adequate ventilation volume (38.5% Paramedics were implemented in two provin- ± 0.8 mVHz to 6.5 ± 1.7 mVHz during the vs. 57.4%; p = .002, ȵ2 = 0.55), and longest pause cial EMS systems. Our objective was to deter- 15 minutes VF (dAMSA −7.2 ± 2.5 mVHz, p < in compressions (16.6 sec vs. 6.2 sec; p = .004, mine the impact of this new model of care 0.01), while it increased to 17 ± 1.2 mVHz after ȵ2 = 0.48). Conclusions: The use of RCDP and on patient/family satisfaction and to describe 5 minutes of CPR (dAMSA 10.5 ± 3.5 mVHz, 112 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

p < 0.01) independently of the duration of well described, there is a paucity of evidence Category of Submission: Student, Resident, untreated VF (dAMSA: 10.7 ± 1.7, 11.3 ± 1.5, for optimal prehospital EBG implementation Fellow and 14.7 ± 1.5 mVHz, for short, intermediate, methods. For scientific advances to reach and long VF duration, respectively, p = NS). prehospital patients, future prospective studies Background: Mass gathering events (MGEs) AMSA during CPR was significantly correlated should compare implementation methodolo- challenge medical directors and emergency with CPP (r = 0.46, p < 0.01). AMSA increased gies in different prehospital contexts. EBG medical services (EMS) agencies with pro- significantly during the first 2 minutes ofCPR, projects should publish reproducible imple- viding appropriate and sufficient medical as compared to the subsequent 2 minutes mentation methods, with “lessons learned” resources. This study aimed to examine EMS after epinephrine (dAMSA 6.2 ± 0.8 vs. 3.6 ± compiled in an easily accessible repository. resource utilization during MGEs at a medium- 0.6 mVHz, p < 0.01). Interestingly, dAMSA Funding priorities should include implemen- sized urban university with a collegiate-based improved similarly in the 3 VF duration groups tation research to ensure the efforts of EBG basic life support (BLS) agency, and how during the first 2 minutes of CPR, but after development translate into practice. such utilization may be associated with spe- epinephrine the magnitude of dAMSA con- cific attributes of these events. Methods:All emergency medical dispatches for the studied tinued to increase only when the duration 45. Are There Disparities in Dispatch CPR ࣙ on-campus EMS agency during MGEs were of untreated VF was 13 minutes, while it Instruction Receipt and CPR included for analysis in this retrospective study, decreased for shorter durations. Conclusions: Performance? High quality CPR allowed for AMSA increases covering MGEs from January 1, 2012 through independently of the duration of untreated VF. Amanda Amen, Patrick Karabon, Brian September 1, 2016. This collegiate-based agency However, epinephrine administration further McNally, Cherie Bartram, Kevin Irwin, Kim- is the sole provider of medical standby details improved dAMSA only in the instance of berly Vellano, Robert Swor, Oakland University at its university. Environmental factors such as longer durations of VF, while it seemed to have William Beaumont School of Medicine Category temperature, location (indoor vs outdoor), esti- a detrimental effect for a shorter duration. of Submission: Student, Resident, Fellow mated event size, and event type were analyzed for each MGE based on data from standby duty 44. Prehospital Evidence-Based Gudieline Background: Dispatch-assisted cardiopul- logs and the National Weather Service. Linear Implementation Methodology: A monary resuscitation (DA-CPR) has been regression, logistic regression and bivariate cor- Systematic Literature Review shown to improve rates of bystander CPR relations were used to determine correlational (BCPR), which enhances survival in Out of relationships between environmental factors Jennifer Fishe, Remle Crowe, Rebecca Hospital Cardiac Arrest (OHCA). Our objec- and patients-per-event presentation rates (PPR) Cash, Nikiah Nudell, Christian Martin-Gill, tives are to evaluate whether there are racial to EMS during these events. Results: No calls Christopher Richards, University of Florida and socioeconomic disparities in the receipt for service occurred for any events with less COM Jacksonville, Department of Emergency of DA-CPR instructions and subsequent CPR than 500 attendees, while at least 1 call for ser- Medicine Category of Submission: Opera- performance. Methods: We performed a retro- vice occurred at 6.1% of events with 500–1000 tions, Quality, Safety, Systems, Disaster spective review of the Cardiac Arrest Registry attendees and at 24.5% of events with over to Enhance Survival (CARES) dispatch registry 1000 in attendance. Neither heat nor humidity Background: As prehospital research advances, from January 2014 to December 2016. Data was found to be significant predictors of PPR, evidence-based guidelines (EBGs) are increas- was collected from a convenience sample of with p-values of 0.72 and 0.65, respectively. ingly implemented into EMS practice. How- dispatch agency supervisor audits of 9-1-1 However, in the subset of events that attracted ever, incomplete EBG implementation may OHCA audio recordings in one state. Elements more than 1,000 people and were outdoor non- hinder improvement in prehospital patient out- related to dispatcher CPR instruction, and sporting events, the linear regression of PPR comes. To inform future EBG efforts, this study barriers to bystander CPR performance were and temperature had a Pearson’s Correlation reviews and summarizes existing evidence recorded. Demographics including patient race Coefficient of 0.983 and a p-value of 0.017. pertaining to prehospital EBG implementation (white, black or other) and Utstein data were Outdoor non-sporting events, as compared to methodologies. Methods: This study is a sys- captured from the parent CARES database. indoor non-sporting events, had an increased tematic literature review followed by the Grad- These data were merged with census tract likelihood of calls for service (OR 4.4, p = ing of Recommendations, Assessment, Devel- data regarding socioeconomic status (SES) 0.18). Outdoor sporting events, as compared to opment, and Evaluation (GRADE) method- of each incident location. The effects of race indoor sporting events, were also more likely ology. PubMed®, EMBASE®,Scopus®,and and SES were analyzed to determine their to have requests for EMS (OR 6.1, p = 0.005). Google Advanced SearchTM were searched association with two outcome variables: caller Conclusions: This study highlights that without language or publication date filters receipt of DA-CPR instructions and subsequent environmental features such as estimated for articles addressing prehospital EBG imple- performance of CPR. Multivariate logistic crowd size, location, event type, and outdoor mentation. Conference proceedings, textbooks, regression analysis was performed. Results: temperature can possibly be used to predict non-English articles, and articles that did not We identified 1,872 cases from 23 dispatch EMS resource utilization at MGEs. University address prehospital EBG implementation were agencies that had dispatch, Utstein, and census administrators, event organizers, and EMS excluded. GRADE was applied to remaining tract data. The population was predominantly agencies can potentially prepare medical plans articles independently by three of five mem- white (70.0%), male (66.0%), with an average for such mass gatherings by pre-assessing these bers of the Prehospital Guidelines Consortium age of 63.5 +/−18.7. DA-CPR instructions were event attributes. Research Committee. Variations in ratings were more commonly associated with an incident resolved by consensus. Study characteristics that occurred in a private residence (ORadj 47. Simple Feedback Form Improves Quality and salient findings are reported. Results:The 3.8, 95% CI (2.5–5.8)) or in highest income of Out-of-Hospital CPR systematic literature review produced 1,375 quartile census tracts [ORadj: 1.65; 95% CI Ben Weston, Jamie Jasti, Melissa Mena, articles, with 41 meeting inclusion criteria. Most (1.01–2.72)]. Older patient age [ORadj: 0.99; Jackson Unteriner, Kelly Tilotson, Ziyan Yin, articles described EBG implementation (N = 95% CI (0.98–0.99)] and black race [ORadj: Mario Colella, Tom Aufderheide, Medical 24, 59%), or implementation barriers (N = 13, 0.61; 95% CI (0.39–0.98)] were negatively asso- College of Wisconsin Category of Submis- 32%). Common study designs were statement ciated with receipt of DA-CPR instructions. sion: Operations, Quality, Safety, Systems, documents (N = 12, 29%), retrospective cohort Subsequent performance of CPR after DA-CPR Disaster studies (N = 12, 29%), and cross-sectional instruction was more common in witnessed = studies (N 9, 22%). Using GRADE, evidence arrests [OR 2.0, (95% CI 1.3–3.0)] and negatively Background: Despite medical advances and quality was rated low (N = 18, 44%), or very associated with black race [ORadj: 0.31; 95% CI = health awareness campaigns, the incidence of low (N 23, 56%). Salient findings included: (1) (0.16–0.58)] but not significantly different by prehospital cardiac arrest remains high while EBG adherence and patient outcomes depend socioeconomic or demographic characteristics. survival rates remain low. Excellent prehospital upon successful implementation, (2) published Conclusions: Although this preliminary study care is tantamount to survival and high quality studies generally lack detailed implementation is limited by incomplete demographic and CPR is a vital contributor to positive outcomes. methods, (3) implementation takes longer than dispatch data, we identified racial disparities A quality improvement program was recently planned (mostly for EMS education), (4) EMS in provision of DA-CPR instructions and implemented to provide simple, goal based systems’ heterogeneity affects implementation, subsequent CPR performance. These findings feedback to prehospital providers after each and (5) multiple barriers limit successful EBG varied minimally by SES or other demographic cardiac arrest resuscitation. Expanding upon implementation (e.g., financial constraints, characteristics. an earlier preliminary study, we aim to assess equipment purchasing, coordination with whether the provision to prehospital providers hospitals and regulatory agencies). The study 46. Utilization of Emergency Medical of a simple CPR feedback form led to improved found no direct evidence for best prehospital Resources at Mass Gathering Events at an quality metrics in out of hospital cardiac arrest EBG implementation practices, including Urban University with a Collegiate-Based resuscitations. Methods: This before and after comparisons of implementation methods, or Emergency Medical Services Agency retrospective review evaluated data from a of methods in different contexts (e.g., urban quality improvement program in a midsized versus rural, ALS versus BLS). Conclusions: Emma Ordway, Neil Sarna, Lindsey DeGe- urban community with BLS and ALS providers. While numerous implementation barriers are orge, Jose Nable, Georgetown University Two 9-month periods, one before and one after NAEMSP 2018 ANNUAL MEETING ABSTRACTS 113

the implementation of the form were evaluated. Background: Children make up ∼10% of all scene was 6.01 minutes (95%CI 5.24–6.78). Metrics measured included the means and rates EMS transports, often require weight-based Where the taxi arrived at scene, the average of goal achievement for compression depth, dosing, and are commonly affected by res- distance from case location to the initial loca- rate, and fraction as well as preshock pause piratory issues. A subset of the EMS Com- tion of the taxi was 763 meters (95%CI 654– time. Results: A total of 439 before encounters pass performance measures addresses pediatric 871). Taxis that were closer to the incident and 621 after encounters were evaluated includ- care, including documentation of weights, vital had a higher likelihood of arriving before the ing those of BLS and ALS providers. Overall, signs, and treatments for dyspnea. No bench- ambulance (763 meters vs. 955 meters, P-value significant differences were found in the mean marks of these measures have been done on a = 0.041). A total of 10 drivers were “Super compression depth (5.0 cm vs. 5.5 cm; p < national scale. We aim to describe these mea- Responders” as they had arrived at the scene 0.001), compression fraction (79.2% vs. 86.4%; sures using a large national cohort. Methods: three times or more. Conclusions: A voluntary p < 0.001), compression rate (109.6/min vs. Using a 6 ½ year sample of 9-4-1 EMS agencies “AEDs on Wheels” program can be an exciting 114.8/min; p < 0.001) and preshock pause time using the ESO electronic health record (EHR), feature of a public AED program (PAD). This (18.8 sec vs. 11.8 sec; p < 0.001). Additionally, we calculated compliance rates among trans- mode of mobilizing AEDs has a high likelihood improvements were noted in goal achievement ported 9-1-1 patients under 15 for the following of utilization, increases the reach of AEDs, and for compression depth (48.5% vs. 66.6%; p < measures: (1) documented weight, (2) at least improves time-to-first shock, all of which are 0.001), compression fraction (68.1% vs. 91.0%; one SpO2 and RR documented for those with important components of successful PAD. p < 0.001), and preshock pause time (24.1% vs. any respiratory illness, (3) at least one dose of a 59.5%; p < 0.001). No significant difference was beta-agonist given to those with asthma, and (4) 51. Medical Command Training for found in goal achievement of compression rate. at least one dose of beta-agonist given to those Emergency Medicine Residents: An Conclusions: We found that the introduction with asthma and an SpO2 <90%. For measures Overview of Medical Command Education, of a simple CPR feedback form to prehospital requiring administration of a medication, only Oversight, and Evaluation providers was associated with improvement in ALS providers were included. For each mea- Abagayle Renko, Nicholas Julius, Chadd prehospital CPR quality. sure, a rate and 95% Confidence Interval were Nesbit, Penn State Milton S. Hershey Medical Cen- calculated. Results: There were 524,856 patients ter Category of Submission: Student, Resi- 48. Cumulative Success of Prehospital analyzed. Of these, 287,719 [54.8% (54.7–55.0%)] dent, Fellow Advanced Airway Management in a had a documented weight. There were 43,067 National Cohort children with a respiratory impression, 37,689 Background: Training Emergency Medicine of these [87.5%, (87.2–87.8%)] had at least one Jeffrey Jarvis, Dustin Barton, Henry Wang, (EM) residents provide medical oversight as SpO2 and Respiratory Rate documented. 6,202 Williamson County EMS Category of a requirement for EM residency accreditation children had an impression of asthma and 4,336 Submission: Medical through the ACGME; yet, no standard curricu- of these [69.9% (68.8–71.1%)] received a beta- lum from which to train residents to develop Background: Repeated attempts at Advanced agonist. Of those children with an impression this essential skill exists and literature describ- Airway Management (AAM) are associated of asthma, 755 were hypoxic and 635 [84.1% ing the current state of resident medical com- with increased risk of adverse events. There (81.5–86.7%)] of them received a beta-agonist. mand training is limited. We sought to assess are few current descriptions of the number of Conclusions: These are the first benchmark the state of medical command training in EM attempts needed for success. We sought to char- data drawn from a large, national dataset residency programs. Methods: A thirty ques- acterize cumulative AAM success rates in a against the EMS Compass measures. These tion survey was created and distributed elec- national cohort of Emergency Medical Services results provide a starting point for quality tronically through email via the Research Elec- (EMS) agencies. Methods: We used 9 years of improvement efforts and suggest areas for tronic Data Capture (REDCap) program. The data from ESO Solutions, a national EMS elec- improvement in pediatric care. Only 55% of survey contained questions regarding demo- tronic health record system. We included all children had documented weights which are graphics, general facility and program descrip- encounters with attempted AAM. We examined needed for correct medication dosing and tors, medical command training procedures, the following subsets: (1) cardiac arrest intu- only 83% of hypoxic asthmatics received a personnel providing command, resident over- bation (CA-ETI), (2) medical non-arrest intu- beta-agonists. This highlights opportunities for sight, and feedback. Descriptive statistics were bation (NA-ETI), (3) rapid-sequence intuba- improvement. collected and analyzed using chi-squared tests tion (RSI), (4) sedation-assisted ETI (SAI), and for categorical variables. Results: A total of (5) some type of supraglottic airway (SGA). 50. AEDS on Wheels: A Pilot Programme to 109 surveys were completed (54.5% response Using binomial proportions with exact confi- Equip Taxis with AEDS rate), and 96 of those programs (88.1%) reported dence intervals, we determined the cumulative that their residents do receive formal medical success rates for each attempt. We also identi- Alexander White, Desmond Mao, Vernon command training. A majority of those pro- fied rates of first-pass success (FPS) and over- Kang, Marcus Ong, Singapore General Hospital grams begin medical command training dur- all success (OS), and the number of attempts Category of Submission: Cardiac ing their residents’ first (42 programs, 43.8%) needed to reach OS. Results: A total of 61,793 or second (40 programs, 41.7%) year of resi- Background: We aimed to determine the fea- patients from 552 EMS agencies underwent dency. Most programs do not have required for- sibility of improving AED utilization rates and AAM efforts, including 38,063 CA-ETI, 19,138 mal classroom-based (56 programs, 57.7%) or time-to-first-shock times by equipping taxis NA-ETI, 7,229 RSI, 3,095 SAI, and 9,993 SGA. online-based (75 programs, 77.3%) training. EM with AEDs. Methods: This is a prospective The number of AAM attempts per patient var- physicians are the primary individuals provid- observational feasibility study conducted in ied (median 1, range 1–10). CA-ETI perfor- ing training (91 programs, 93.8%). Most pro- Singapore, a densely populated Southeast mance was: FPS 71.4% (95% CI: 70.8–71.9%), grams allow their residents to begin giving Asian nation with 5.54 million people on a land 4 attempts to reach the OS threshold of 91.7% medical command in their second year of res- area of 719 square kilometres. There are 3,300 (91.4–92.1). NA-ETI performance was: FPS idency (52 programs, 54.7%). A majority of pro- licensed SMRT taxis in Singapore. 155 drivers of 66.3% (95% CI: 65.4–67.2%), 3 attempts to reach grams do not have a system in place to track the SMRT taxi company were recruited, trained the OS threshold of 80.4% (79.6–81.1%). RSI how many medical command calls their resi- and certified in CPR+AED skills. They were performance was: FPS 75.9% (95% CI: 74.9– dents take (63 programs, 66.3%), nor do they then assigned to 100 taxis equipped with AEDs 76.9%), 5 attempts to reach the OS thresh- assign dedicated medical command shifts to and displaying AED decals on taxis’ windows old of 96.3% (95.8–96.7). SAI performance was: their residents (85 programs, 89.5%). Most pro- and interior. A phone app alerted drivers to FPS 66.9% (95% CI: 65.2–68.6%), 4 attempts grams allow their residents to issue medical cardiac arrests within 1.5 km. Drivers receiving to reach OS threshold of 86.9% (85.6–88.1%). command orders without the presence of an the alert would choose to accept or decline SGA performance was: FPS 88.8% (95% CI: attending physician (62 programs, 65.3%). A to respond. Upon arrival, the drivers either 88.1–89.4%), 5 attempts to reach OS thresh- majority of programs indicated that their res- provided AED to lay bystanders on scene or old of 93.2% (92.6–93.6%). Conclusions:Inthis idents are provided feedback on their perfor- applied it themselves. If paramedics arrived at national series, first pass prehospital AAM suc- mance for their command call management the scene first, taxis would be notified to stand cess rates have improved from prior studies (83 programs, 85.6%) and most programs indi- down. Post-incident, drivers were required but are still low. Multiple attempts are com- cated that medical command calls by residents to document incident and submit AED for mon and often unsuccessful. These results may are not routinely audited (51 programs, 53.4%). check-up and maintenance. Results:From guide protocols limiting AAM attempts. Conclusions: Most EM residencies train their November 2015 to July 2017, more than 2,400 residents in providing medical command, yet activations were sent to a total of 71 drivers. 49. Benchmarking EMS Compass there is wide variation in how this is accom- A total of 24 taxi drivers accepted 192 alerts to Performance Measures Using a Large plished. Further research and analysis are mobilize. Of these mobilizations, 22 taxi drivers National Dataset: Pediatric Care required to make recommendations for a more arrived at scene of 105 potential out-of-hospital uniform system of resident command training. Jeffrey Jarvis, Dustin Barton, Lauren Sager, cardiac arrest cases prior to ambulance arrival. NIck Nudell, Williamson County EMS Cate- The mean time of activation-to-acceptance of 52. Near Misses in a Two-Tiered Suburban gory of Submission: Operations, Quality, the case was 1.17 minutes (95%CI 0.90–1.43). EMS System: A Descriptive Study on Safety, Systems, Disaster The average time of activation-to-arrival at Down-Triaged Patients Who Are Taken 114 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

Emergently to the Operating Room or and (4) likelihood of future suicidal behavior. 0.98] and 0.99(0.99–1.0)], and positive LR Admitted to Intensive Care Units In prior studies, a SBQ-R score of 7 or greater [19(17–22) and 13.6(11.6–16.0)] for ruling in has been validated as an effective predictor of sepsis, but lower sensitivity [0.34(0.33–0.36) Joslyn Joseph, Joshua Bucher, David Feldman, suicidal behavior. The SBQ-R score has pre- and 0.07(0.06–0.08)]. Comparing the qSOFA Albert Ritter, Frederick Fiesseler, Morristown viously demonstrated ability to identify indi- score recommended in the Sepsis-3 definition Medical Center Category of Submission: Oper- viduals at risk for suicide with 93% specificity to the previously recommended SIRS score, ations, Quality, Safety, Systems, Disaster and 95% sensitivity. We used Pearson’s chi- qSOFA was better for ruling in sepsis [pos- square to determine the relationship between itive LR 9.1(8.5–9.7) vs. 2.7(2.6–2.8)], while Background: A two-tiered EMS system has the suicidality and gender, age, shift-length, hours SIRS was better for ruling out sepsis [neg- advantage of incorporating volunteer, public, worked per week, years in EMS, race, practice ative LR 0.67(0.65–0.70) vs. 0.74(0.72–0.75)]. and private BLS into the system to setting, service type, family history of suicide, Conclusions: Paramedics had low rates of decrease response times and spread resources and knowing an EMS provider who commit- documented suspicion of infection in sepsis further. An ALS unit who responds to a scene ted suicide. Results: We received 289 completed patients. Paramedic screening strategies may may down-triage or “release” to BLS if no surveys analyzed less than 2 weeks after survey help to identify sepsis, but the choice of strategy ALS interventions are warranted outside of distribution. 30.8% (89) [95% confidence inter- will depend on whether the goal is to correctly BLS scope of practice to allow their unit to val (CI): 25.5–36.1%] of individuals had SBQ- rule out versus rule in these diagnoses. stay in service. To date, no studies have eval- R scores greater than or equal to 7, reflecting uated the characteristics of high-risk patients suicidality. The strongest predictors of suicidal- 55. Preliminary Impact of Adding “released” to BLS and then taken to the Oper- ity were family history of depression or suicide Follow-Up Home Visits On Call Volumes ating Room (OR) or admitted to the Intensive [OR = 3.0 (1.8–5.1)], and working in a hospital- Generated by EMS “Super-Users” Enrolled Care Unit (ICU). In order to make safer triage based service [OR = 2.0 (1.0–4.0)]. Gender, in a New Mobile Integrated Health decisions, we sought to describe this “near- age, race, practice setting, shift length, hours Protocol miss” mistriaged population of patients who worked per week, years in EMS, and know- were ultimately deemed to be critically ill by Roger Stone, Jamie Baltrotsky, Alan Butsch, ing an EMS provider who committed suicide Emergency Departments and had the poten- Ashley Robinson, Barry Reid, Montgomery were not found to be statistically significant pre- tial to decompensate quickly. Methods: Set- County MD Fire Rescue Services Category dictors of suicidality. Conclusions: High rates ting: A suburban two-tiered EMS system in of Submission: Operations, Quality, Safety, of suicidality exist within the EMS community; which ALS units evaluate approximately 14,000 Systems, Disaster however, further research on risk factors and patients per year. Patients: All patients from potential solutions needs to be conducted. 2007–2015 "released" to BLS, transported to Background: Rising EMS call volumes tax EMS an Emergency Department, and subsequently resources in many jurisdictions. A significant admitted to an ICU, Cardiac Catheterization 54. Identification of Sepsis in the contributor to volumes includes the frequent Lab, or OR. Protocol: Demographics, history Prehospital Setting: An Observational 9-1-1 callers, some of whom may return home of present illness, vital signs, GCS, disposition, Study of Paramedic Sepsis Screening from hospitals with limited resources. After final diagnosis, and interventions done prior Strategies a new partnership in 2015 between EMS and to EMS arrival and by EMS personnel were our County’s HHS agency helped facilitate extracted via chart review and 95% Confidence Daniel Lane, Ian Blanchard, Gerald services for 9-1-1 “Super-users”, our previous Intervals (CIs) calculated when appropriate. Lazarenko, Laurie Morrison, Steve Lin, study found a preliminary association with Results: Out of 17,639 patients from 2007–2015 Hannah Wunsch, Sheldon Cheskes, Refik reduced call volumes. Our agency has now who were evaluated by ALS and triaged to BLS, Saskin, Damon Scales, Institute of Health Policy, partnered with discharging hospitals to start 372 patients (2%) were mistriaged to BLS. The Management and Evaluation, University of Toronto a new home visit program under Maryland’s average age of patients was 66.4 years CI (61.0– Category of Submission: Student, Resident, new Mobile Integrated Health (MIH) Protocol 71.7) and 52% were female. The most com- Fellow beginning March 2017. We wished to establish if this additional intervention was associated mon mistriaged final diagnosis category was Background: Sepsis is a life-threatening syn- Neurological, 24% CI (23.3–24.7), followed by with a reduction of EMS call volumes from drome where earlier recognition and prompt enrollees in the protocol. Hypothesis: Initiation GI/Abdominal Emergencies 15%(14.3–15.7%). intervention is critical to improving patient Sepsis was mistriaged 10.2% CI (9.5–10.9) of of follow-up home visits by our paramedics outcomes. In modern healthcare systems, and hospital outreach nurses has an impact on the time, and 9 patients, 2.4% CI (2.3–2.6) were paramedics encounter many sepsis patients taken emergently to the Cardiac Catheteriza- EMS utilization by a selected group of enrolled first, offering an opportunity for earlier detec- 9-1-1 super-users. Methods: After our EMS- tion Lab. Conclusions: This is the first step to tion. The purpose of this study was to provide investigate this phenomenon unique to two- HHS partnership identified 9-1-1 super-users, the incidence of paramedic reported suspicion we recruited a voluntary cohort to enroll in the tiered EMS systems. From our study, we can of infection, and to compare the accuracy of conclude that more education is needed to rec- MIH program. We retrospectively measured published paramedic screening strategies for using CAD and EMS records cumulative call ognize prehospital Neurological and Abdomi- sepsis within a cohort of Emergency Medical nal/GI Emergencies to avoid near misses in the volumes for the group of new enrollees, 90, 60 Services (EMS) patients. Methods: Apreviously and 30 days before and after the home visits future. More research is also needed to deter- published systematic review that identified mine which patients, if any, had poor outcomes program started. Results: A cohort of Patients strategies for paramedic identification of sep- (N = 10) was enrolled in the MIH protocol and as a result of being mistriaged to make triage sis was updated and used as the source for protocols safer for our patients. scheduled for home visits beginning March 1, paramedic screening strategies. A one-year 2017. Cumulatively, those patients generated cohort of EMS data linked to in-hospital 53. Astounding Rates of Suicidality in EMS = 63, 53, and 30 calls during the periods 90, 60, Providers: A Hidden Epidemic administrative databases (n 131,745;89% and 30 days, respectively, prior to the home vis- linkage rate) was used for the cohort of EMS its. Thereafter, those calls decreased to 7, 8, and Al Lulla, Jyotirmoy Das, Ghady Rahhal, patients. Sepsis was identified by Emergency 18 calls for the periods of 30, 60, and 90 days, Rebecca Dougherty, Bridgette Svancarek, Department (ED) International Classification of respectively, after visits began. The change Washington University in St. Louis Category of Diseases v.10 Canadian (ICD-10CA) diagnosis yields 9-1-1 call reductions of 77%, 85%, and Submission: Student, Resident, Fellow codes, and EMS clinical information. The 71% during the post intervention three months. incidence of paramedic documented suspicion Conclusions: We believe super users in our Background: EMS providers experience severe of infection in patients diagnosed with sep- large system benefit from a coordinated pro- workplace stress, which increases their risk of sis in the ED, and the sensitivity, specificity, gram of EMS partnerships with public health suicidality. Past suicidal thoughts and attempts positive, and negative likelihood ratios (LR) agencies and hospitals. A new partnership have been established as placing individuals for each of the screening strategies, using the with Hospital Outreach and the initiation of at high risk for future suicidal behavior. We recommended score threshold as originally follow-up home visits had preliminary impacts sought to assess the severity of the problem published where applicable are reported. on call volumes generated by the enrollees over of suicidality in EMS providers and to iden- Results: Paramedics documented suspicion a 30–90 day period. More studies are needed to tify potential factors that place individuals at of infection in 350 of 2,713 [13%(95% Confi- prospectively prove value, sustainability and higher risk. Methods: We administered a 19 dence Interval) 2–14%] sepsis patients. Twelve best practices of these programs, and which item online survey to a convenience sample paramedic sepsis screening strategies were interventions during home visits make the of 16 EMS agencies and 1,688 EMS providers. identified in the literature. The PRESS, HEWS most difference. In order to assess for suicidality, the Suicide (score of > = 2), and Robson scores had the Behaviors Questionnaire Revised (SBQ-R) was highest sensitivities [0.98(0.98–0.99), 0.87(0.86– 56. Multi-Disciplinary Community Health utilized. SBQ-R assesses 4 dimensions of suici- 0.88), 0.74(0.72–0.76) respectively], and lowest Care Interventions Reduce EMS dality using a Likert scale. These 4 dimensions negative LR [0.08(0.04–0.08), 0.27(0.24–0.30), Utilization by Elders are (1) lifetime suicidal ideation and/or suicide and 0.39(0.37–0.42), respectively] for ruling out attempt, (2) frequency of suicidal ideation over sepsis. The PSP score (high risk) and Sepsis Joseph Petrosino, Jeffrey Boyd, Joanne past 12 months, (3) threat of suicide attempt, Alert strategies had high specificity [0.98(0.98– McGovern, James Dziura, Gina Stover, NAEMSP 2018 ANNUAL MEETING ABSTRACTS 115

Fangyong Li, Geliang Gan, Ryan Carter, system between January 2013 and December and fewer missed and false recordings (p = Sandy Bogucki, Department of Emergency 2016. The off-line and on-line medical con- 0.002). Delays revealed significant linear trends Medicine, Yale University School of Medicine trol databases were queried to identify all (p = 0.018 for delays in recording and p < Category of Submission: Professional patients for whom the Provider Impression 0.001 for delays in care), as increasing group was “Cardiac Arrest.” The records were indi- size corresponded with lesser delays. Greatest Background: Previous studies in a small, subur- vidually examined to determine the EtCO2 improvement was noted to be between groups ban town showed that more than half of elders readings and whether these patients received of 3 and 4 participants. Conclusions:OHCA who fall and require lift assists will activate the NaHCO3. Results: A total of 182 OHCA cases simulations using FCP demonstrate increased 9-1-1 system again within 30 days. Community- were selected which had a documented EtCO2, provider comfort, increased recording accu- based interventions involving paramedics, vis- with 93 receiving NaHCO3 and 89 not receiv- racy, and decreased delays as the group size iting nurses, and primary care providers sub- ing NaHCO3. The results were analyzed using increased. While the application may improve stantially reduced the frequency of repeat EMS a Welch’s t-test. A significant difference was recordings for PCRs and future research, the and lift assist calls. This study was designed to found in EtCO2 readings between the two data suggest a sufficient number of providers evaluate these findings across larger and more groups, with a mean EtCO2 of 26 mmHg in (>3) should be present to achieve reliable data diverse populations of elders at risk for falls. the NaHCO3 group and a mean of 19.7 mmHg without compromising patient care. Methods: For this non-randomized, prospec- in the non-NaHCO3 group, with a p-value of tive study, informed consent to follow subse- 0.026. A subgroup analysis showed that when 59. Influence of Neighborhood quent health care utilization was obtained from comparing the 50 highest EtCO2 readings, the Socioeconomic Status on Disparities in 2,265 participants residing in AMR’s regional significance was even greater, with a mean Emergency Medical Services Use and response areas. Participants chose to have no of 39.9 mmHg in the NaHCO3 group and Quality of Prehospital Care for Ischemic intervention, or the interventions that included 27.7 mmHg in the non-NaHCO3 group, with Stroke sequential home visits by a research paramedic a p-value of 0.0018. When the EtCO2 readings Timmy Li, Manish Shah, Adam Kelly, Jeremy evaluating disability and home safety, a visiting were below 20 mmHg, there was no significant Cushman, David Rich, Edwin van Wijngaar- nurse assessing for home health care require- difference. Conclusions:Therearenowidely den, Gina Lovasi, Courtney Jones, North- ments and eligibility, plus an offer of free trans- accepted guidelines for the technique of TOR in well Health Category of Submission: Student, portation for a primary care provider visit. Par- OHCA patients. The value of employing EtCO2 Resident, Fellow ticipants were enrolled during (1) an EMS call readings in TOR decisions is unclear. This study for lift assist, (2) an ED visit, or by (3) self- indicates that administering NaHCO3 during Background: A minimal amount is known referral. Subsequent EMS calls were captured OHCA will significantly elevate the EtCO2, and regarding the effect of neighborhood socioe- by matching identifiers in our study database NaHCO3 administration complicates the utility conomic status (nSES) on emergency medical with those in AMR’s call records. Outcomes of EtCO2 when levels are above 20 mmHg. Fur- services (EMS) use and quality of prehospi- compared the proportion of participants that ther study of the use of EtCO2 in TOR decisions tal stroke care. We assessed the association had at least one EMS call during the 30 or is necessary. between nSES and EMS use, decision delay 90 days following enrollment (nonintervention time, and quality of prehospital care among group), or completion of the intervention, using 58. Feasibility of Recording stroke patients. Methods: A retrospective a generalized estimating equation approach, Out-of-Hospital Cardiac Arrest cohort study was performed using the Get in SAS. Results: As of May 31, 2017, 980 Treatment Via Use of a Mobile With The Guidelines-Stroke registry at two non-intervention group participants completed Smartphone Application hospitals to identify patients with a hospital >30 days of follow up, and 652 completed diagnosis of ischemic stroke between 2012 and >90 days, vs. 1,285 intervention group partic- Samuel Sondheim, Joseph Devlin, William 2016. Registry data were merged with data ipants completing > 30 days, and 980 com- Seward IV, Aaron Bernard, Richard Feinn, from EMS medical records and the United pleting >90 days. At 30 days, the intervention David Cone, Frank H. Netter MD School of States Census Bureau. Patient addresses were group showed a 51% reduction, and at 90 days, Medicine, Quinnipiac University Category of geocoded and a one-kilometer buffer was cre- a 38% reduction in the proportion of partici- Submission: Student, Resident, Fellow ated around each patient’s address to represent pants with at least one EMS response (both p their neighborhood. Census data from each < 0.001), compared with nonintervention. ED Background: Given the demanding nature of buffer were used to create a composite nSES enrollees benefitted most, with a 45% reduction out-of-hospital cardiac arrest (OHCA) resus- score, which was categorized into quartiles. in EMS utilization at 30 days (p < 0.001), and citations, recordings of the times of interven- Multivariable log-binomial regression models a 25% reduction at 90 days (p = 0.009). Con- tions in EMS patient care reports (PCRs) are assessed the associations between nSES and 1) clusions: This study demonstrates short-term often inaccurate. The American Heart Associ- EMS use, and 2) decision delay time to calling effectiveness of our multidisciplinary commu- ation developed Full Code Pro (FCP), a smart- 9-1-1. Among EMS patients, we also assessed nity health care interventions at reducing EMS phone application designed to assist providers associations between nSES and (1) dispatched utilization by the elderly. ED enrollees, by our in recording the timing of interventions per- EMS level of care, (2) EMS response time, (3) metrics the group that was most disabled at formed. Through OHCAsimulations, this study EMS on-scene time, (4) Cincinnati Prehospital baseline, appeared to benefit the most from the assessed the group size necessary to use the Stroke Scale (CPSS) assessment, and (5) hospi- interventions. FCP recording functions accurately and safely tal prenotification by EMS. Results: Of 1,472 without compromising patient care. Program patients, 48% were aged 50–74 years, 50% were 57. Effect of Sodium Bicarbonate evaluation was based on participant feedback female, 73% were white, and 59% used EMS. Administration During Out-of-Hospital surveys, data accuracy, delays between record- Compared with patients in the highest nSES Cardiac Arrests on End-Tidal CO2 ing and performing interventions, and delays in quartile, patients in the lowest nSES quartile Readings in Considering Termination of care attributed to using the application, strat- were 20% less likely to use EMS (risk ratio (RR): Resuscitation ified by group size. Methods: Simulations of 0.80; 95% confidence interval (CI): 0.67, 0.95). a standard OHCA scenario using the Gau- Brandon Morshedi, Alysha Joseph, Ray EMS providers performed the CPSS on 65% mard TraumaHal mannequin and a dedicated Fowler, University of Texas – Southwestern of patients. Patients of lower nSES were less iPhone 5 pre-loaded with FCP version 3.4 were Category of Submission: Cardiac likely to have a CPSS performed: risk ratios, run with group sizes of 2–6 participants, with compared with the highest nSES quartile, were group sizes determined by participant avail- Background: The administration of sodium 1.72 (95% CI: 1.14, 2.60), 2.91 (95% CI: 2.00, ability. Participants included Connecticut certi- bicarbonate (NaHCO3) during out-of-hospital 4.21), and 3.39 (95% CI: 2.30, 4.99) for nSES fied paramedics and paramedic students who cardiac arrests (OHCA) has been shown to pro- quartiles 2, 3, and 4 (lowest nSES), respectively. had completed the respective coursework. A duce increased end-tidal capnography (EtCO2) nSES was not significantly associated with seven-item feedback survey using a Likert scale during resuscitations. Traditionally, EMS sys- other outcomes. Conclusions: Among a sam- established participant feedback on the applica- tems may authorize termination of resusci- ple of ischemic stroke patients, 41% did not tion. Videos of the simulations were analyzed to tation (TOR) efforts after prolonged periods use EMS and those of lower nSES used EMS < assess for delays. One-way ANOVA with trend where the EtCO2 remains 10 mmHg. How- more frequently. EMS providers performed the analysis was used to test if outcomes differed ever, if NaHCO3 has been administered, the CPSS assessment less frequently on patients of by group size and if differences tended in one EtCO2 may be elevated, possibly resulting in lower nSES. Understanding reasons for these direction in parallel with group size. Results: prolonged resuscitation efforts. The purpose observations is vital to improving the quality There were 37 simulations including 142 partic- of this study was to determine the effects of of prehospital stroke care. the administration of NaHCO3 during OHCA ipants. The feedback survey questions achieved on EtCO2. We hypothesized that there would a Cronbach’s alpha of 0.91 signifying high reli- 60. Paramedic Recognition of Paroxysmal be no observable difference in EtCO2 readings ability, and demonstrated a linear trend sup- Supraventricular Tachycardia between OHCA TOR patients who received porting greater satisfaction with FCP as group < NaHCO3 and those who did not. Methods: size increases (p 0.001). Similarly, increasing Spencer Sample, Colleen Shortt, Erich Hanel, A retrospective analysis was performed on all group size displayed linear trends with greater Michelle Welsford, Michael G. DeGroote School = OHCA TOR patients in a large, urban EMS numbers of interventions recorded (p 0.009) of Medicine, McMaster University, Hamilton, 116 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

Ontario Category of Submission: Student, computer automated dispatch (CAD) system All prehospital data were obtained from the Resident, Fellow was used to identify all cases from 2011–2015. EMS electronic health record; hospital out- The TEMS and EMS records for cases meeting comes were obtained from receiving hospitals. Background: Paroxysmal supraventricular inclusion criteria were extracted. Demograph- Results: Of 444 eligible OHCAs, 227 received tachycardia (PSVT) is a common group of ics, injury description, prehospital index (PHI) mechanical and 217 received traditional CPR. arrhythmias that Advanced Care Paramedics scores, disposition, and interventions were Crude ROSC (29.1% vs. 39.2%) and survival (ACPs) can often manage with vagal maneu- collected. Hospital disposition and outcome to discharge (5.7% vs. 13.8%) were lower with vers, adenosine, and/or cardioversion, pro- data were linked using the regional trauma mechanical CPR, but mechanical CPR cases vided that they correctly identify the rhythm. registry. Using gender, injury year/type, age, were also less likely to be witnessed arrests The purpose of this study is to determine and ISS a case-match controlled comparison and less likely to present with a shockable the accuracy of ACP identification of PSVT. between EMS and TEMS records (2:1) was rhythm. In the propensity score analysis of 187 Methods: Following ethics approval, all calls conducted. Chi-square (or Fisher’s Exact) test patients with mechanical CPR well-matched to ࣙ with patients 18 years with a 12-lead ECG for categorical and t-test (or Wilcoxon) for 187 patients with traditional CPR, both ROSC available, who were assessed by ACPs within continuous variables. Results: Of the 122,707 (29.2% vs. 39.5%; difference: −10.3%; CI: −0.7% a region of western Ontario between July 2015 CAD events, only 2243 met inclusion criteria. to −19.9%) and survival to discharge (7.0% vs. and December 2015 and had a documented Seventy TEMS records and 140 EMS case 14.1%; difference: −7.1%; CI: −0.9% to −13.1%) > heart rate 150 bpm, were included. Paramedic matched controls were included. Majority were remained significantly lower for patients receiv- call reports were retrospectively reviewed for male (90%) civilians (99%) with a median age ing mechanical CPR. Conclusions:InanEMS study data, including documentation of ACP of 31. Sixty percent of patients were injured system with optimized deployment, mechani- identified PSVT. The reference standard was secondary to a shooting, 30% stabbing, and cal CPR was associated with decreased ROSC consensus between a fellow and prehospital 10% assault. Moderate to severe bleeding was and decreased survival to discharge. physician who adjudicated each ECG for the encountered in 75% of patients, and 46% sus- presence of PSVT in a blinded, independent tained major trauma (PHI ࣙ 4). TEMS providers 63. Gender Disparities in the Prehospital fashion. In the event of a disagreement, a had a shorter response time compared to EMS Setting among Known St-Segment third, blinded prehospital physician was used providers; 6 vs. 13 minutes, p < 0.0001. Cohorts Elevation Myocardial Infarction Patients for consensus. Results: Of the 442 patients had similar PHI scores and intervention per- Krystal Baciak, Stephen Sanko, Marc Eck- included, 197 (45%) were male and the median formance rates. Final hospital disposition and stein, University Of Southern California-Los Ange- age [Interquartile range(IQR)] was 70.0 years hospital resource utilization were comparable. les County And Los Angeles (58.0–82.8). ACPs identified 74 (16.7%) patients Both had similar number of ventilator, ICU, Category of Submission: Student, Resident, as having PSVT. Of these, 48.5% had a his- and hospital days. There was no difference Fellow tory of previous arrhythmia, compared to in mortality rates. Conclusions:Inthisstudy, 31.9% of patients with no ACP identified TEMS providers exhibited shorter response Background: Identification of a ST elevation PSVT (p = 0.026). They were also significantly times and performed medical interventions at myocardial infarction (STEMI) in the prehospi- younger [median(IQR) = 63.0 (47.0–72.0)] similar rates to traditional EMS. Although no tal setting has been shown to decrease door-to- compared to those without ACP identified differences in patient outcomes were noted, balloon time and mortality. Up to 20% of STEMI PSVT [median(IQR) = 72.0 (61.0–85.0)] (P < all patients who died prior to hospital arrival patients do not present with typical symptoms 0.0001). Sensitivity of ACP identified PSVT were excluded. Future studies are needed to and gender disparities exist in the prehospi- was 97.3% (95%CI:85.8–99.9%) and specificity determine how response time impacts the rate tal setting in the assessment of patients ulti- was 90.6% (95%CI:87.3–93.3%). The positive of preventable death. mately found to have ACS. Our hypothesis is predictive value (PV) of ACP identified PSVT women are more likely to have delayed STEMI was 48.6% (95%CI:41.1–56.3%), the negative care than men. Methods: This is a retrospective PV was 99.7% (95%CI:98.1–99.9%), the positive 62. Optimizing Deployment of Mechanical cohort study of 9-1-1 patients who were trans- likelihood ratio (LR) was 10.4 and the negative CPR Does Not Improve OHCA Outcomes ported by a single large urban EMS provider LR was 0.03. Moderate inter-rater agreement When Compared with Manual CPR to STEMI-Receiving Centers (SRC) from Jan- was seen between initial ECG interpretations Brandon Oyler, Louis Gonzales, Jeff Hayes, uary 2011 to December 2015 and were diag- [387 (87.6%)] (kappa = 0.42, 95%CI:0.29–0.54) Mark Escott, Jose Cabanas, Paul Hinchey, nosed with a STEMI, had emergent PCI, and by the fellow and prehospital physician, while Lawrence Brown, Dell Medical School at the were found to have a culprit coronary artery agreement was higher (good) between the University of Texas Category of Submission: obstruction. Our primary outcome was EKG- two prehospital physicians [49/55 (89.1%) Cardiac to-balloon time (E2B). Our exclusion criteria (kappa = 0.70, 95%CI:0.48–0.92)]. Conclusions: were: interfacility transfer, age under 18, inabil- These results indicate that ACPs are adept Background: Deploying mechanical CPR in ity to calculate E2B, and missing gender data. at identifying PSVT, but are prone to false out-of-hospital cardiac arrest (OHCA) is logisti- Our secondary outcomes were: time intervals positives. Given the relatively good sensitivity cally challenging. Inefficient deployment might from 9-1-1-call through device time. Results: and specificity seen in this investigation, future explain reports of unfavorable OHCAoutcomes Of the 2,778 patients eligible for analysis, 2,148 studies should investigate ACP recognition of associated with mechanical CPR. We hypoth- patients were included in final analysis after specific rare arrhythmias (antidromic accel- esized that in an EMS system with optimized application of the exclusion criteria. Women erated atrial fibrillation) that may require deployment, sustained ROSC and survival to had longer on-scene times, longer times from different management including avoidance of hospital discharge will not differ for OHCA 9-1-1-call to arrival at the SRC, time from first adenosine. patients managed with and without mechani- medical contact (FMC) to balloon, and time cal CPR. Methods: In 2015, we initiated a qual- < 61. Police Department Tactical Medicine from 9-1-1 call to EKG (P 0.001). Time from ity improvement process to choreograph and first medical contact to cath lab arrival was (TACMED) Program Impact on Trauma optimize deployment of mechanical CPR. All Patient Mortality: Review of a Large longer in women, but did not reach statisti- primary first response agency (attending ±75% < Urban EMS and TACMED System cal significance (P 0.002) using a very con- of OHCAs) field personnel attended in-person servative Bonferroni-corrected p-value. There Elliot Ross, David Wampler, Avery Kester, training and practical exercises emphasizing were no statistically significant differences in Xandria Gutierrez, Crystal Perez, Lauren high quality traditional CPR, timely defibril- whether or not a prehospital EKG was per- Reeves, Alejandra Mora, Joseph Maddry, lation, airway management / ventilatory sup- formed or transmitted, whether a prehospi- Craig Manifold, San Antonio Uniformed Services port and first-round medication administration tal EKG indicating STEMI was noted, whether Health Education Consortium Category of before initiating mechanical CPR. We then ana- or not aspirin was given, transport time, time Submission: Student, Resident, Fellow lyzed all adult, non-traumatic OHCA attended from EKG to cath lab arrival, EKG-to-balloon by the first response agency during 2016. Dur- or door-to-balloon (p > .001). Conclusions:Our Background: Tactical Emergency Medical ing the study period, mechanical CPR devices study demonstrates women are more likely to Services (TEMS) is a growing subspecialty of were deployed on some—but not all—first have delayed times from 9-1-1-call to hospital prehospital care. Tactical providers are ideally response units; use of mechanical CPR was arrival, FMC to balloon, and time from 9-1-1 call suited to provide care at the point of injury in based primarily on availability and/or whether to EKG, but do not have a delayed E2B or door- areas traditional EMS cannot enter. A minimal patients achieved ROSC after initial resusci- to-balloon time. Limitations include short trans- amount is currently known regarding the tation attempts. We therefore used propensity port times, a single urban EMS service, and the clinical impact of these programs. This study score matching to select cases with and with- retrospective nature of the study. examines patient outcomes of those treated by a out mechanical CPR that had similar patient Police based TEMS system vs. traditional EMS. demographics and arrest characteristics. We 64. Statewide Retrospective Analysis on Methods: Study inclusion criteria consisted of excluded OHCAs with sustained ROSC follow- the Characteristics of EMS Refusals of trauma patients where police were dispatched ing only CPR or defibrillation without medica- Care and EMS was staged and were then transferred tion administration, terminations of resuscita- to a Level I trauma hospital. All patients that tion without meaningful resuscitation attempts Novneet Sahu, Patrick Matthews, Ross died at the scene or enroute were excluded. The (including DNRs), and EMS-witnessed arrests. Megargel, Rutgers University–New Jersey NAEMSP 2018 ANNUAL MEETING ABSTRACTS 117

Medical School Category of Submission: measure was the frequency of use of POCUS the optimal method for inter hospital transfer Student, Resident, Fellow during OHCA. Secondarily, we characterized of critical patients. image quality by expert (ultrasound fellowship Background: Improving EMS systems of care trained) faculty review (using kappa statistic 67. Patient Preferences toward Emergency requires a better understanding of out-of- for agreement), and identified barriers to the Medical System Provider Attire hospital refusals of care. There is a paucity of use of prehospital POCUS. Results:From Jesse Olsen, Jeffrey Lubin, Khaled Iskan- data on EMS refusals of care. Studies over the November, 2016 to March, 2017, 348 physician darani, Penn State College of Medicine Category past three decades have shown widely vary- field responses were reviewed, including of Submission: Operations, Quality, Safety, ing results on the characteristics, demograph- 127 cases of OHCA, and 56 (44%) cases with Systems, Disaster ics, and rates of EMS refusals of care. The pur- POCUS performed. Still or video images were pose of this study is to analyze, at the state level, recorded in 48 (86%) cases and video in 34 Background: In a health-care landscape driven the characteristics, demographics, and rates of (61%) cases. From video images, agreement in by patient satisfaction and quality assurance, EMS refusals of care to provide a platform identifying cardiac motion between prehospital preferences towards provider attire has become for identifying targets to help improve EMS physician and expert reviewer occurred in 91% a topic of interest. Uniforms afford essential systems of care. Methods: Delaware statewide = of cases (K 0.82). Reasons cited for not using visual clues for personnel identification; recent EMS data for all refusals and transports were POCUS included return of circulation soon research demonstrates attire impacts patient queried for the calendar year of 2016. Age, gen- or before arrival, prioritizing interventions, preferences for both nurses and physicians in der, dispatch reason, time of year, and location provider preference, not having the ultrasound emergency settings. In emergency medical sys- were aggregated and retrospectively analyzed device, mechanical failure, and cessation of tems, teams rely on trust for effective and suc- through descriptive statistics and multi-variate resuscitation per advanced directives. Conclu- cessful responses. In the context of EMS person- logistic regression. Results: Of the 155,303 EMS sions: Use of POCUS by novice prehospital nel, no studies have addressed patient percep- incidents, 12,244 (7.9%) resulted in refusals of physician ultrasonophraphers to detect wall tion of attire. This prospective study addresses care. Patients 65 years and older had a smaller motion in OHCA is feasible and correlates how EMS attire influences patient perception percentage of refusals than adults 18–64 years with expert interpretation. Several avoidable of care through five different variables: like- old and children <18 years old (6.4% vs. 8.8% barriers to the use of prehospital POCUS may ability, trust, confidence, willingness to confide, vs. 10%, p < 0.001). Men had a greater refusal be addressed through additional educational and intelligence. Methods: Over six weeks in rate than women (8.5% vs. 7.3%, p < 0.001). interventions and increased familiarity with the the Emergency Room at Penn State Hershey, Diabetes-related problems (36.2%) and motor device. 165 surveys were completed evaluating a team vehicle accidents (28.5%) resulted in the high- of two EMS providers. Participants surveyed est rates of refusal of care (p < 0.001). The high- 66. Air Versus Ground Transfer to viewed one of three two-minute videos of an est percentage of overall refusals occurred dur- Comprehensive Stroke Center in Patients EMS team responding to a patient with chest ing mid-summer (8.8%, p < 0.001). Locations with Large Vessel Occlusion Stroke pain. In each video EMS personnel wore a dis- of care which include places of recreation and tinct outfit: a blue tee shirt, a white button-up bodies of water had the highest refusal rates Ali Shams, Chris Kanaan, Rebbeca shirt or turnout gear. Participants subsequently (45.6% p < 0.001). Conclusions:Inthispopu- Grysiewicz, Chris Kazmierczak, Laura completed a six question survey addressing lation, geriatric patients had lower refusal pro- Steucher, Robert Swor, Beaumont Health providers on a 5-point Likert scale. Attires portions; whereas, prior studies suggested that Category of Submission: Student, Resident, were compared using a two tailed Kruskal- geriatric refusal numbers are greater than other Fellow Wallis test, a non-parametric equivalent of an age groups. The greater refusal rate among Background: Optimal treatment ischemic ANOVA. Results: Of 165 surveys completed, men is consistent with previous literature. Prior stroke caused by a large vessel occlusion (LVO) 87.5% of responders rated EMS attire as impor- studies have shown the highest rates of refusals involves timely transfer from a primary stroke tant. No differences in responses were found for motor vehicle accidents and other trauma, center to a comprehensive stroke center (CSC) related to patient age, gender or ethnicity. Anal- however, diabetes-related problems comprised that can offer mechanical endovascular therapy. ysis of the likert data, showed no significant the highest percentage of refusals in this popu- Transfers are either done via air or ground, differences with respect to perceived provider lation. Mid-summer time of year and places of however data have not shown a clear benefit trust, smartness, likeability or confidence. How- recreation also comprised high percentages of of one method of transfer over the other. The ever, participants answered significantly lower refusals and further investigation is necessary objective of this study was to compare air vs on the Likert scale for willingness to discuss to identify root causes of these patterns. ground transfer times from decision to transfer confidential information with the providers in to definitive care in patients with LVO strokes the turnout gear compared to the other two transferred to a single CSC. Methods:This attires at an alpha of .0057. Conclusions:Based 65. Feasibility of Point-of-Care is a cohort study of patients transferred to a on our results, EMS provider attire does not Ultrasound (Pocus) in Out-of-Hospital single suburban CSC (January 2015–December impact patient perceived quality of care. Lower Cardiac Arrest (OHCA) by Novice 2016) from seven primary stroke centers within responses were found for turnout attire, possi- Ultrasonographers a 15-mile radius with the diagnosis of LVO bly from a lack of association of EMS providers James Fitzgibbon, Emily Lovallo, Marek stroke. Key time intervals including transport with fire gear. Studies drawing a larger sample, Radomski, Jeremiah Escajeda, Christian time, time from decision to transfer (access and those that analyze more outfits or aspects Martin-Gill, Department of Emergency Medicine, to sending hospital EMR allowed characteri- of provider appearance would lend support to University of Pittsburgh School of Medicine zation of this time point), and time intervals this conclusion. Our study was small, limited Category of Submission: Cardiac from arrival to first ED to interventional skin by length of the videos, and number of outfits puncture (access) and reperfusion at the CSC tested but our results conclude attire as a minor Background: Point-of-care ultrasound were recorded. Non-parametric statistics were factor in EMS responses. (POCUS) may be a useful tool to predict used for comparisons. Median and range are survival and guide interventions in out-of- reported. Results: There were 30 inter-hospital 68. Multivariable Analysis of Factors hospital cardiac arrest (OHCA), yet a paucity of transfers from within a 15-mile radius. Of these Associated with EMS Non-transports data exists on its prehospital use by users with 16 were by air and 14 were ground transfers. Rickquel Tripp, Jonathan Elmer, Francis limited ultrasound experience. We aimed to Air transport times were significantly shorter Guyette, Christian Martin-Gill, Department determine the feasibility of using POCUS dur- (16.5 vs. 30.0 minutes, p = 0.013). There was of Emergency Medicine, University of Pittsburgh ing OHCA by resident and fellow physicians no difference between transfer decision-CSC School of Medicine Category of Submission: staffing a 24/7 prehospital response vehicle ED arrival between air and ground (65.5 vs. Operations, Quality, Safety, Systems, and identify barriers to its use. Methods:We 67.5 minutes, p = 0.967, respectively). In Disaster deployed a portable ultrasound device (iViz, by hospital processes for air and ground transfer Sonosite) for use by prehospital physicians for patients at the CSC were shorter but not signif- Background: Emergency response without OHCA in an urban EMS system. All physicians icantly so, CSC door-table (2.5 minutes vs. 16.5, transport confers a risk of negative patient out- = received POCUS education as part of graduate p 0.44) and CSC door to access (28.0 vs. 40.5, comes, increased liability, and non-payment. = training, and were provided an instructional p . 44). Time interval for air and ground trans- Yet, few rigorous studies have identified risk video on use of the iViz device. POCUS use fer were not different for arrival to 1st ED to factors for non-transports. We aimed to identify = was limited to identifying cardiac motion access (155.5 vs.172, p 0.118 or arrival - reper- demographic and clinical characteristics pre- = during pulse checks, without interrupting fusion (208.5 vs. 211, p 0.495). Conclusions: dictive of non-transports using a large database resuscitation, and the results could be used In our small pilot study, despite shorter trans- of out-of-hospital EMS responses. Methods:We to guide management at the physicians’ dis- port times, there was no significant difference retrospectively reviewed consecutive patient cretion. Data were recorded prospectively by between air and ground transfer from decision care records from 21 urban, suburban, and rural saving video and still images on the device and to transfer to CSC arrival, or time from first EMS agencies in Western Pennsylvania from through a custom electronic form within the hospital to access or reperfusion. Assessment April 2013 to December 2016. We identified patient care report (emsCharts). The primary of unmeasured intervals are needed to assess age, gender, race, ethnicity, level of transport, 118 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

last vital signs (BP, RR, HR, SPO2, and GCS), thus, 155 comprised the study cohort. Median ter understand the reasons behind candidate loss of consciousness (LOC), abnormal mental age was 61 years; 71% male. Hypotension retesting including personal and educational status (AMS), medical category, and time occurred in 10 (14%) with inferior STEMI and experiences. of day. We excluded cases of cardiac arrest, 3 (4%) with other STEMI, RR 1.13 (95%CI 1.00, interfacility/scheduled transports, EMS assist, 1.23) p = 0.04. Hypotension was mild; one 71. Interfacility Transport of the no patient encountered, and patients aged patient with inferior STEMI arrived with SBP Pregnant Patient: A 5-Year Retrospective <18 years or unknown age. For non-transports, <90 mmHg due to cardiac arrest. Inter-rater Review of a Single Academic Center Based we described the incidence of protocol-defined reliability was excellent, kappa 0.93 (95% CI Critical Care Transport Program abnormal vital signs (HR <50, >100; SBP <100, 0.80, 1.0). Mean decrease in SBP was −15 ± >200; DBP <50, >100; RR <12, >24; SpO2 23 mmHg and −10 ± 22 mmHg in inferior and Philip Nawrocki, Asa Margolis, Shawn Brast, <95; GCS <15), LOC, and AMS. We used other STEMI, respectively, median difference in Matt Levy, Johns Hopkins Lifeline Category of unadjusted and adjusted logistic regression the decrease in SBP −4.5 mmHg (95% CI −12.0, Submission: Student, Resident, Fellow to identify independent predictors of non- 3.0). Compared to patients treated with PCI transport. Results: We identified 385,908 cases in any other location, hypotension after NTG Background: Interfacility transport of pregnant meeting study criteria, with 35,266 (9.1%) non- among patients with proximal or mid RCA patients involves unique challenges and con- transports. Patient characteristics were: median lesions was similar, RR 1.0 (95%CI 0.9, 1.1) p = siderations. Data from the National Emergency age 59 years (IQR 41–77), 55.6% female, 16.8% 0.6. Conclusions: When compared with other Medical Services Information System (NEM- Black, 0.7% Hispanic, and 96.3% advanced life STEMI patients, those with inferior STEMI had SIS) dataset indicate that 0.6% of all EMS support (ALS). Incidence of abnormal vitals a slightly higher risk of mild hypotension after transports and 0.6% of interfacility transports were HR (N = 4435, 12.6%), SBP (N = 539, field NTG; RCA lesion location was not associ- involve pregnant patients. Limited informa- 1.5%), DBP (N = 1324, 3.8%), RR (N = 159, ated with an increased risk. tion exists surrounding the safety and adverse 0.5%), SpO2 (N = 1543, 4.4%), and GCS (N = events of this patient population in the out- 834, 2.4%). There were 785 (2.2%) with LOC 70. Characteristics of Emergency Medical of-hospital setting. This study aimed to exam- and 2031 (5.8%) with AMS. In adjusted mul- Technician Graduates Unsuccessful on ine clinically significant adverse events that tivariable analysis, we identified associations the National Certification Cognitive occur during the interfacility transport of preg- (OR, 95%CI) with non-transports and male Examination nant patients. Methods: A retrospective review gender (1.08, 1.00–1.16); ALS (1.60, 1.04–2.47); of quality assurance data was performed. The Rebecca Cash, Remle Crowe, Madison and morning [6:00–11:59] hours (0.79, 0.70– study population consisted of pregnant patients Rivard, Ashley Larrimore, William Krebs, 0.88) and evening [18:00–23:59] hours (1.07, transported to the labor and delivery units of Jeremy Miller, Ashish Panchal, National Reg- 1.03–1.11), compared to overnight [0:00–5:59] two hospitals within an academic quaternary- istry of Emergency Medical Technicians Category hours. Medical categories most associated with care hospital system between January 2012 and of Submission: Operations, Quality, Safety non-transports were trauma (2.37, 1.79–3.14), December 2016. Primary outcomes (adverse Systems, Disaster, Disaster dizziness/syncope (1.80, CI 1.47–2.20), and events) were defined as: hypotension, respira- allergic reaction (OR 1.54, CI 1.33–1.79). Race, tory distress, exacerbation of hypertensive dis- Background: Research on EMT student perfor- ease of pregnancy (preeclampsia, eclampsia), ethnicity, LOC, and AMS were not associ- mance has focused on pass rates and character- ated with the incidence of non-transports. need for vasoactive medications, dysrhythmia, istics related to success. Conversely, a minimal intubation or unintended extubation, change Conclusions: Patients not transported by EMS amount is known regarding EMT graduates often have abnormal heart rate and are asso- in mental status, need for restraints, cardiac who were unsuccessful at passing the examina- arrest or death, and delivery during transport. ciated with complaints of trauma, dizziness/ tion. The objective of this study was to describe syncope, or allergic reaction. This information Use of online medical direction and reason for demographics and test-related performance of consultation were secondary outcomes of inter- can guide patient refusal protocols and future graduates unsuccessful on the computer adap- research on outcomes of these at-risk patients. est. Results: Our critical care transport system tive National EMT Certification examination. performed 30,181 total interfacility transports We hypothesized that the majority of candi- 69. Among Stemi Patients, Is Inferior ST within the five year study period. 709 patients dates who are unsuccessful on the examina- Elevation Associated with a Higher (2.4%) met inclusion criteria. Clinically signif- tion are close to the passing standard (max- Frequency of Hypotension after Field icant adverse events occurred during 32/709 imum length testers) and would be likely to Nitroglycerin? patient transports (4.5%). The most frequent retest. Methods: National EMT Certification events were: exacerbation of hypertensive dis- Nichole Bosson, Jayson Morgan, Benjamin cognitive examination results for graduates of ease requiring intervention (25), hypotension Isakson, Amy Kaji, Atilla Uner, Katherine non-military EMT education programs from the (4), and altered mental status (2). There were Hurley, Timothy Henry, Marianne Gausche- class of 2013 were analyzed as a cross-sectional zero instances of cardiac arrest, death, or deliv- Hill, James Niemann, LA County EMS Agency evaluation. The computer adaptive test termi- ery. Conclusions: Interfacility transport of preg- Category of Submission: Cardiac nates when the 95% confidence interval sur- nant patients is a common occurrence that rounding the estimate of the candidate’s ability involves unique challenges and risks. Within Background: Patients with inferior STEMI is entirely above or below the passing standard. the experience of this critical care transport pro- involving the right ventricle are believed to be Test length ranged from 70 to 120 questions. gram, significant adverse events were identi- at higher risk for hypotension after nitroglyc- Unsuccessful testers were defined as candidates fied in 4.5% of transported patients over a5- erin (NTG). The objective of this study was who had a grade of fail or incomplete (did year period. This data will help guide the train- to determine if inferior STEMI is associated not finish the examination) on their first exam- ing of prehospital providers and the formation with increased risk of hypotension upon ED ination attempt. Chi-square tests were used to of protocols to mitigate and respond to these arrival in patients treated with NTG by EMS. compare demographics of candidates and to events. Notable limitations include the use of Methods: Consecutive adult patients with sus- assess for differences in retesting between min- data from a single system, absence of scene pected STEMI transported by EMS to one of imum and maximum length testers. Results:A transports, and use of paramedic/nurse crew three participating PCI-capable hospitals were total of 59,560 EMT graduates from the class configuration. prospectively identified and maintained ina of 2013 attempted the National EMT Certifica- log during an 18-month period. Investigators tion cognitive examination and 33% (n = 19,899) reviewed records for initial field and ED vital were unsuccessful the first attempt. The pro- 72. Advanced Provider Response Unit signs, field NTG treatment, and hospital out- portion of males and females who were unsuc- (APRU), an Answer to Low-Acuity 9-1-1 comes. Inter-rater reliability was assessed on cessful did not differ (males: 34%, n = 12,642; Calls? = = a random 10% sample of records using the females: 33%, n 6,187, p 0.05). More than Saman Kashani, Stephen Sanko, Marc kappa statistic. Patients with a hospital diagno- one-third of unsuccessful candidates received Eckstein, USC Keck School of Medicine, Dept of sis of STEMI treated with NTG were included. the maximum number of questions (36%, n = = Emergency Medicine, Los Angeles Fire Department Patients with hypotension on EMS arrival were 7,128) while 40% (n 7,985) received the min- Category of Submission: Student, Resident, excluded. Inferior STEMI was defined as ST- imum number of questions. Of those unsuc- Fellow elevations in the inferior leads on the prehos- cessful on the first attempt, 66% (n = 13,111) pital ECG. The frequency of ED hypotension, attempted a second examination. More maxi- Background: The Los Angeles Fire Depart- defined as a triage SBP less than 100 mmHg, in mum length testers attempted a second exam- ment (LAFD) has experienced an unsustainable patients with inferior STEMI was compared to ination compared to minimum length testers increase in 9-1-1 calls. Over the past 2 years, patients with other STEMI. Patients were fur- (72%, n = 5,156 vs. 60%, n = 4,763, p < 0.001). call volume rose by 14%; vastly higher than the ther stratified by lesion location. The frequency Conclusions: Two-thirds of first-time candi- historical rate of increase of 1–2%. To address of hypotension was compared with Fisher’s dates unsuccessful on the National EMT Certi- the increasing call volume, while still pro- exact test and change in SBP with Hodges- fication cognitive examination attempted a sec- viding care for the citizens of Los Angeles, Lehmann’s median difference. Results: Of 239 ond examination. A greater proportion of those the LAFD launched the Advanced Provider patients with STEMI, 46 were excluded for ini- close to the passing standard (maximum length Response Unit (APRU), a specialized ambu- tial hypotension and 38 did not receive NTG; testers) retested. Future work is needed to bet- lance staffed by a licensed advanced practice NAEMSP 2018 ANNUAL MEETING ABSTRACTS 119

provider (APP) and a /paramedic 89.3%, respectively. Among each component Hundt, George Lindbeck, Karen Johnston, with the mission of treating and releasing of criteria, altered mentality showed highest University of Virginia School of Medicine Cate- patients on scene and providing linkage to sensitivity and AUC for mortality, which was gory of Submission: Medical further care. This is a description of the first 89.2% (95% CI 87.4 to 91.0) and 0.699 (95%CI 19 months of service. Methods: This was a ret- 0.687 to 0.711). Amputation and chest wall Background: We conducted this study to iden- rospective review of LAFD electronic health instability in anatomic criteria showed highest tify differences between patients arriving by records from January 2016 to August 2017 in the specificity for mortality, 99.8% (95%CI 99.6% EMS versus those arriving by private vehicle Los Angeles area. The APRU was active 4 days to 99.9%). Altered mentality showed highest with acute ischemic and hemorrhagic stroke. a week for approximately 82 weeks. Enrolled sensitivity and AUC for disability, which was Determination of these differences may allow patients were either low-acuity 9-1-1 callers, 75.9% (95% CI 74.3% to 77.5%) and 0.671 (95%CI for refinement of public education on the identified through monitoring 9-1-1 radio traf- 0.658 to 0.684), respectively. Conclusions:The timely treatment of acute stroke. Methods:This fic or housed (i.e., non-homeless) 9-1-1 fre- physiologic criteria of field triage guidelines study was conducted at an academic medi- quent users identified from prior LAFD health showed high sensitive for mortality. Anatomic cal center that is an accredited comprehen- records. Summary descriptive statistics were and mechanical criteria showed low sensitivity sive stroke center. Consecutive patients with collected. Results: The APRU was linked to and high specificity. The trend was similar for acute stroke were enrolled between January 1,079 incidents over approximately 328 days of disability. Altered mentality of physiologic 2015 and May 2017, and were categorized by service (mean 3.3 incidents/day). Of these inci- criteria showed highest sensitivity and AUC mode of arrival (EMS vs. private vehicle). The dents, there were 127 cancellations, 88 found among each component of field triage scheme. type of stroke (hemorrhagic vs. ischemic) was no patient, 13 refused care, and another 12 identified and the NIHSS measured in theED were ineligible for APRU care. The remain- 74. Effect of Chest Compression Parameter for all stroke patients, with the ICH Score ing 839 were treated (77.8%). Of those treated, Variation on Waveform Characteristics of and Hunt & Hess Score determined for ICH 379 (45.2%) were treated and care was trans- the Ventricular Fibrillation and SAH respectively. Age, gender, PMH of ferred to another transporting unit, 360 (42.9%) Electrocardiogram stroke, and “time last known well” were iden- were treated and released on scene, and 100 tified. Statistical analysis was performed using David Salcido, Matthew Sundermann, Alli- (11.9%) were treated and transported. Of the 100 the Yates corrected Chi-Square, Mann-Whitney, son Koller, Rena Sufrin, John Kucewicz, transported by the APRU, 58 were transported and Kruskal-Wallis tests. Results: A total of 935 Pierre Mourad, Graham Nichol, James to a non-emergency room with 55 transported patients were enrolled with 716 (77%) arriving Menegazzi, Adeyinka Adedipe, Department directly to mental health clinics and 3 to a sober- by EMS and 219 (23%) arriving by private vehi- of Emergency Medicine, University of Pittsburgh ing center. Of the 360 treated and released on cle. Of these, 636 (68%) had ischemic strokes, School of Medicine Category of Submission: scene, the APRU spent an average of 23 min- 190 (21%) had ICH, 92 (10%) had SAH, and Cardiac utes on scene (minimum 1 minute, maxi- 17 (2%) were not classified. Ac greater propor- tion of ICH (93%) and SAH (93%) patients than mum 1 hour 15 minutes, median 20 minutes). Background: The ventricular fibrillation (VF) ischemic stroke patients (69%) arrived by EMS Conclusions: The LAFD APRU has shown electrocardiogram (ECG) waveform is known (p < 0.001). Patients arriving by EMS had sig- promise in decreasing costly EMS transports to deteriorate over time if untreated, recover nificantly higher NIHSS (9.2 vs. 2.7,p < 0.001), and ED care. Furthermore, by leveraging the with CPR, and to predict defibrillation suc- ICH scores (1.7 vs. 0.3; p < 0.001), and Hunt diagnostics skills of the APP, patients can cess. VF ECG measures could inform CPR & Hess scores (2.8 vs. 2.0) than those arrive by be treated and released on scene or medi- quality feedback algorithms based on patient car. The “last known normal” time was signifi- cally cleared for alternate destinations. Further physiologic response. Objectives: Investigate cantly lower for the EMS arrival group (mean research is needed to study this novel type of the effects of chest compression rate, depth = 547 minutes; median = 211 minutes) than EMS care. and duty cycle (DC) on VF ECG waveform the private vehicle group (mean = 1,407 min- characteristics in a swine cardiac arrest model. utes; median = 715 minutes; p < 0.001). Demo- 73. Predictive Value of Each Component Methods: Twelve mixed-breed domestic swine graphic data and prior history of stroke were Field Triage Guidelines on Hospital were sedated (ketamine & xylazine), anes- similar based on mode of arrival. Conclusions: Outcome in EMS-Treated TBI thetized (fentanyl) and paralyzed (vecuro- Stroke patients arriving by EMS have signifi- nium), followed by endotracheal intubation cantly higher NIHSS, ICH score, and Hunt & Sola Kim, Sang Do Shin, Kyoung Jun Song, and mechanical ventilation. Animals were Hess score and significantly shorter time from Young Sun Ro, Jeong Ho Park, Seoul National instrumented with a battery of physiological “last known well” than those arriving by car. University Hospital Category of Submission: sensors, including multi-lead ECG (BioAmp, Because a significant proportion of ischemic Student, Resident, Fellow ADInstruments, Inc), recorded continuously stroke patients arrive by car, targeted public with a high-fidelity data acquisition unit (Pow- Background: Unbiased estimates for field education efforts should focus on identification erLab, ADInstruments, Inc) at 1000 Hz. Ventric- triage guideline performance are important of stroke patients with longer symptom dura- ular fibrillation was induced with a 3-second in optimizing trauma systems and improving tion and those with lower NIHSS. 100 mA transthoracic shock. After 7 minutes, outcomes among seriously injured patients. animals were randomized to receive continu- The accuracy of each triage component has not 76. Carotid Blood Flow Is Dependent on ous CPR with a custom robotic device using been evaluated in traumatic brain injury (TBI) Rate And Duty Cycle during CPR Cardiac. 1 of 6 pre-programmed, 2-phase CPR schemes patients. Based on evaluation as a diagnostic that varied 1 parameter in 5 x 1-minute intervals Joshua Lampe, Karen Moodie, Jeffrey Gould, test, we considered the standard to be mortal- per phase while holding the other 2 parameters Christopher Kaufman, Norman Paradis, Fein- ity and disability, which is the final hospital fixed. Frequency (AMSA) and slope-based (MS) stein Institute for Medical Research Category of outcome. The aim of this study is to predict the quantitative ECG characteristics of artifact- Submission: Cardiac performance of each component of field triage filtered ECG were calculated from 3-second guidelines on hospital outcomes in TBI patients. segments at the end of each 1-minute inter- Background: We have previously presented Methods: This was a cross-sectional observa- val and compared between rate, depth and DC data that blood flow generated by piston-type tional study using a nationwide, prospective schemes, as well as experimental phases. Cor- mechanical chest compressions (CC) is sensi- registry of severe trauma patients treated by relations between CPR parameter settings and tive to changes in the inter-compression pause emergency medical services (EMS) providers ECG characteristics were calculated. Results: time, which changes both chest compression in 10 provinces in Korea. The study population Compression rate showed a low-to-moderate rate and duty cycle. We sought to clarify the was adult TBI patients between January 2013 correlation (0.454) with change in MS in Phase dependence of CC generated blood flow on and December 2013. The main exposure was I, however neither DC nor depth showed a cor- changes in CC rate and duty cycle during pis- each component of field triage set by the relation with either AMSA or MS. In ANOVA ton type CPR. Hypothesis: We hypothesized American College of Surgeons Committee on models, MS differed between CPR groups at the that the observed dependence of CC generated Trauma and Centers for Disease Control and end of Phase I (p = 0.046) but not AMSA, sug- blood flow on changes in intra-compression Prevention as determined by EMS provider. gesting limited response of quantitative ECG pause time is due to the change in CC duty The primary outcome was hospital mortality measures after extended time intervals. Con- cycle. Methods: CPR was performed on five and secondary outcome was disability at dis- ∼ clusions: In this study only chest compression domestic swine ( 30 kg) using standard phys- charge. Disability is defined as new disability rate in early phase CPR appeared to be related iological monitoring. Blood flow was mea- or worsened Glosgow Outcome Scale (GOS) to quantitative characteristics of the VF ECG. sured by Doppler in the right common carotid including death than pre-event GOS. Sensitiv- artery. Ventricular fibrillation (VF) was electri- ity, specificity and area under the curve (AUC) 75. Variation in the Characteristics of cally induced. CC were started after 5 minutes were calculated. Results: Total 5,133 patients Patients with Acute Stroke Arriving by of untreated VF. CC were delivered at a rate of met the field triage guidelines. 21.5% died, and EMS Versus Those Arriving by Private 125 or 50 compressions per minute (cpm) with a 51.4% of patients had disability. The sensitivity Vehicle duty cycle of 45% or 27% for each rate, and at a and specificity for mortality of the physiologic, depth of 2” for a total of 6 minutes after 2 min- anatomic and mechanical criteria were 91.4% Robert O’Connor, Karen Braden, Joseph utes of “break-in” CPR (increased depth from and 47.3%, 20.0% and 93.15%, 57.8% and Carrera, Nicole Chiota-McCollum, Elizabeth 1 inch to 2 inches). CC rate or duty cycle were 120 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

changed every 1.5 minutes. Results:Atarateof Seo Young Ko, Sang Do Shin, Kyoung Jun Methods: Data were collected as part of a 125 CPM, CC delivered at a duty cycle of 45% Song, Ki Jeong Hong, Young Sun Ro, So Yeon benchmarking program conducted at multiple generated roughly twice the carotid blood flow Kong, Tae Han Kim, Seoul National University U.S. hospitals. Compression rate and depth in L/min of CC delivered at a duty cycle of 27% Hospital Category of Submission: Cardiac were recorded using standard compression (0.157 ± 0.086 L/min vs. 0.075 ± 0.04 L/min, mannequins and RTAVF defibrillators (R respectively). However at a rate of 50 CPM, Background: Dispatcher-assisted cardiopul- Series, ZOLL Medical). The program included blood flow was not dependent on duty cycle monary resuscitation(DA-CPR) is an important subjects enrolled before (n = 756) and after (n (45%: 0.045 ± 0.015, 27%: 0.037 ± 0.015). This intervention to improve outcomes of out- = 995) introduction of the 2015 Guidelines, relationship appeared to be conserved when of-hospital cardiac arrest. We studied the with target compression parameters modified blood flow was compared at the level of Lper association between the time to detect cardiac accordingly. At baseline subjects performed compression. Conclusions: The results of these arrest by dispatcher and outcomes in out-of- 2 min of continuous compressions with RTAVF experiments suggest that carotid blood flow is hospital cardiac arrest (OHCA). Methods:We feedback disabled. After a brief RTAVF orien- dependent on both rate and duty cycle. These conducted a cross-sectional study. All adult tation, subjects repeated 2 min of continuous data suggest that the dependence of CC gen- OHCAs of presumed cardiac etiology and compressions with feedback enabled. The erated blood flow on intra-compression pause bystander witnessed between 2013 and 2015 2010 Guidelines cohort and 2015 Guidelines time cannot be assigned to either the change in were analyzed. The main exposure of interest cohort were compared with regard to the per- rate or duty cycle, but is a combination of both was time from EMS call to detection of cardiac centage of compressions meeting appropriate effects. These data highlight possible mechanis- arrest by dispatcher. Patients with unknown rate/depth targets with and without use of tic differences between piston and vest CPR. time to detection by dispatcher or extremely RTAVF. Results: An increase in compression > longer detection time ( 20 minutes), and guideline adherence was observed with use 77. Rearrest Incidence and Post-ROSC unknown outcomes were excluded. Time to of RTAVF for both the 2010 Guidelines cohort Rhythms after Prehospital Return of detection of cardiac arrest by dispatcher was [60.3% to 96.0%, OR 15.9 (10.8–23.6), p < Spontaneous Circulation in classified into the early (0–90 seconds), middle 0.01] and the 2015 Guidelines cohort [16.7% Out-of-Hospital Cardiac Arrest (91–180 seconds), and late (181–1,200 seconds) to 95.0%, OR 94.4 (67.9–131.2), p < 0.01]. groups. The primary outcome was survival The proportion of subjects requiring RTAVF Amber Rice, Joshua Gaither, Daniel Spaite, to discharge and secondary outcome was to achieve adherence increased from the 2010 Vatsal Chikani, Sean Wentworth, Tyler good neurological recovery. Multivariable Guidelines cohort to the 2015 Guidelines cohort Vadeboncoeur, Taylor George, Terry Mullins, logistic regression analysis was performed, [36.1% vs. 79.3%, OR 6.8 (5.5–8.4, p < 0.01), p Bentley Bobrow, University of Arizona adjusting for patient, arrest, environmental, < 0.01]. There were no statistically significant Category of Submission: Cardiac and dispatcher factors. Results: Of 83,083 differences between the 2010 Guidelines cohort OHCAs, 6,539 (7.9%) patients were instructed Background: Limited out-of-hospital cardiac and the 2015 Guidelines cohort with regard DA-CPR between 2013 and 2015. A Total of arrest (OHCA) studies have found that rearrest to the proportion of subjects that could not be 6,383 (7.7%) patients were enrolled, excluding = after return of spontaneous circulation (ROSC) corrected [3.6% vs. 4.0%, OR 1.1 (0.7–1.9), p cases who did not receive bystander CPR. The is both common and independently associ- 0.63] or became nonadherent [0.4% vs. 1.0%, rates of DA-CPR performed were 28.7%, 43.0%, = ated with lower survival. To better understand OR 2.6 (0.7–9.3), p 0.16] with RTAVF. Conclu- and 28.3% in early, middle, and late detec- prehospital rearrest after ROSC, we sought to sions: The use of RTAVF increases adherence to tion groups, respectively. Overall, survival to describe rearrest cardiac rhythms for adults chest compression guidelines, particularly with discharge occurred in 635 (9.9%) OHCAs and with OHCA of presumed cardiac etiology in an application of the narrower 2015 Guidelines good neurological outcome was observed in expanded and more recent sample of OHCAs. targets for compression depth and rate. 441 (6.9%) patients. After adjusting for potential Methods: Cases were identified from Septem- confounders, longer time to recognize cardiac 80. Direct Transport to Comprehensive ber 2008 to December 2015 from three EMS sys- arrest was associated with decreased odds of Stroke Center May Not Expedite tems in Arizona. Minute-by-minute post-ROSC survival to discharge for both middle (AOR Reperfusion of Large Vessel Occlusion and rearrest rhythms were grouped into Utstein 0.74, 95%CI 0.59–0.91) and late groups (AOR Stroke categories by two emergency medicine trained 0.75, 95%CI 0.59–0.94) compared with early physicians after analysis of continuous defibril- Ali Shams, Chris Kanaan, Rebbeca group. There was no significant association lator ECG data (E Series, ZOLL Medical). Rear- Grysiewicz, Chris Kazmierczak, Laura between recognition time and good neurolog- rest was defined as 1 minute of lethal arrhyth- Steucher, Robert Swor, Beaumont Health Cat- ical outcome [Middle vs Early AOR(95% CI): mia or crew restarting CPR for any length egory of Submission: Student, Resident, 0.81 (0.63–1.04), Late vs Early AOR (95%): 0.79 of time, indicating loss of pulses. Descrip- Fellow (0.60–.03), Late vs Middle AOR (95% Cl): 0.98 tive statistics were used to describe the dis- (0.76–1.26)]. Metropolitan status was significant tribution of post-ROSC and rearrest rhythms. Background: A body of knowledge has evolved effect modifier (p < 0.001). In non-metropolitan Results: Of 1,603 adult OHCA patients, there that has demonstrated improved survival and areas, compared to the early group, AORs (95% were 409 cases of ROSC (25.5%) and 350 were functional outcome from LVO strokes with Cl) for survival to discharge were 0.65 (0.49– included in this analysis. Cases were excluded timely mechanical endovascular therapy. To 0.85) in the middle group, 0.68 (0.51–0.90) in if age <18 (2), non-cardiac etiology (34), ROSC decrease time to care, EMS policy makers have the late group. In metropolitan areas, there was was not achieved prior to ED arrival (1,194) begun to develop methods to identify and no significant association between recognition or adequate electrocardiograph (ECG) rhythm triage EMS LVO stroke patients directly to com- time and survival to discharge [Middle vs Early recordings were not available (23). There was a prehensive stroke centers (CSC). Our objective AOR (95%CI): 0.91(0.64–1.30), Late vs Early total of 4,009 minutes of ROSC (not including was to assess whether time to definitive care AOR(95%Cl): 0.88(0.60–1.29)]. Conclusions: rearrest) with 7 distinct post-ROSC rhythms. for LVO stroke patients is decreased in patients The shorter duration from the EMS call to recog- Sinus rhythms predominated after achieving who present directly to a CSC compared to nition of cardiac arrest by dispatcher was asso- ROSC, with sinus tachycardia representing the patients who are transferred from a primary ciated with favorable outcomes after OHCA. greatest percentage (52.15%) of all rhythms. stroke center. Methods: We performed a cohort study of patients admitted to a single suburban A smaller percentage of minutes were seen 79. Impact of Real Time Chest Compression CSC (July 2015 –December 2016) with a diagno- of sinus rhythm (21.14%), sinus bradycardia Feedback Increases with Application of sis of LVO stroke. Patients presented directly to (5.00%), V-tach (4.41%), idioventricular (8.91%), the 2015 Guidelines atrial fibrillation/flutter (1.88%), and junctional the CSC, or were transferred by air or ground rhythms (1.31%). Almost half of ROSC patients Kenan Kunstal, Tifany Hoyne, Sara Wat- from a primary stroke center. Time intervals in this sample (45%) sustained at least one tenbarger, Stacie McCauley, Laurel Linder, fromarrivalateitherfirsthospitalorCSC episode of rearrest and 22 patients (7%) sus- Daniel Davis, ZOLL Medical Category of to interventional skin puncture (access) and tained multiple rearrests. The most common Submission: Cardiac reperfusion at the CSC were recorded. Trans- rearrest rhythms in this sample were pulseless fer distance was calculated using Google Maps. electrical activity (62.3%) and VT/VF (32.6%). Background: Cardiac arrest survival is depen- Because we sought to assess impact of triage Conclusions: This study demonstrates that dent upon chest compression quality. Target within a regional EMS system, we included rearrest is common after ROSC in cases of pre- parameters for compression depth and rate patients transferred within a 15-mile radius. hospital OHCA. In this analysis, a wide variety became more specific from the 2010 Guide- Non parametric statistics were used for compar- ࣙ of both post-ROSC and rearrest rhythms were lines [ 2 inches, 80–120/min] to the 2015 isons. Median and range are reported. Results: observed. This information helps prepare EMS Guidelines [2.0–2.5 inches, 100–120/min]. We had a total of 62 cases admitted to our rescuers for rearrest and provides the poten- Real-time audiovisual feedback (RTAVF) may CSC, with 54 transported within 15 miles. Of tial for targeted interventions to prevent OHCA improve compression guideline adherence, these, 25 patients were direct transports (15 rearrest. but the impact of RTAVF with application of via EMS and 10 via private car) and 29 were more specific targets is unknown. Hypothesis: transferred from 7 hospitals. As expected, trans- 78. Effect of Early Detection by Dispatcher Dependence on RTAVF to achieve compression ferred patients had shorter times from CSC on Survival Outcomes after guideline adherence will increase with appli- arrival to access and reperfusion [median, 30.5 Out-of-Hospital Cardiac Arrest cation of the more specific 2015 Guidelines. (6–216) vs. 156 (30–248), p < 0.001, and 69 (25– NAEMSP 2018 ANNUAL MEETING ABSTRACTS 121

288) vs. 209 (99–315), p < 0.001], respectively. examination success at other provider levels lated for the starting and ending ECG segments When comparing first hospital arrival to out- have been explored, little is known regarding around the bout, and CPR performance met- comes, direct transport patients had a small the AEMT level. Our objective was to examine rics were calculated for the intervening bout of decrease in time to access [156 (30–248) vs. 171 the association between AEMT graduate char- CC. CC process metrics included rate, depth, (115–384), p = 0.03] and no difference to reper- acteristics and success on the National AEMT duty cycle, fraction, bout duration, dosed rate, fusion [208.5 (25–288) vs. 209 (142–412), p = 1.0]. Cognitive Examination. We hypothesized dosed depth, and dosed duty cycle. We then Conclusions: Using this small pilot data set, that prior EMT experience, program entrance analyzed the relationship between CC metrics direct transport of LVO patients to a CSC had exams, course-ending final exams, and exam and QECG by regressing the change in QECG a minimally shorter time to access and no dif- fee payor would be associated with success. measures from the start each bout to the end ference in time to reperfusion compared to Methods: We performed a cross-sectional of each bout against the CC process parameters those transferred. EMS systems need to criti- evaluation of all first-attempt National AEMT for that bout in multivariable models includ- cally assess the benefit of direct transport vs Certification cognitive examination results ing bout duration and patient characteristics. early transfer as a component of strategies to from October 2016 to April 2017. Upon com- Results: CC rate was associated with change in optimize care for LVO stroke patients. pletion of the examination, a brief, voluntary QECG value and was significant for change in questionnaire was administered assessing MS (t = 2.13, coefficient 8.92, p = .0330). All 81. Benchmarking EMS Compass Cardiac graduates’ characteristics and experiences. other associations between chest compression Performance Measures Using a Large Descriptive statistics were calculated, and the parameters and dQECG were not significant. National Dataset association between characteristics reported Conclusions: These results suggest a limited by graduates and success on the exam was relationship between CC process metrics and Jeffrey Jarvis, Dustin Barton, Lauren Sager, assessed using univariable logistic regression QECG measures during resuscitation of out-of- Nick Nuddel, Williamson County EMS Cat- models (OR, 95%CI). Results: In the study hospital cardiac arrest. egory of Submission: Operations, Quality, period, 3,835 AEMT graduates attempted the Safety Systems, Disaster, Disaster cognitive examination and 2,372 completed 84. The Utilization of a Province Wide EMS System by Children and Youth with Background: Early defibrillation of shockable the post-test questionnaire (response rate = Mental Health Complaints cardiac arrests, aspirin and 12 lead ECG, and a 62%). Among those who completed the questionnaire, 56% (n = 1323) were successful combination of nitroglycerin and non-invasive Aaron DeRosa, Michael Zhang, Judah Gold- on the first attempt. Compared to those with pressure ventilation (NIPPV) in acute decom- stein, Carl Jarvis, Md Shamsuzzaman, Uni- no EMT experience prior to enrollment in an pensate heart failure has been shown to pro- versity of Prince Edward Island, Atlantic Regional AEMT program, those with one to five years of vide meaningful clinical benefit. There has not Training Centre Category of Submission: Stu- experience had greater odds of passing (1.37, yet been work done to provide benchmarks dent, Resident, Fellow on these measures based on large national 1.10–1.71), while more than five years of EMT datasets. We aim to describe national perfor- experience was not significantly associated Background: Children and youth Emergency mance on these measures. Methods:Using with examination success (1.09, 0.84–1.42). Department (ED) and hospital based mental a 6 1/2-year convenience sample of records Attending an AEMT program that required an health(MH) service use is increasing in Canada from 9-4-1 consenting EMS agencies using entrance exam was not associated with odds and the United States. This may extend to the ESO Solutions electronic health record (EHR), of success (0.85, 0.69–1.05). However, respon- EMS setting. Our objective was to describe we calculated compliance with the follow- dents who were required by their program trends and characteristics of EMS utilization ing performance measures: the average time to complete a final course-ending cognitive by children and youth with MH complaints. from dispatch to first defibrillation in shock- examination exhibited higher odds of success Methods: We conducted a retrospective pop- able rhythms, the proportion of these provided compared to those who did not (2.18, 1.78– ulation based quantitative descriptive study, within 5 minutes, the proportion of patients 2.65). Compared to those who paid for their using secondary data from the provincial EMS over 35 with non-traumatic chest pain who own exam, there was no difference in odds database. Patients 5 to 18 who utilized EMS received both aspirin and a 12 lead ECG, and of passing for those whose employers (1.21, for MH related complaints between 2010 and the proportion of patients with acute decom- 0.99–1.49) or programs (1.16, 0.85–1.58) paid 2015, inclusive, were used in the analysis. We pensated heart failure (ADHF) as defined by some/all of the exam fees. Conclusions:Prior described prevalence, demographics, and oper- SBP > 200 and either a RR > 30 or an SpO2 EMT experience and program course-ending ational characteristics. MH calls were based on < 90 who received both NTG and NIPPV. For cognitive examinations were significantly chief complaint or clinical impression relating times, we provide the average, median and associated with increased odds of success to MH and resemble the Canadian ED short interquartile rank. For proportions, we also cal- on the National AEMT Examination. Future list of Diagnosis under Mental and Behavioural culated the 95% confidence interval. Results:Of work should examine the impact of program Disorders. Continuous and discrete variables 11,144 cardiac arrests with an initial shockable entry requirements and program curriculum reported as n, mean, SD; Categorical as n, rhythm, 1,630 or 14.6% (14.0–15.3%) were defib- composition on graduate performance. %. Results: Our electronic query retrieved rillated within 5 minutes. The average time to 16,169 EMS responses for children and youth; 83. Change in Quantitative Ventricular first shock was 13.65 min, IQR 9.0(6.4, 13.2). of which 2108(16%) were related to MH. The Fibrillation Over Bouts of Chest There were 533,127 patients over 35 with non- mean age was 16.26(SD1.699) and most MH Compressions in CPR traumatic chest pain. Of these, 199,123 or 37.4% calls were female (n = 1238, 59%). There was (37.2–37.5%) received both aspirin and a 12 lead Matthew Sundermann Sundermann, David a 27% increase in total MH calls over the 6 ECG. There were 2,612 patients with ADHF and Salcido, James Menegazzi, Department of Emer- year study period compared to a 9% increase 2,100 or 80.4% (78.9–81.9%) of these received gency Medicine, University of Pittsburgh School of in all EMS calls in the same age group. Females both NTG and NIPPV. Conclusions:Therewas Medicine Category of Submission: Student, had the largest increase (47%) in MH related a low rate of rapid defibrillation pointing out Resident, Fellow complaints over the study period. The major- the difficulties with achievement of this metric ity of patients were single users (n = 1436, without non-EMS (public) support. There was Background: Chest compressions (CC) given 68%), whereas, 180 repeat users accounted also poor compliance with a chest pain bun- during cardiac arrest generate blood flow to the for 503(24%) responses, ranging from 2–13 dle of aspirin and 12 lead ECG use. On the brain and other vital organs, but the effect of CC incidents over the study period. Most patients other hand, there was much better use of NTG is dependent on their performance characteris- were transported (n = 1920; 91%). The two most and NIPPV in ADHF. These data provide base- tics. Quantitative ECG (QECG) features of the common conditions addressed by paramedics line performance benchmarks for use in system ventricular fibrillation (VF) waveform correlate were overdose/poisoning (n = 1747; 83%), and improvement. with myocardial perfusion levels during car- depressed/suicide (n = 250; 12%). Anxiety (n diac arrest and therefore may be a good quality = 257; 35%) was the most prevalent charted co- 82. Characteristics Associated with metric. We hypothesized that there would be an morbidity, followed by Attention-Deficit Dis- Success on the National AEMT association between change in QECG measures order/ Hyperactivity Disorder (n = 207,28%). Certification Examination and CC characteristics. Methods:CCprocess When categorizing patients over a calendar and associated continuous prehospital ECG year 1635 patients were low users (1 call per Madison Rivard, Rebecca Cash, Remle Crowe, data were retrospectively extracted from defib- year), 108 patients were medium users (2–4 Jeremy Miller, Ashish Panchal, The National rillator downloads obtained from the continu- calls per year), 8 patients were high users (5–14 Registry of Emergency Medical Technicians Cat- ous chest compression (CCC) trial of the Resus- calls per year). Conclusions: We observed an egory of Submission: Operations, Quality, citation Outcomes Consortium (ROC). Cases increasing trend in MH related EMS service use Safety Systems, Disaster, Disaster were included if they had at least one defibril- by children and youth. The majority of patients Background: Advanced emergency medical lator file with a bout of CC bounded by ana- are transported by paramedics to the ED. This technician (AEMT) certification, the provider lyzable ECG signal segments, and amounted trend should be considered when developing level between emergency medical technician to 25,210 bout-gap intervals spanning 1,099 EMS policies, programs, and training for (EMT) and paramedic, was first issued on a unique cases. For each bout, the QECG mea- paramedics. national level in 2011. While characteristics of sures AMSA, MS, LAC, and DFA were calcu- 122 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

85. Push Dose Epinephrine Use in Critical of six care elements aligned with AHA recom- 48.3%, and the lowest 46.4%) (p < 0.01). AORs Care Transport mendations: dispatcher provided instructions (95% CIs) per 10% increment in CPR awareness for CPR when possible, bystander or FR initi- were 1.05 (1.00 to 1.11) for arrest recognition, Francis Guyette, Gabriela Galli, Neal ated chest compressions (pre-ambulance CPR), 1.11 (1.06 to 1.17) for CPR instruction, and 1.07 McQuaid, Jonathan Elmer, Christian Martin- bystander or FR placed an AED (pre-ambulance (1.03 to 1.11) for bystander CPR. Conclusions: Gill, Department of Emergency Medicine, Univer- AED), compression fraction during EMS CPR Although the dispatcher’s recognition rate sity of Pittsburgh School of Medicine Category of > 0.8, compression rate during EMS CPR of of OHCA was not different according to the Submission: Student, Resident, Fellow 100–120/minute, and number of pauses >10 sec community CPR awareness level, dispatchers in duration during EMS CPR was < 3. Only provided more CPR instruction in communities Background: The use of push dose epinephrine the first 10 minutes of compressions were con- with higher CPR awareness level. Finally, more (PDE) is becoming increasingly common in sidered for EMS CPR criteria. Data sources bystander CPR was provided to the patients in the treatment of profound hypotension in the included audio recordings of dispatch calls, higher CPR awareness communities. prehospital setting. However, no quantitative the Cardiac Arrest Registry to Enhance Sur- research has been done to analyze the patient vival (CARES) registry data, and transthoracic 88. Effect of Text Message Alert System for populations receiving this treatment. We aim to impedance data tracings. Results: Adherence Trained Citizens on Bystander describe the population of patients treated with to individual guidelines was generally high: Cardiopulmonary Resuscitation and PDE as compared to hypotensive patients not dispatcher instructions for CPR = 100%, pre- Survival to Discharge in a Metropolitan treated with PDE. Methods: We performed a ambulance CPR = 93%, pre-ambulance AED = City: A Before-After Population-Based retrospective cohort study to describe the use 72%, compression fraction = 84%, compression Study of PDE in a critical care transport system. We rate = 91%, and number of pauses >10 sec < 3 evaluate the use of PDE for management of = 81%. Care was delivered in accordance with Sun Young Lee, Sang Do Shin, Kyoung Jun prehospital hypotension from January 2015 to all six criteria (AI = 6) in 52% of events (n = 153) Song, Ki Jeong Hong, Young Sun Ro, Soyeon April 2017. We reviewed prehospital and in- and the AI was ࣙ 5 in 78% of events (n = 228). Kong, Tae Han Kim, Seoul National University hospital medical records for patients treated The number of events with AI ࣙ 5increased Hospital Category of Submission: Cardiac and transported by a multi-state air medical from 70% among 2014 cases to 83% among 2015 service that incorporated PDE into its proto- Background: Bystander cardiopulmonary cases (p = 0.009). Conclusions: Adherence to cols (epinephrine 100 mcg IV/IO every 2 min- resuscitation (CPR) is a key factor to improve the guidelines for optimal prehospital OHCA utes for SBP < 70 mmHg or peri-arrest state). survival outcomes in out-of-hospital cardiac management that were studied is very high in Patients were selected if they were hypotensive arrest (OHCA) patients. A text message (TM) this system of care and appears to be increas- and met inclusion criteria for PDE use in the alert system for trained citizens was imple- ing. Identified opportunities for improvement current protocol. We compared pretreatment mented to increase bystander CPR in the include increasing pre-ambulance AED use and characteristics and vital signs for patients fol- community. This study aimed to determine reducing pauses during EMS CPR. lowing an index event (SBP < 70). We utilized the effects of a TM alert system on bystander non parametric (rank sum tests) and chi-square CPR rate and survival outcomes after OHCA. to identify differences between the cohorts. 87. Recognition of Out-of-Hospital Methods: A before-after population based Results: 1862 eligible (SBP < 70) cases were Cardiac Arrest during Emergency Calls by study was conducted with resuscitation identified, PDE was administered to 23%. Cases Community Level Public Awareness of attempted OHCAs between 2014 and 2015 vs. controls differed by age, PDE median age Cardiopulmonary Resuscitation: A in the study districts of Seoul, South Korea. 65 (IQR 55–76) No PDE 61 (IQR 50–72), but Multi-Level Analysis Seoul implemented a TM-alert system as a not gender or race. Patients receiving PDE were community intervention in May, 2015. The Sun Young Lee, Young Sun Ro, Sang Do Shin, most commonly treated for post arrest, cardio- intervention group was defined as OHCA cases Kyoung Jun Song, Ki Jeong Hong, Soyeon genic shock, trauma and sepsis. Patients receiv- that occurred from May to December in 2015, Kong, Tae Han Kim, Seung Sik Hwang, Seoul ing PDE were also more likely to be intubated and the historical control group was defined National University Hospital Category of Sub- (PDE 32.4%, No PDE 14.3% Pr0.00) and vaso- from the same period (May to December) in mission: Cardiac pressor dependent (PDE 32.8%, No PDE 15.5% 2014. Endpoints were bystander CPR rate and Pr0.00) prior to flight crew arrival. Patients also Background: In dispatcher-assisted car- survival to discharge. Multivariable logistic differed with respect to Lactate level (PDE 8.2 diopulmonary resuscitation (CPR) program, regression analysis was used to evaluate the (IQR 4.5,9) vs. No PDE 3.7 (IQR2.3,7) and pre- dispatchers’ recognition of out-of-hospital effect of TM alert intervention compared with treatment crystalloid (PDE 1000 IQR 500,2600) cardiac arrest (OHCA) is the first step to initiate historical control group. Results: A total of vs. No PDE (PDE 1000 IQR 200,2000). Other bystander CPR. This study aimed to investigate 1,124 OHCAs were analyzed, with 560 OHCA pretreatment variables (HR, SpO2, RR) did not whether the community CPR awareness is cases in the intervention group and 564 OHCA differ. Conclusions: Prehospital administration associated with recognition of arrest, provi- cases in the historical control group. Bystander of PDE in our system is administered in only sion of CPR instruction, and bystander CPR. CPR was performed in 141 patients (25.1%) in a fraction of patients meeting protocol crite- Methods: A nationwide population-based 2014 and 119 patients (21.3%) in 2015 (p-value = ria. PDE administration is associated with intu- observational study was conducted with adult 0.14). Survival to discharge was observed bation, vasopressor use, increased lactate, and OHCA patients with cardiac etiology between in 31 patients (5.5%) in 2014 and 56 patients = crystalloid compared to patients not receiving 2013 and 2015. Exposure was community (10.0%) in 2015 (p-value 0.57). The adjusted PDE possibly indicating a selection or indica- level awareness of CPR using the national odds ratios (95% CI) of bystander CPR and tion bias. Korean Community Health Survey database survival to discharge for intervention group categorized into quartile (the lowest, lower, compared to control group were 0.80 (0.60 86. Adherence to Recommendations for higher, and the highest) groups. Endpoints to 1.06) and 0.94 (0.57 to 1.54), respectively. Prehospital Cardiac Arrest Care Across were recognition of arrest, provision of CPR Conclusions: The text message alert system for an EMS System of Care: How Well Are We instruction, and bystander CPR. Multi-level CPR trained citizens was not associated with Implementing Guidelines? logistic regression analysis was performed a significant increase in bystander CPR and survival to discharge rates. Jonathan Kamrud, Lori Boland, Andrew for study outcomes. Adjusted odds ratios Stevens, Jessica Jeruzal, Charles Lick, Allina (AORs) per 10% increment in community CPR 89. Comparison of Manual vs. Mechanical Health Emergency Medical Services Category of awareness were calculated adjusting for poten- Chest Compression Quality during Submission: Cardiac tial confounders. Results: A total of 43,875 OHCAs were included in the final analysis. Prehospital Cardiac Resuscitation Background: To evaluate adherence to Amer- Of those cases, 20,182 cases (46.0%) were rec- Joshua Gaither, Amber Rice, Chengcheng Hu, ican Heart Association (AHA) recommenda- ognized during the emergency calls and CPR Robyn McDannold, Margaret Mullins, Daniel tions for optimal care for out-of-hospital car- instructions were given in 17,804 (40.6%) cases. Spaite, Tyler Vadeboncoeur, Taylor George, diac arrest (OHCA) across the spectrum of Compared with the lowest CPR awareness Terry Mullins, Bentley Bobrow, University of prehospital care by analyzing care rendered communities, AORs (95% CIs) for arrest recog- Arizona Category of Submission: Cardiac by bystanders, dispatchers, first responders nition were 1.06 (0.96 to 1.17) in lower, 1.12 (FR), and emergency medical services (EMS) (1.02 to 1.23) in higher, and 1.19 (0.99 to 1.22) Background: Cardiopulmonary resuscitation providers within a system of care. Methods: in the highest CPR awareness communities. (CPR) quality is strongly linked to outcomes fol- A total of 294 OHCA events treated by a sin- For CPR instruction, AORs (95% CIs) were lowing out-of-hospital cardiac arrest (OHCA). gle ambulance service in Minnesota in 2014– 1.13 (1.00 to 1.27) in lower, 1.25 (1.08 to 1.44) Manual CPR quality varies and has risk to 2015 occurred before ambulance arrival in adult in higher, and 1.25 (1.09 to 1.44) in the highest providers. We hypothesized that use of a patients who sustained non-traumatic arrest, CPR awareness communities. Bystander CPR mechanical CPR device might provide higher and had complete data available for bystander, was done in 21,973 cases (50.1%) and the quality CPR than manual CPR during tech- dispatch, first responder, and EMS care ele- communities with the highest CPR awareness nically challenging periods of OHCA resusci- = ments. An adherence index (AI; range 0to showed higher bystander CPR rate (51.4%) tation, including the packaging, loading, and 6) was calculated based on successful delivery than other communities (higher 50.9%, lower transporting of patients. Methods:Casesof NAEMSP 2018 ANNUAL MEETING ABSTRACTS 123

OHCA at a single site from 10/2008–10/2016 patients under 13 years old, 287 (10.4%) were James Vretis, Center for Tactical Medicine were identified. Two CPR quality metrics, for “Allergy/Anaphylaxis.” The average age Category of Submission: Pediatric chest compression fraction (CCfr) and CC rate of patients was 6.5 years and 63% were male. (CCra), were measured using accelerometer- 59% (CI: 54–65) of these patients received Background: Young children and adoles- based technology (E & X-Series), and com- epinephrine - 49% (CI: 44–55) prior to EMS cents are frequently injured in peacetime and pared between 3 groups: packaging (terminal arrival, and 10% (CI: 6–13) by ALS personnel. wartime. Reviews of trauma registries at U.S. 5 minutes on scene), loading (terminal 3 min- The percent of patients who received appro- military medical facilities during the Iraq and utes on scene), and transport. Mechanical CPR priate treatment was 62% (CI: 56–66%). Of the Afghanistan conflicts show as the age of a child was performed using AutoPulse® (ZOLL Med- inappropriate treatments, epinephrine was a child decreases the injury severity and mor- ical), while most cases of manual CPR were given inappropriately 30% (CI: 24–35%) of the tality increases. Tourniquet use for control of performed with real-time audiovisual feedback time, and was withheld inappropriately 9% extremity hemorrhage in adult trauma patients (Real CPR Help®). Manual CPR [metronome (CI: 5–12%) of the time. Conclusions: Despite is associated with increased survival with only rate of 100 beats per minutes (bmp)] and increasing incidence and public awareness minimal tourniquet associated morbidity. Use mechanical CPR (set CCra of 80 bpm) were of life-threatening allergic reactions, both of commercial tourniquets on pediatric patients compared by the median proportion of time in laypeople and prehospital providers struggle treated at US military facilities shows survival which CCra was within +/−5 bmp of the target to diagnose and treat anaphylaxis in pediatric benefits similar to those seen in the adult range (pCCra) and the mean CCfr is reported patients. More education is needed to recognize population. Hypothesis: We hypothesized that using the Wilcoxon rank-sum test. Results: 357 this disease process and treat it appropriately. there wound be differences in the efficacy of cases were reviewed and 239 excluded: no age commercial tourniquets designed for adults or age <18 years (6), medical or unknown when applied to pediatric patients of different 91. Pediatric Out-of-Hospital Cardiac location (31), non-cardiac etiology (87), data ages. Methods: The institutional Ethics Review Arrest Outcomes before and after unavailable (115), leaving 118 included. No sig- Board approved the study. The study was Implementation of a Standardized nificant difference in CCfr was noted between a prospective and non-blinded test of nine Resuscitation Tool the two groups during transport (p = 0.47). In commercial tourniquets on a pediatric arm hemorrhage test model using six sized man- cases with mechanical CPR, CCfr was higher Scott Alter, Lisa Clayton, Richard Paley, = nequins to simulate pediatric arms. The Stretch during packaging 85.0 vs. 74.5 (p 0.0043) and Richard Shih, Florida Atlantic University = Wrap And Tuck (SWAT), TacMed K9 (TMK9), loading 86.0 vs. 72.2 (p 0.001) than in cases Category of Submission: Pediatric with manual CPR. With mechanical CPR, CCra and Rapid Application Tourniquet System was more frequently within the target range Background: Pediatric out-of-hospital car- (RATS) tourniquets apply compressive forces during all study periods 0.4 versus 0.8 (p = diac arrest (POHCA) occurs infrequently, yet by the elastic recoil action of the tourniquet 0.001), 0.3 vs. 1 (p = 0.0021), and 0.5 vs. 0.8 (p requires the same urgency as for adults. There- strap. The Combat Application Tourniquet = 0.0002). Conclusions: In adults with OHCA, fore, it is imperative that prehospital providers (CAT), Sam XT (SAMXT), Tactical Mechani- use of a mechanical CPR device was associ- are prepared to rapidly treat POHCA. To meet cal Tourniquet (TMT), and the SOF Tactical ated with higher CCfr during patient packag- this need, pediatric-specific tools have been Tourniquet – Wide (SOFTTW) use a windlass ing and loading and a higher proportion of developed. This study compares POHCA to increase circumferential compression by time within the target CCra rate during all time outcomes before and after implementation decreasing strap length. The Child Ratcheting periods. Use of mechanical CPR may improve of an age-based resuscitation tool. Methods: Medical Tourniquet (CRMT) uses a ratchet and CPR quality without exposing providers to the Design: retrospective chart review. Setting: ladder mechanism for circumferential compres- risks of performing manual CPR during the county-based ALS service with 87,000 calls per sion. The Mechanical Advantage Tourniquet packaging, loading, and transport of OHCA year, covering a population of 635,000 over (MAT) has a turnkey apparatus mounted on patients. 2,000 square miles. Subjects: patients <18 years a fixed length C-shaped housing that pulls a old who sustained POHCA with resuscitation portion of the retaining strap into the housing as a mechanism to increase circumferential 90. Is Prehospital Epinephrine Used attempt without return of spontaneous cir- pressure. Results: The SWAT, TMK9 and RATS Appropriately in Pediatric Anaphylaxis? culation (ROSC) before EMS arrival between January 1, 2012 and December 31, 2016. On were successful stopping the flow of water on Joslyn Joseph, Brian Walsh, David Feldman, January 1, 2014, a commercial tool for POHCA, all sized mannequins. The CRMT was the only Morristown Medical Center Category of Submis- consisting of age-based medication dosing mechanical advantage tourniquet that was suc- sion: Pediatric protocols, was implemented. Rates of ROSC, cessful in stopping fluid flow on all mannequin survival to hospital admission, and survival sizes. The TMT and SOFTTW started failing on Background: Anaphylaxis is an acute, life- to hospital discharge were calculated and mannequins with 6.35 cm diameters. The CAT, threatening condition that requires immediate compared between the pre-implementation SAMXT, TMT, and SOFTTW all failed on the recognition and treatment. The goal of therapy and post-implementation groups. Results:A 5.08 cm diameter mannequin. The MAT failed should be early recognition and treatment total of 132 POHCA patients were identified, on the 7.62 and smaller diameter mannequin. with epinephrine to prevent progression of whom 24 were excluded for having ROSC Conclusions: We have shown that many com- to life-threatening respiratory compromise before EMS arrival. The remaining 108 patients mercially available tourniquets do not stop or cardiovascular collapse. More prehospital had average age of 1.61 years, with similar fluid flow in our pediatric arm hemorrhage test providers, parents, and school nurses, are being baseline characteristics between groups. In the model. instructed in using epinephrine. We sought two years preceding the tool implementation 93. Prehospital Blood Pressure to determine how often epinephrine is used (control group), there were 37 cardiac arrests. Measurement in Major Traumatic Brain in children and, more importantly, how often Of these, two had ROSC after EMS arrival and Injury: Concordance between EMS it is administered correctly for anaphylaxis. none survived to hospital admission. In the Provider Documentation and Methods: Setting: A suburban two-tiered EMS three years after implementation (experimental Non-invasive Monitor Data Tracking system in which ALS units evaluate approx- group), there were 71 cardiac arrests. Of these, imately 600 patients under age 13 per year. 13 had ROSC after EMS arrival. All patients Octavio Perez, Octavio Perez, Eric Helfenbein, Patients: Children less than 13 years old over with ROSC survived to hospital admission and Bruce Barnhart, Saeed Babaeizadeh, Dawn a 5-year period for whom ALS was dispatched 3 survived to hospital discharge. Between the Jorgenson, Chengcheng Hu, Vatsal Chikani, for “Allergy/Anaphylaxis”. Protocol: Demo- control and experimental groups, there was a Joshua Gaither, Samuel Keim, Duane Sherrill, graphics, history of present illness, vital signs, 13% difference in ROSC after EMS arrival (5% Daniel Spaite, University of Arizona Category and interventions performed prior to EMS − vs. 18%; 95% CI: 0.01–0.24), 18% difference of Submission: Operations, Quality, Safety arrival and by EMS personnel were extracted in hospital admission (0% vs. 18%; 95% CI: Systems, Disaster, Disaster using chart review. The percentage of patients 0.06–0.29), and 4% difference in overall survival with 95% confidence intervals (“CI”) who were to discharge (0% vs. 4%; 95% CI: −0.06–0.12). Background: Recent studies have shown that given epinephrine prior to EMS arrival, by Conclusions: After implementation of an age- the lowest prehospital systolic blood pressure EMS, and overall were calculated. Anaphy- based resuscitation tool, there was a statistically (SBP) is strongly associated with mortality laxis was defined as acute cutaneous and/or significant increase in POHCA survival to hos- across a remarkably wide range (far above mucosal involvement after antigen exposure pital admission. ROSC rate obtained after EMS 90 mmHg) in traumatic brain injury (TBI). plus one of the following: respiratory compro- arrival and survival to hospital discharge also Furthermore, in TBI research, case ascertain- mise, cardiovascular compromise, or persistent increased, though failed statistical significance. ment and risk-adjustment are highly depen- GI symptoms. Appropriate treatment was Based on these results, EMS agencies may con- dent upon documentation of prehospital BP. defined as epinephrine being administered sider implementing an age-based resuscitation Objective: To identify the concordance between when the patient’s clinical syndrome met the tool as part of a strategy to improve POHCA the lowest SBP documented by EMS person- definition of anaphylaxis, or being withheld treatment. nel in patient care records (PCR) and the when the clinical syndrome did not meet the recorded non-invasive monitor data in TBI. definition. The percentage of patients who 92. Comparison of Commercial Methods: A subset of major TBI cases (moder- were treated appropriately was then calculated Tourniquets in a Pediatric Trauma Patient ate/severe; CDC Barell Matrix 1) in the EPIC with CI. Results: Out of 2,750 ALS calls for Model EMS TBI Study (NIH 1R01NS071049) were 124 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

evaluated (3/13–3/17). Cases from 6 EMS = 0.03), the overall increase was less than one Rebecca Cash, Evan Crowe, Remle Crowe, agencies that report continuous monitor data percentage point (21.4% in 2007 to 22.1% in Madison Rivard, Anne Knorr, Ashish Pan- (Philips MRxTM) as part of EPIC were included. 2016). A change of less than 2% was noted in chal, Douglas Kupas, National Registry of Emer- All monitor data available for this post-hoc 8 of 9 year-to-year comparisons. Conclusions: gency Medical Technicians Category of Submis- review were displayed and accessible to the While the proportions of females earning ini- sion: Operations, Quality, Safety Systems, providers during EMS care. We compared the tial National EMS Certification increased for Disaster, Disaster lowest PCR-documented SBP to the monitor- EMTs, the population earning paramedic certi- recorded value in each patient. Results: 132 fication remained relatively stable over the ten- Background: Recent crash testing shows cases were included (median age: 52, 65% year period. Despite other health care fields EMS professionals are at high risk of injury male). In 96 cases (72.7%), the lowest PCR- closing the gender gap, paramedic certification or death while riding unrestrained in an documented SBP was exactly concordant with has not followed this trend. Future research is ambulance, yet seatbelt use is reportedly low. the lowest monitor value. When concordance needed to identify the underlying reasons and Variation in seatbelt use based on seating was defined by the difference being ࣘ5 mmHg, barriers for the lack of change in the paramedic location and patient acuity is unknown. Our 113 (85.6%) were concordant. Among the 16 gender composition of those earning National objectives were to describe the prevalence of patients with guideline-defined hypotension EMS Certification. seatbelt use by seating location and identify identified by the monitor< ( 90 mmHg), only factors associated with seatbelt practices. We 11 (68.8%) were documented in the PCR. 95. Impact of Community Paramedic Home hypothesized that seatbelt use would be low Conclusions: Significant disparities were iden- Visits on CHF Patients: A Pre-Post in the patient compartment regardless of pres- tified between the lowest monitor-recorded Assessment of Heart Failure on Quality of ence of a patient, seating position, or patient SBP and the PCR-documented value. Further- Life acuity. Methods: We analyzed a cross-sectional electronic questionnaire administered to a more, PCRs failed to identify one third of Sandi Wewerka, Joseph Pasquarella, Ann monitor-documented hypotension. This may be random sample of nationally-certified EMS Majerus, Aaron Burnett, Matthew Simpson, professionals. Respondents reported frequency explained, in part, by ongoing care responsi- Paula Miller, Regions Hospital Category of bilities and scene distractions that may cause of seatbelt usage in the prior 12 months. Inclu- Submission: Operations, Quality, Safety Sys- sion criteria consisted of practicing EMTs or providers to miss BP readings. Our findings tems, Disaster, Disaster identify a potential hidden contributor to poor higher in non-military settings who work in ambulances. We defined consistent seatbelt outcomes if hypotension goes unrecognized, Background: Effective management of conges- use as reporting frequency of use >50% of and untreated, rather than simply not being tive heart failure (CHF) often requires patients the time in a seating location. Denominators documented. Furthermore, case ascertainment, to make significant lifestyle changes, which reflect respondents reporting sitting in the confounding, and risk-adjustment in TBI stud- may be best managed in partnership in the specific seat. Multivariable logistic regression ies may be substantially impacted. Whenever patient’s home. The objective of this study was (OR, 95%CI) using an investigator-controlled possible, quality improvement and research to evaluate the effectiveness of a fire-based backwards selection process was used to projects should utilize monitor data to iden- community paramedic (CP) program on CHF assess characteristics associated with wearing tify and evaluate hypotensive TBI patients. management in patients recently discharged a seatbelt on the crew bench while transporting Future development of monitor-based real- from the hospital using the Minnesota Living patients. Results: A total of 1,431 responses time audiovisual feedback technology might with Heart Failure Questionnaire (MLHF). ® met inclusion criteria (response rate = 11.4%). improve provider identification of hypotension. We hypothesize that CP visits will contribute Most respondents wore a seatbelt while driving to improvement in the patient’s quality of life theambulance(97%,n = 1,181/1,221). In the 94. Evaluating the Gender Gap in EMTS as assessed by the MLHF. Methods: Patients patient compartment without a patient being and Paramedics Obtaining National EMS with a CHF-related hospitalization who pro- transported, consistent seatbelt use was poor Certification from 2007 to 2016 vided consent to participate in the CP pro- regardless of seat position (forward-facing seat: gram completed the MLHF prior to discharge. 60% [n = 49/82], rear-facing airway/jump William Krebs, Remle Crowe, Rebecca Cash, The CP program entailed weekly home vis- seat: 59% [n = 670/1,136], crew bench: 36% Madison Rivard, Ashley Larrimore, Chris- its from a CP. The MLHF is a validated ques- [n = 362/997]). During patient transport, tine Hamilton, Ashish Panchal, Department of tionnaire that uses a Likert scale to measure consistent seatbelt use on the crew bench was EM, The Ohio State University Wexner Medical the effects of CHF symptoms, functional limi- reported at 23% with stable patients and 11% Center Category of Submission: Operations, tations and psychological distress. Each symp- with critical patients. Factors associated with Quality, Safety Systems, Disaster, Disaster tom is rated on a 0–5 scale, with a score of increased odds of seatbelt use on the crew 5 corresponding to the greatest detriment to Background: With roots in battlefield medicine bench when transporting a critical patient quality of life (QOL). Total MLHF scores range and the fire service, the EMS workforce has (lowest seatbelt use) included having a com- from 0–105. 4–6 weeks after discharge, patients traditionally been comprised of mostly male pany policy for seatbelt use (6.25,4.06–9.60) and repeated the MLHF. Pre/post survey scores providers. As the EMS profession has evolved EMT provider level (2.39,1.52–3.78 [referent: were analyzed descriptively using means and in both prominence and function, it is unknown AEMT/Paramedic]), controlling for years of standard deviations. Scores were assessed with how the gender composition of the workforce experience. Conclusions: Seatbelt use by EMS Wilcoxon signed-rank tests in three dimensions: has changed on a national level. The objective personnel in the patient compartment was low total score, emotional symptoms, and physi- of our study was to describe the proportion and varied by seat and patient acuity, with use cal symptoms. Results: Twenty-three patients of females who earned initial National EMS highest in forward-facing seats. Seatbelt use completed the pre- and post-tests from March Certification at the EMT and paramedic levels was lowest in the patient compartment during 2015 to May 2017. The mean total scores on over a 10-year period (2007–2016). We hypoth- the potentially more hazardous transport of the pre-assessment (score = 57.83, SD = 28.09) esized that the proportion of female EMTs and critical patients. Future work should examine and post-assessment (score = 45.30, SD = 30.77) paramedics earning certification increased dur- ways to increase seatbelt use in the patient were significantly different (p = 0.022). Mean ing this time. Methods: This was a longitudinal compartment. pre-score for physical assessment questions was assessment of all EMTs and paramedics earn- = 25.78 (SD 12.06) while on the post assessment 97. Feasibility of Manual Active ing initial National EMS Certification from 2007 = it was 21.22 (SD 11.66). Mean of the emotional Compression Decompression CPR in a through 2016. There is no national database = of all licensed EMS professionals, however score on the pre-assessment was 12.17 (SD Thirty-Degree Head Up Position 8.55) while on the post assessment it was 9.96 National EMS Certification is required to earn = initial licensure at one or more provider lev- (SD 8.84). Total scores were significantly dif- Heather Ellis, David Chase, Ventura City Fire els in the majority of states. We assessed all ferent between the pre and post assessments Department Category of Submission: Cardiac (p = 0.0216). Scores for the physical questions EMS professionals who earned initial EMT or Background: Manual active compression paramedic certification between January 1, 2007 of the assessment were significantly different between the pre and post assessments (p = decompression CPR (ACD CPR) with ITD and December 31, 2016. Descriptive statistics (impedance threshold device) in supine were calculated. A non-parametric test of trend 0.0218). The pre–post difference in emotional scorewasnotdifferent(p= 0.21). Conclusions: position has shown improved outcome in was used to assess for increasing or decreas- out-of-hospital cardiac arrest. Automated ACD ing trends in the proportion of females earning Using the MLHF, we found significant improve- ment in QOL of CHF patients who completed CPR with ITD in a thirty-degree head up certification during the study period. Results: position (HUP) has shown improved cerebral In 2007, a total of 28.7% of EMTs earning ini- the CP program. This study is limited by the small sample size but demonstrates encourag- perfusion in porcine and human cadaver mod- tial certification were female compared to 34.8% els. There is controversy regarding the ability in 2016, representing a percent change of 21.3% ing improvements to this patient population. < to perform high quality manual ACD CPR in (p-trend 0.001). An increase was noted in 7 of 96. Seatbelt Use by Ambulance Personnel HUP. Hypothesis: High quality manual ACD 9 year-to-year comparisons. However, the pro- in the Patient Compartment Is Low CPR in HUP to specific standards is feasible. portion of females earning initial paramedic Regardless of Patient Presence, Seating Methods: A recording simulation mannequin certification was stagnant during the 10-year Position, or Patient Acuity was placed in HUP. After brief instruction period. While statistically significant (p-trend and practice using the Zoll ResQCPRTM NAEMSP 2018 ANNUAL MEETING ABSTRACTS 125

system continuous ACD CPR was started by discharge. This was substantially higher than IV dose of epinephrine. All other compo- a three-member first response team. The com- the out of hospital cardiac arrest survival rate nents of the cardiac arrest protocol where pressor straddled the mannequin. After each reported by the CARES registry (p < 0.001). unchanged and followed the ACLS algorithm. 200 compressions there was a break to switch Conclusions: The media’s depiction of cardiac Each patient was closely followed through a compressors.TheCPRfeedbackfromthe arrest survival often does not include survival Quality Assurance and Quality Improvement mannequin and the ResQCPRTM system was to discharge information. When television and process. Data was compared from February recorded and analyzed looking at depth, rate, film survival to discharge rates are known, through July 2016, with epinephrine adminis- and decompression negative pressure (>10 they are significantly greater than actual cardiac tered every 3–5 minutes; to February through kg). 80% beat-to-beat compliance for depth and arrest survival rates. This may lead to unreal- July 2017, with epinephrine administered once. decompression and an average rate between istic expectations regarding out of hospital car- Evidence of neurological status was obtained 75 and 85/minute was considered high quality diac arrest victims’ chances of survival in the from the physician discharge summary in the CPR. Zoll recommends a rate of 80/minute for general public. patient’s medical record. Results: In the 2016 this system. After completion of 15–20 minutes period, 134 cardiac arrest calls were identified of simulated manual ACD HUP CPR the team 99. Benchmarking the Use of Red Lights from a total of 27,282 EMS calls. Thirty-three members were asked to complete a survey to and Sirens in 9-1-1 Systems: A Review of a patients achieved return of spontaneous circu- assess the degree of fatigue and muscle strain Large, National Dataset lation (ROSC) with 10 surviving to discharge. they experienced in comparison to standard Three of the 33 patients survived to be dis- Jeffrey Jarvis, Dustin Barton, Lauren Sager, CPR. Results: 5984 separate compressions charged home with no documented neurologi- Nick Nudell, Williamson County EMS Cate- were recorded. Mean (SD; CI95) rate was 78.1 cal deficit. In the 2017 period, 134 cardiac arrest gory of Submission: Operations, Quality, (6.9; 75.6–80.6)/minute and mean depth was calls were identified from a total of 27,572 total Safety Systems, Disaster, Disaster 2.16 (0.07; 2.14–2.19) inches. 30 separate 200 EMS calls. Thirty-nine patients achieved ROSC compression efforts were analyzed for beat-to- Background: The use of Red Lights & Sirens with 8 surviving to discharge. Seven of the beat compliance for depth and decompression. (RLS) in responses to and from the scene of 39 patients survived to be discharged with no Mean depth compliance was 78.6% (6.08%; a 9-1-1 call has long been tradition in EMS, documented neurological deficits. Outcomes: 75.8–81.3%). Mean decompression compliance although with limited evidence of clinical effi- The number of patients who received the “one- was 91.4% (1.1%; 88.0–94.8%). 10 of 10 survey cacy. There is a growing body of evidence of dose epinephrine” protocol and achieved ROSC respondents described manual ACD CPR HUP the dangers of RLS response and the effec- increased by 18%. Patient survival to discharge as more fatiguing than standard CPR and 9 of tiveness of priority dispatch triage for better home with no documented with neurological 10 described muscle strain. Discussion: Beat-to- triage of RLS responses. Little data has been deficits increased from 30% in 2016 to 87.5% beat % depth compliance fell just short of the published which defines the prevalence of RLS in 2017. Conclusions: Utilization of the “one- benchmark set. All other defined benchmarks use to and from 9-1-1 scenes. We sought to dose epinephrine” protocol demonstrated sig- were met. The authors anticipate that with describe the proportion of RLS responses using nificant improvement in the percentage of vic- more instruction and practice the beat-to-beat a large national dataset. Methods:Usingan tims who survived a medical cardiac arrest with depth compliance of 80% would be achieved. electronic review of 6 1/2 years of data from no documented neurological deficits. Conclusions: High quality manual ACD HUP 9-4-1 consenting agencies using ESO’s Elec- 101. Association between Initial Blood CPR can be done; however, it is more fatiguing tronic Health Record (EHR) system, we identi- Glucose in Out-of-Hospital Cardiac and causes more muscle strain than standard fied the transport mode of all responses toand Arrest and Return of Spontaneous CPR. from the scene of a 9-1-1 call that resulted in Circulation transport to a hospital. The proportion of calls to 98. Television and Film Depict Unrealistic and from the scene using RLS was determined, Rates of Cardiac Arrest Survival Caitlin Howard, Hattie McAviney, David along with 95% confidence intervals. Results: Wampler, Jeremy Allen, Justin Smith, David Johanna Innes, Brian Clemency, Maxwell Did- There were 7,709,012 9-1-1 calls that resulted in Miramontes, Joan Polk, United States Army, dams, Peter Natalzia, Deborah Waldrop, Uni- a patient transport. Of these, 5,846,038 (75.8%, UTHSCSA Category of Submission: Student, versity at Buffalo Category of Submission: 75.8–75.9%) involved RLS response to the scene Resident, Fellow Cardiac and 1,494,378 (19.4%, 19.4–19.4%) resulted in RLS response from the scene to the hospital. Background: Elevated blood glucose is Background: The media’s portrayal of cardiac Conclusions: Using a large national dataset, we associated with poor outcomes in patients arrest management and outcomes may shape provided baseline information on the preva- resuscitated from out-of-hospital cardiac arrest public perception of a cardiac arrest victim’s lence of the use of RLS to and from 9-1-1 calls. (OHCA). In this study, we evaluate whether chance of survival. We sought to determine While we are unable to assess the necessity of initial blood glucose level in OHCA patients is the rates of cardiac arrest survival depicted in such response, given the known prevalence of associated with return of spontaneous circula- television and film. We hypothesize that the high-acuity 9-1-1 calls, it is possible that the 76% tion (ROSC). Methods: This was a retrospective survival rates portrayed on television and in of RLS responses to 9-1-1 scenes could safely review of a registry containing details of movies were significantly higher than actual be decreased with appropriate priority dispatch each resuscitation attempt by a large, urban cardiac arrest survival rates. Methods:Wecon- processes and ongoing quality improvement. fire-based EMS system where the prevalence ducted a meta-analysis of existing studies of Further efforts using patient outcome should of diabetes is much higher than the national cardiac arrest resuscitations depicted on tele- assess the necessity of RLS response from the average (14.2% vs. 9.3%). Data from January 1, vision and film. A PubMed search was con- scene. 2016 through August 15, 2016 was analyzed. ducted using the following search terms: “car- Patients were included in the study if the diopulmonary resuscitation and television,” or 100. Usefulness of Epinehprine in Cardiac following variables were available: age, gender, “resuscitation and television,” or “heart arrest Arrest initial blood glucose, and outcome (no ROSC and television.” Two reviewers independently vs. ROSC). Patients were excluded if age < James Hehl, Matthew Wells, Beth Langley, reviewed all studies. Studies that included sur- 17, no age, gender, or initial blood glucose JE Winslow, Cape Fear Valley Mobile Integrated vival data from in hospital and out of hospital recorded, multiple blood glucoses crossing Healthcare Cumberland County EMS Category cardiac arrest patients depicted on television or 200 mg/dl, or no outcome recorded. Only the of Submission: Cardiac in movies were included in the analysis. Subject initial blood glucose obtained at the onset of demographics, rates of return of spontaneous Background: The landscape for treatment of resuscitation was considered. Patients were < circulation (ROSC), and survival to discharge cardiac arrest is evolving. The importance of divided into two groups: blood glucose 200 > were reviewed and compared to published data prompt, high quality cardiopulmonary resusci- mg/dl and blood glucose 200 mg/dl. A from the Cardiac Arrest Registry to Enhance tation and early defibrillation is receiving more t-test was used to analyze continuous variables χ Survival (CARES) registry. Results: The initial emphasis. For decades, intravenous (IV) admin- and a 2 test was used to analyze categorical PubMed search yielded 260 unique references. istration of epinephrine every 3–5 minutes has variables. Results: 620 patients were included + There were 412 resuscitation attempts among been a component of the standardized proto- in this study. Mean age was 64.23 17.20 years 532 cardiac arrests, from 8 studies which met col for treatment of cardiac arrest, yet recent with 385 males (62.10%). 453 patients (73.06%) < the inclusion criteria. The most common cause studies suggest that frequency of administra- had an initial blood glucose level 200 and 167 > of cardiac arrest was trauma (46.2%). All studies tion could impede neurological recovery.There- patients (26.94%) had a glucose level 200. Of < had data on ROSC, which occurred in 203 cases. fore, our EMS agency developed a “one dose the patients with glucose 200, 171 (37.75%) > The average rate of ROSC among the studies epinephrine” prehospital protocol for medi- obtained ROSC. Of those with glucose 200, was 49% (range 19% - 79%). Three studies had cal cardiac arrest as a quality improvement 63 (37.72%) obtained ROSC. There was no no information on survival to discharge. Five project. Hypothesis: Utilizing a “one dose association between blood glucose levels and = studies had survival to discharge statistics; 73 epinephrine” protocol will improve neurolog- achievement of ROSC (P 0.10). Conclusions: (25.2%) subjects were lost to follow up. Sur- ical recovery in survivors of cardiac arrest. We found no significant association between vival to discharge information was available for Methods: The protocol was revised and imple- initial blood glucose levels in OHCA patients 217 subjects of which 63 (29.0%) survived to mented in February of 2017 to include one and likelihood of achieving ROSC. The main 126 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

limitation to this study was that the patient vention, management of complex processes, paramedics in both cities (June–July 2017). population was restricted to San Antonio, and to help produce reliable outcomes. On After transcribing the interviews verbatim, Texas. Additionally, we only considered the April 1, 2016 a termination of resuscitation team members independently performed pre- initial blood glucose obtained during the (TOR) checklist was implemented for use dur- liminary coding. Ensuing group data analy- resuscitation. ing out-of-hospital cardiac arrests (OHCA) by sis sessions led to the development of final Milwaukee County Emergency Medical Ser- codes and thematic generalizations recurrent 102. Implementing a Prehospital Protocol vices (EMS) online medical control (OLMC) in the interviews. Results: All eight partic- to Treat Behavioral Emergencies with physicians concurrently staffing an emergency ipating community paramedics were inter- Midazolam Leads to Effective Control of department. Objective: To evaluate if the use viewed. Of the paramedics, five were women Agitated Patients of a TOR checklist by OLMC impacted return and all were non-Hispanic whites. The mean of spontaneous circulation (ROSC) for medi- age was 43. Participants typically had exten- Christopher Richards, Ryan Huebinger, Katie cal or traumatic OHCA. To compare if check- sive backgrounds in healthcare, primarily as Tataris, Joseph Weber, Kenneth Pearlman, list use changed the duration of resuscitations EMS providers, but minimal experience with Eddie Markul, Matthew Strzalka, Mark Kiely, performed by EMS providers and the duration community . All reported some Leslee Stein-Spencer, Leslie Zun, Northwestern of the OLMC call. Methods: Medical and trau- prior geriatrics training. Four themes emerged Feinberg SOM Department of Emergency Medicine matic OHCA data were extracted from the Mil- from the interviews: (1) certain characteristics and Center for Healthcare Studies, Chicago EMS waukee County EMS database from April 1, make coaches more likely succeed in this pro- System Category of Submission: Medical 2015 to September 30, 2015 (452 medical, 44 gram; (2) active rather than passive learning Background: Combative patients are com- trauma) and April 1, 2016 to September 30, may achieve the best results for community monly encountered by EMS providers and pose 2016 (482 medical, 71 trauma). Patient outcomes paramedic CTI training; (3) training program challenges for both patient care and provider were measured by occurrence of ROSC during components require minor refinements; and (4) safety. Chemical sedation with midazolam is resuscitation and by presence of ROSC at hospi- continuing education should more effectively commonly used in the emergency department tal arrival. Analysis of the data was done using address the paramedic coaches’ evolving needs. setting to treat agitation from psychiatric dis- t-tests. Results: In medical OHCA, incidence Conclusions: Paramedics represent a crucial turbances and intoxication. However, limited of ROSC during resuscitation increased from and largely untapped resource for supporting data exist regarding midazolam use in the pre- 41% (185/452) to 46% (220/482) with imple- ED-to-home care transitions, such as through hospital setting to treat agitation. We sought mentation of the TOR checklist and ROSC at the CTI. Training that leads to the appropri- to describe our experience after implementing hospital arrival increased from 35% (160/452) ate knowledge, skills, and attitudes is critical a protocol for treating patients with behav- to 40% (191/482). There was also a significant for effective implementation, including choos- < ioral emergencies using midazolam in a large (p 0.001) increase in mean duration of resus- ing the optimal candidate coaches, delivering urban EMS system. Hypothesis: We hypothe- citations (26 to 30 minutes) and duration of training in the most effective manner for the stu- size that implementation of a prehospital pro- OLMC (13 to 15 minutes) after the checklist was dents, and delivering content targeted to stu- tocol using midazolam to treat patients having implemented in cases of medical OHCA. Con- dent needs. a behavioral emergency leads to improved clin- clusions: In medical OHCA the use of a TOR 105. Emergency Medical Services Response ical conditions without causing significant clin- checklist by OLMC significantly increased the to Mass Shooting and Active Shooter ical deterioration. Methods: We performed a duration of both resuscitations and OLMC time. Incidents, United States, 2014–2015 retrospective review of EMS records following The rates of ROSC during resuscitation and at hospital arrival increased after the checklist was the implementation of a behavioral emergen- Matthew Sztajnkrycer, Aaron Klassen, implemented for medical OHCA. These results cies protocol in a large urban EMS system from Morgan Marshall, Mengtao Dia, N Clay show a potential clinical benefit for OLMC use February 2014 through April 2016. Paramedics Mann, Mayo Clinic Department of Emergency of a TOR checklist for medical OHCA, and were instructed to administer midazolam 1 mg Medicine Category of Submission: Trauma intravenous (IV) or intraosseous (IO) or 5 mg also inform resource utilization in an academic intramuscular (IM) or intranasal (IN), repeat- Emergency Department. In traumatic OHCA Background: According to Federal Bureau of ing once as needed, and to record the response there were no significant changes in duration of Investigation statistics, the number of active to treatment. Patients receiving midazolam for resuscitation or OLMC and there was a decrease shooter incidents has increased over the past the indication of “behavioral emergency” were in ROSC; further study with a larger sample decade. The purpose of the current study was included, and any patient receiving midazo- size may be needed. Neurological outcomes to describe the EMS response and interven- lam for “seizure” were excluded. Descriptive are unknown and further research may provide tions to mass shooting and active shooter statistics were used to report results, and Spear- a better understanding of the impact of these incidents. Methods: Retrospective analysis of man’s rho was calculated to determine cor- findings. 2014 and 2015 National Emergency Medical relation of dose and route. Results:Intotal, Services Information System (NEMSIS) data 104. Qualitative Evaluation of Community midazolam was administered in 435 instances sets. Date, time, and location for mass shoot- Paramedic Care Transitions Intervention to 390 patients. Median age was 33 (IQR 24– ing incidents were obtained from the open Coach Training 50) years; 69.0% were male, and 53.1% were source Gun Violence Archive and then corre- African American. Doses administered were Hunter Lau, Matthew Hollander, Jeremy lated with NEMSIS data set records. Active 1 mg (11.8%), 5 mg (72.3%), and 10 mg (15.1%) Cushman, Amy Kind, Courtney Jones, shooter incidents were identified through FBI via IM (42.2%), IN (41.1%), IV (16.5%), and Michael Lohmeier, Manish Shah, University data. A de-identified database was generated IO (0.2%) routes. In 37 patients, a second of Wisconsin School of Medicine and Public Health for final analysis. Results: A total of 608 mass = dose was required, and the same dose (rho Category of Submission: Student, Resident, shooting were identified, of which 19 were < = < 0.84, p 0.0001) and route (rho 0.68, p Fellow classified as active shooter incidents. Mean 0.0001) as the first administration was com- number of injured victims was 4.6 ± 2.5, mon. Paramedics reported slight or substan- Background: The Care Transitions Intervention while mean number of fatalities was 1.2 ± tial improvement in clinical condition in 75.3% (CTI) has potential to improve the emergency 2.2. NEMSIS data identified 652 EMS activa- of patients, and 24.7% had no clinical change. department (ED)-to-home transition for older tions to 226 unique incidents; 5 were active No paramedic reported clinical deterioration adults. Community paramedics may function shooter incidents. 76% of victims were male. in a patient’s condition following midazolam as the CTI coaches instead of nurses who tradi- 80% of victims were African American. The administration. Conclusions: A protocol using tionally serve in that role. To do so requires that mean age was 27.7 ± 11.1 years. Dispatch com- midazolam in behavioral emergencies can be the community paramedics possess the appro- plaint was reported as not known or unknown successfully implemented in a large urban EMS priate knowledge, skills, and attitudes, which problem/man down in 14.6% of records. The system. Midazolam successfully treated agita- are not inherently part of traditional EMS edu- predominant response configuration was ALS tion, and paramedics did not feel that patients’ cation. The aim of this study is to evaluate an (78.8%). Volunteer services responded to 7% clinical conditions worsened after midazolam expert-panel developed training program for of events. The most commonly reported inci- administration. community paramedics serving as CTI coaches dent locations were Street/Highway (38.2%), who support the ED-to-home transition. Meth- Home/Residence (32.4%), and Trade/Service 103. Termination of Resuscitation ods: This study is a component of an ongoing (11.5%). Location of wounds included extrem- Checklist: Duration and Outcomes of two-center randomized controlled trial evaluat- ities (38%), chest (9%), and head (9%). Tourni- Resuscitation ing a community paramedic-implemented CTI quet use was documented in 6 victims. Gun- to enhance the ED-to-home transition. Com- shot wound was self-inflicted in 2.3% of vic- Katherine Kuefler, Aurora Lybeck, Thomas munity paramedic training covered multiple tims. When present, cardiac arrest occurred Grawey, M. Riccardo Colella, Medical College of domains including the CTI program, geriatrics, after EMS arrival in 37.5% of cases. 35.9% of Wisconsin Category of Submission: Student, motivational interviewing, ED discharge, and victims were transported to the closest facility. Resident, Fellow community paramedicine. One year after start- Conclusions: Mass shooting and active shooter Background: Checklists are often used in medi- ing the study, we conducted audio-recorded incidents are prevalent in the United States, cal and non-medical fields to aid in error pre- semi-structured interviews with community with an average of 5.8 victims per incident. NAEMSP 2018 ANNUAL MEETING ABSTRACTS 127

Despite the fact that extremity wounds were a unique Community Paramedic (CP) part- health care needs) at risk for secondary trans- the most common injury noted, suggesting a nership. Hypothesis: Patients with congestive port or interfacility transport (IFT). IFT deci- role for public access bleeding control, doc- heart failure who receive CP visits for 30 days sions are made quickly, but patients risk sub- umented EMS tourniquet use was uncom- post-discharge have a reduced rate of readmis- optimal pre-transfer care, and suffer delays in mon. While mass shooting events pose high sion and an increased use of clinic visits. Meth- definitive care and increased morbidity. Quan- risk for responders, dispatch information was ods: Inpatients with CHF were offered visits by titative physiologic data (vital signs, capillary lacking in nearly 15% of records. Respond- a CP for up to 30 days post discharge. Inclusion refill time, hospital-based scoring systems) in ing EMS agencies were diverse and included criteria included, local residentTia, no home- isolation do not accurately or reliably pre- BLS providers and volunteers, emphasizing the care services upon discharge, diagnosis of CHF, dict the need for pediatric specialty/critical need to ensure all EMS providers are prepared English speaking, and consent to home visits by care. Combining quantitative and qualitative to respond to mass shootings. a CP. The CP visited the patient in the home prehospital assessments promises more accu- 1–2 times per week for 4 weeks following dis- rate, reliable prediction of specialty/critical 106. When Dogs Fly: Use of Air Medical charge. At each visit the CP conducted med- care needs. After reviewing the evidence, the Services to Transport Operational K9s ication reconciliation, a physical exam, home expert panel’s modified-Delphi process pro- Injured in the Line of Duty safety evaluation, coordination of follow-up duced a pediatric prehospital destination EBG care and referral to community or healthcare (“PDTree”). The PDTree is formatted as an Chelsea Hogan, Chadd Nesbit, Department of resources as needed. Pre/post comparisons algorithm, matching 14 non-trauma condi- Emergency Medicine, Penn State Milton S. Her- were analyzed descriptively using means and tions/risk factors (including ALTE, seizure shey Medical Center Category of Submission: standard deviations. Scores were assessed with requiring EMS-administered benzodiazepine, Student, Resident, Fellow Wilcoxon signed-rank tests. Results: A total sepsis, and emergencies related to conditions Background: Instances of operational K9 air of 64 patients were enrolled between Febru- treated at a medical home) to three differ- medical transports have been documented in ary 2015 and July 2017; 32 patients completed ent levels of pediatric care (specialty, compre- the popular press. There have been no stud- the program with complete data. A compari- hensive, regional). Conclusions:Existingmed- ies to look at the prevalence of such trans- son of 90-day healthcare utilization pre- and ical literature identifies the need for prehos- ports or to determine what policies flight pro- post-admission showed that patients who were pital transport destination guidance for non- grams have in place to address this challeng- provided CP services had a significant decrease trauma pediatric patients. That evidence sup- < ing transport issue. We sought to assess the in hospital admissions (68%, p 0.0001) and ported the modified-Delphi process that pro- < prevalence of operational K9 transports as well ED visits (62%, p 0.0001), and had a 14% duced the “PDTree,” a new non-trauma pedi- = as existence and content of protocols to con- increase in clinic visits (ns, p 0.45). A group of atric prehospital destination EBG. “PDTree” duct such a transport should one be deemed patients that met inclusion criteria but declined will be pilot tested by computerized resource necessary. Methods: We distributed a survey consent to participate was compared to the modeling, prehospital provider simulation, and to air medical programs in the United States patient group that participated in the CP pro- implementation in three diverse EMS agencies. via the Research Electronic Data Capture (RED- gram. Patients who completed the program 109. Duplicate Procedures and Charges Cap) program. Programs were identified using had a significantly higher decrease in admis- = = Associated with Pediatric Inter-Facility the Atlas and Database of sions (p 0.0145) and ED visits (p 0.0009) Transfer from Emergency Departments (ADAMS ). Programs that could not be reached pre- to post-hospitalization than those who did not enroll (n = 20). There was no significant via email were excluded. A survey containing Ali Aledhaim, Jon Mark Hirshon, Jennifer difference in change in clinic utilization. Con- up to 23 questions inquiring about K9 trans- Fishe, Jennifer Anders, University of Maryland clusions: Partnership between fire-based EMS ports, policies and procedures was emailed to Department of Emergency Medicine Category of and hospitals for Community Paramedic pro- 295 identified programs. Results: We received Submission: Pediatric 147 total survey responses (49.8% response). grams can be successful. CP’s providing post- Twenty-two programs (15%) reported receiv- discharge care results in a shift of healthcare Background: Interfacility Transfer (IFT) of ing a request to transport a K9 and of those, utilization toward reduced admissions/ED vis- patients with emergency conditions from an 15 reported flying the K9. Forty-one K9 trans- its and increased clinic visits. Further research Emergency Department (ED) delays defini- ports were reported. Smaller numbers of pro- with a larger cohort is needed to determine if tive care and burdens the patient with poten- grams reported having any additional train- utilization patterns would be sustained past 90 tially harmful duplicate procedures and extra ing related to care or transport of operational days. charges. This physical and economic hardship K9s or a pre-designated emergency veterinar- may be preventable if patients are taken to a 108. “PDTREE”: Development of a New ian. Six programs reported carrying some type definitive care facility for their initial destina- Pediatric Prehospital Transport of equipment for use on K9s and 7 programs tion. Objective: To determine duplicate pro- Destination EBG reported having some type of protocol in place cedures and charges sustained by pediatric for these types of flights. Ninety-five of the Jennifer Fishe, Kye Fratta, Jennifer Anders, patients undergoing IFT for inpatient admis- programs reported that they would be able to University of Florida COM - Jacksonville, Depart- sion after an ED visit to a different facility. fly the K9 and handler as well as the normal ment of Emergency Medicine Category of Sub- Methods: This study utilized three years (2010– flight crew. Conclusions: The goal of this sur- mission: Pediatric 2012) of Maryland HCUP ED and inpatient visit vey was to quantify the number of transports data. A modified probabilistic linkage was per- for injured operational K9s and to identify any Background: Prehospital triage should match formed to identify ED patients who were dis- policies or procedures that programs have in patient needs with hospital service availabil- positioned to IFT and admitted to a distant place to carry out a transport if one is requested. ity. EBGs guide EMS’ destination choice for facility. Included patients were 0–17 years of Although supposedly a rare occurrence, 15% of adult patients suffering from trauma, MI, and age with any of the 20 most common Diag- our respondents have reported such a request. stroke. However, analogous guidelines do not nosis Categories (DxC) and whose conditions Of those requests the majority of transports exist for any pediatric condition save trauma. were classified “emergent” or “urgent”. After were completed. While some programs may This study’s objective was to create a non- linkage, duplicate procedures were identified decide that they will not transport an injured trauma pediatric prehospital transport des- and classified as administrative or clinical. Mul- operational K9, those programs that will should tination EBG. Methods: A systematic liter- tiple regression analysis was used to com- establish policies and procedures for this type of ature search identified articles pertinent to pare the average total charges of IFT patients, mission. non-trauma pediatric prehospital destination including duplicate charges, to non-IFT admit- choice. Resulting articles were reviewed using ted patients presenting with the same top 20 107. Community Paramedic Partnership: GRADE and compiled into an evidence pro- DxC. Results: Of the 9,447 IFT inpatients iden- Shifting Healthcare Utilization through file. An expert panel (including stakeholders tified, 2,254 patients were successfully linked, Partnership between Municipal Fire/EMS from pediatric EM, EM, EMS medical direc- of which 1713 (76%) had one of the top 20 and the Local Level I Trauma Center tors, EMS providers, and patient/family advo- DxC. The most frequent administrative dupli- cates) reviewed the evidence profile and data cate procedure was ER EMTALA emergency Tia Radant, Joseph Pasquarella, Ann Majerus, from the statewide EMS system where the EBG medical screening (1,407). Notable duplicate Matthew Simpson, Paula Miller, Sandi would undergo pilot testing. Using a modified- clinical procedures involving repeat radiation Wewerka, Aaron Burnett, Regions Hospital Delphi process with three voting rounds and were chest X-ray (239) and CT scan of head EMS Category of Submission: Operations, 75% agreement threshold, the panel selected (97) or body (32). IFT patients incurred an aver- Quality, Safety Systems, Disaster, Disaster items for inclusion, refined terminology, and age total charge of $11,786.61 including an aver- Background: A partnership between a Level reached consensus on a pediatric prehospi- age duplicate charge of $1,627.84. In compari- I Trauma Center and an urban, municipal tal transport destination EBG. Results:The son, the average charge incurred by a non-IFT Fire/EMS Department for patients with con- literature search produced 60 articles. After was $8,209.72. Adjusting for the effect of age, gestive heart failure (CHF) was launched in GRADE review, 47 articles were included in gender, and race, a weighted regression model < 2014. The program aimed to improve healthcare the evidence profile. Articles identified specific estimated an average 34% (30.1–37.6%, p utilization and reduce readmissions through pediatric populations (ALTE, seizures, special 0.001) increase in total charges for an IFT patient 128 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

compared to a non-IFT patient. Conclusions: have STPs that are either mandatory or serve tests using 0 as the standard landmark. The Both safety harms (radiation exposure) and sig- as a guide for medical directors. The purpose average distance from the landmark on the nificant economic burden are seen in the subset of this investigation is to describe the extent humerus was 5.06 cm (95% CI: 4.06–6.06). of patients undergoing IFT from an ED for inpa- to which STPs include DAI and the variabil- The average from the tibia was 4.13 cm (95% tient admission to a distant facility. EMS sys- ity in pharmacopeia utilized. Methods:Cross CI: 3.16–5.10). Both were statistically signifi- tems can minimize this inefficiency and burden sectional study of STP utilizing a standardized cant with a p value of <0.0001. Conclusions: by transporting patients to definitive care facil- review of DAI protocols and medications. Pro- These results show a low accuracy among EMS ities whenever feasible. tocol revision date was also captured. Results: providers in identifying correct landmarks for Thirty one out of fifty states (64%) issue STPs, intraosseous needle placement. This suggests 110. Clinical Events In Prehospital seven (22%) of which serve as guidelines. RSI is additional training and skills review may be Patients With St-Elevation Myocardial included in the STP of 17 states (55%). Sedative- needed across the state in order to safely per- Infarction Transported To A PCI Center By only intubation is included in the STP of 5 states form this procedure. Basic Life Support Paramedics In A Rural (16%). The most commonly included induc- Region tion agents are etomidate and midazolam (19 113. Paramedic Recognition and Management of Anaphylaxis in the Pierre-Alexandre LeBlanc, Sylvain Bussières, STPs each, 61%); other induction agents include Prehospital Setting François Bégin, Alain Tanguay, Jean-Michel ketamine (11 STPs, 35%), fentanyl (2 STPs), and propofol (1 STP). Succinylcholine is the Paradis, Denise Hébert, Richard Fleet, Départe- Rakesh Gupta, Krystyna Samoraj, Simerpreet most commonly included paralytic (17 STPs, ment de Médecine d’Urgence – Université Laval Sandhanwalia, Matt Kerslake, Luke Ryan, 55%); rocuronium (11 STPs, 35%) and vecuro- Category of Submission: Student, Resident, Colleen Shortt, Michelle Welsford, McMaster nium (7 STPs, 23%) are other approved para- Fellow University Category of Submission: Student, lytic agents. 16 states (52%) permit intubation of Resident, Fellow Background: Rural areas have limited hospi- both adult and pediatric patients while 6 states tal staff and often rely on basic life support (19%) only allow DAI of adult patients. All pro- Background: Anaphylaxis is a life-threatening (BLS) paramedics for inter-facility transport. tocols have been revised within the past 5 years condition that paramedics are equipped to treat No previous study has established whether and 75% of protocols were revised since 2015. effectively in the field. Current literature sug- ST-segment elevation myocardial infarction Conclusions: The NAEMSP position statement gests improvements in paramedic recognition (STEMI) patients transported in ambulance on drug-assisted intubation recommends the and treatment of anaphylaxis could be made. over long distances are at risk of suffering from use of a paralytic during DAI, as it increases the The aim of this study was to compare the clinical events such as bradycardia or hypoten- likelihood of first pass success. Just over half proportion of cases of anaphylaxis appropri- sion. The objective of this study was to estab- of all STPs allow for DAI, and 16% allow for ately treated with epinephrine by paramedics lish clinical events, and to determine if the sedative-only intubation despite the NAEMSP before and after a targeted educational inter- complications occurring in the presence of BLS position statement on DAI. There is significant vention. Methods: This was a retrospective paramedics are influenced by the transporta- variation in both the induction agent as well as medical records review of patients with ana- tion time. Methods: In a retrospective cohort the paralytic utilized for intubation across STPs. phylaxis managed by primary or advanced care study, we reviewed 896 consecutive STEMI There is also variation in the number of states paramedics in five Emergency Medical Ser- patients diverted and transported to the near- that allow for both adult and pediatric intu- vice areas in Ontario, before and after an edu- est PCI-capable center according to an emer- bation. Additional research is needed to deter- cational module was introduced. This mod- gency physician interpretation of a 12-lead ECG mine optimal agents and protocols for prehos- ule included education on anaphylaxis diagno- transmitted by paramedics. Patients had contin- pital intubation. sis, recognition, treatment priorities, and feed- uous electrocardiogram (ECG) and vital signs 112. Assessment of Intraosseous Needle back on the recognition and management from monitoring during transport. A focus group Placement by EMS Providers the before period. All paramedic call records composed of the authors established clinically (PCRs) coded as “local allergic reaction” or important and minor events based on liter- Alexandra Petrie, Jeffrey Lubin, Penn State Col- “anaphylaxis” during 12-month periods before ature search. A multivariate ordinal logistic lege of Medicine Category of Submission: Oper- and after the intervention were reviewed by regression model was used to study the asso- ations, Quality, Safety Systems, Disaster, trained data abstractors to determine if patients ciation between transportation time (0–14, 15– Disaster met an international definition of anaphylaxis. > 29 and 30 min) and the occurrence of clin- The details of interventions performed by the ical events. Results: Clinically important and Background: Intraosseous (IO) needle place- paramedics were used to determine primary minor events were experienced by 18.6 and ment can be used to provide quick delivery and secondary outcomes. Results: Of the 600 12.16% of STEMI patients, respectively. Trans- of various fluids to the patient, particularly PCRs reviewed, 99/120 PCRs in the before and portation time was not associated with higher in cases in which venous access is compro- 300/480 in the after period were included. Of = risk of suffering from clinical events (p mised; however, if done incorrectly, it can lead the charts included, 63/99 (63.6%) in the before 0.182). The most frequent events were brady- to unwanted complications such as extrava- and 136/300 (45.3%) in the after period met cri- cardia (8.87%), followed by hypotension (6.1%), sion of fluid, poor flow, and catheter dislodge- teria for anaphylaxis (p = 0.002). Of the cases and ventricular tachycardia / ventricular fib- ment (Paxton 2009; Dev 2014; Gluckman 2014). meeting anaphylaxis criteria, 41/63 (65.1%) in rillation (VT/VF) (5.13%). All patients suffer- The purpose of this study is to see if EMS the before and 88/136 (64.7%) in the after ing from VT/VF were successfully resuscitated providers can adequately locate the correct period were correctly identified as anaphylaxis with defibrillation. No death on arrival at PCI locations for the placement of IO needles in (p = 0.96). Epinephrine was administered in center was recorded. Conclusions:Prehospi- live models. Methods: We assessed the accu- 37/63 (58.7%) of anaphylaxis cases in the before tal STEMI diagnosis by transmission of a 12- racy of intraosseous placement by asking EMS period and 76/136 (55.9%) in the after period lead ECG interpreted by emergency physicians providers from a statewide conference to sim- (p = 0.70). Anaphylactic patients with only and triage for primary PCI by paramedics with- ulate where they would use an intraosseous two-system involvement received epinephrine out advanced care training is a safe option that needle on standardized patients. Each partici- in 20/40 (50.0%) cases in the before period could use less advanced staff in rural areas with pant also filled out a demographic survey that and 45/93 (48.4%) in the after period (p = limited resources. included their experience with intraosseous 0.86). Conclusions: There are gaps in paramedic needles and a knowledge of acceptable EZIO 111. Description of Drug-Assisted recognition and management of anaphylaxis, intraosseous needle landmarks from a list of Intubation in Statewide Treatment particularly in cases of two-system involve- options. Measurements were established on Protocols ment. These gaps persisted after the imple- live human models using transfer paper with mentation of an educational intervention. Other Steven Sommerville, Daniel Wilner, David stickers placed in tibial and humeral IO spots, quality interventions and periodic refreshers Schoenfeld, Beth Israel Deaconess Medical Center marked so that they easily lined up with the may be necessary to improve prehospital treat- Category of Submission: Student, Resident, model via landmarks. The participant was ment of anaphylaxis. Limitations include an Fellow asked to place a sticker directly on the model increase in overall cases and decrease in rate where they would insert the EZIO at both of true anaphylaxis in the after period, which Background: Endotracheal intubation in pre- locations. Afterward, a transfer sheet with the may relate to better case identification after hospital airway management has been a focus sticker placed at a location correlating with electronic PCR implementation and changes in of research and debate for decades. Endo- standard placement was compared against the paramedic recognition. tracheal intubation is performed using drug- participant-placed sticker. Differences in place- assisted intubation (DAI) or without medica- ment were measured with a ruler to the near- 114. National Description of Patient tion. DAI is divided into rapid sequence intu- est half centimeter. Direction was qualitatively Refusals Following Prehospital bation (RSI) where a sedative as well as neu- noted. Numbers were assigned to each par- Administration of Naloxone romuscular blockade is used or sedative-only ticipant so that the demographic survey, loca- intubation. The extent to which DAI is incor- tion survey, and sticker location could be linked Mirinda Gormley, Juan Lu, Virginia Common- porated in statewide treatment protocols (STP) to each individual subject (N = 30). Results: wealth University Category of Submission: has not been described. The majority of states Results were analyzed via several 2 sample t Medical NAEMSP 2018 ANNUAL MEETING ABSTRACTS 129

Background: Emergency medical services be in status epilepticus. For measures requir- Seung Chul Lee, Sun Young Lee, Sang Do (EMS) personnel deliver Naloxone to reverse ing administration of a medication, only ALS Shin, Jeong Ho Park, Dongguk University Ilsan deadly opioid overdoses. However, EMS per- providers were included. For each measure, a Hospital Category of Submission: Cardiac sonnel may experience challenges with patient rate and 95% Confidence Interval were calcu- care, including being unable to convince a lated. Results: A total of 147,238 patients had Background: Understanding the epidemiologic patient to be transported to the hospital. a documented blood glucose <60. Of these, characteristics of anaphylaxis-associated out- Without accessing appropriate follow-up care, 117,358 (79.7%, 95% CI 79.5–79.9%) received of-hospital cardiac arrests (OHCAs) is the these patients could overdose again. Objec- some type of glucose. Of 11,148 patients with first step for developing preventative strate- tive: Identify characteristics associated with a status epilepticus, 8,072 (72.4%, 71.6–73.2%) gies and optimizing care systems. We aimed patients who received Naloxone from EMS but had a blood glucose documented and 6,250 to describe and compare the epidemiologic refused to be transported to hospital. Methods: (56.1%, 55.1–56.0%) had some type of ben- features and outcomes among patients with Data came from the 2015 National Emergency zodiazepine given by ALS agencies. Conclu- anaphylaxis-associated OHCAs according to Medical Services Information System. The sions: We describe the compliance rates on sev- causative agents group. Methods: We identi- incident/patient disposition was used to eral EMS Compass measures using a national fied emergency medical service (EMS)-treated create a binary outcome (“transported” or cohort. We found a low rate of benzodiazepine anaphylaxis-associated OHCA patients from a “refused”), where “treated, transferred care,” use for status epilepticus. It is possible that nationwide OHCA registry between 2008 and “treated, transported by EMS,” and “treated, this is a function of poor, non-standard doc- 2015. We compared epidemiologic character- transported by Law Enforcement” made up umentation, imprecise measure definitions, or istics and outcomes according to the causal “transported,” and “no treatment required,” poor clinical performances. In any case, these agents and evaluated temporal variability in “patient refused care,” “treated and released,” results identify opportunities for important sys- anaphylaxis-associated OHCA incidence. The and “treated, transported by private vehicle” tem improvement. rate of survival to discharge was compared comprised “refused.” Characteristics included among causative agents groups using mul- age, gender, race, prior aid, location, U.S. 116. Analysis of Medication Storage tivariate logistic regression analysis. Results: census region, and urbanicity. Descriptive and Temperatures in a Modern EMS Fleet: During the study period (8 years), a total of 224 multivariable logistic regression were utilized. Preliminary Results from the Analysis of anaphylaxis-associated OHCAs were included Results: In 2015, EMS agencies reported 585,108 Medication Storage Temperatures Trial in the analysis. Natural agents group includ- Naloxone administrations by personnel of a (AFIRE) ing insect sting and foods were 192 (85.6%) transport unit during a 9-1-1 response. After and iatrogenic agents group were 32 (14.3%). Timothy Burns, Alan Butsch, Cristopher treatment, 1.6% of patients refused transport. There was significant variability in the fre- Touzeau, Roger Stone, Barry Reid, Mont- These patients were primarily male (65.0%), quency of anaphylaxis-associated OHCA by gomery County (MD) Fire And Rescue Service < white (76.8%), and had a median age of 48 (IQR hour of the day (p value 0.01) and sea- Category of Submission: Professional < = 32–61). Compared to transported patients, son of the year (p value 0.01), with the highest incidence occurring during the day- those who refused were more likely to be found Background: EMS operational programs time (7:01 am to 3 pm; 64.6%) and in summer in a residence (75.6% vs. 68.0%), or receive aid deploy medications using a variety of means (June to August, 48.7%). Compared with nat- prior to EMS arrival (60.3% vs. 23.9%). Larger under all kinds of conditions. Because of this ural agents, the adjusted odds ratios (AORs) proportions of patients went to the hospital if deployment versatility, medications that were for survival to discharge in iatrogenic agents found in a public location (19.7% vs. 13.5%), once limited to somewhat controlled clinical were statistically insignificant (AORs 3.61, 95% or a rural/wilderness area (10.4% vs. 6.6%). settings are now deployed on vehicles whose CIs 0.86 to 15.06). Conclusions: There was sig- Patients had nearly double the odds of being climate control is more difficult. Purpose: nificant temporal variability in the incidence transported from a public location rather than To explore whether or not EMS medications = = of anaphylaxis-associated OHCA, with its peak a residence (OR 1.704, 95% CI 1.58–1.84), deployed in modern fire and EMS vehicles during the summer. Anaphylaxis-associated and patients in rural/wilderness locations were experience temperatures that are outside OHCA by natural agents accounted for the 1.5 times more likely to be transported than storage temperature ranges from the US Phar- = = greater proportion of anaphylaxis than iatro- urban patients (OR 1.58, 95% CI 1.44–1.73). macopeia. Hypothesis: Medications will be genic agents but there was no difference in sur- Patients who did not receive aid prior to EMS exposed to temperatures outside the guidelines vival to discharge between the two groups. arrival were nearly twice as likely to go to the in all types of our apparatus. Methods:We hospital (OR = 1.71, 95% CI = 1.61—1.81). recorded ambient temperatures on two of our 118. Relationship between Adult Body Conclusions: While effective at reversing paramedic engines and in two of our transport Mass Index and Anticipated Failure Rate fatal overdoses, prehospital administration of units during two summer months in 2017 using of Needle Decompression Using a 5cm Naloxone is not sufficient to address addiction, temperature data loggers. Once downloaded Needle for Tension Pneumothorax whereas those transported to hospital could into a database, these measurements created access treatment. EMS agencies should work a continuous stream of temperature data for John Lyng, Kristin Pokorney-Colling, together with public safety partners to plan the entire study period. Results:Datafrom Michaela West, Gregory Beilman, North howtoworkwithpatientsmostatriskof the paramedic engine location reveals that the Memorial Health Ambulance and Air Care Cate- refusing transport following initial treatment. ambient temperature was above the definition gory of Submission: Trauma of “extreme heat” from the USP (104°F) for 115. EMS Compass Benchmarks Using a 1,350 minutes (1.4%) of the 94620-minute study Background: Tension pneumothorax is trau- National EMS Dataset: Status Epilepticus period, in the range “warm” (86–104°F) for matic injury that can lead to rapid circulatory and Hypoglycemia Performance Measures 60168 minutes (64%) of the study period, and collapse and death. Emergent needle thoracos- out of the “controlled room temperature” tomy can quickly treat tension pneumothorax, Jeffrey Jarvis, Dustin Barton, Lauren Sager, range 89229 minutes (94%.) Neither position in but the best anatomic location and catheter Nick Nudell, Williamson County EMS Cate- the transport unit was subjected to “extreme length necessary to perform the intervention gory of Submission: Medical heat,” but they were in the “warm” range has been questioned in the recent years given the increasing rates of obesity in our popula- Background: Status epilepticus and hypo- for 5759 minutes (6%) and 12092 minutes tion. Methods: We conducted a retrospective glycemia are emergent conditions, both of (13%) respectively, during the study period. review of a convenience sample of all trauma which can be effectively treated by EMS. It is Transport unit temperatures were outside of patients admitted to our level 1 trauma center unclear how often these assessments and treat- the “controlled room temperature” range for in Minneapolis, MN that underwent chest com- ments are given. EMS Compass is a national 51138 minutes (54%) and 67131 minutes (71%). puted tomography (CT) during their admis- organization that has developed several clini- Conclusions: Temperature is much more sion between 2011 and 2012. Using these CT cal measures. No work has been done to bench- controlled in the transport units than in the radiographs, chest wall thickness was mea- mark these measures against large, national Paramedic Engines. Medications deployed on sured bilaterally at the 2nd intercostal space datasets. This is necessary for quality improve- our paramedic engines experience a significant (ICS) at the midclavicular line, and at the 4th ment efforts and refinement of the measures “extreme heat” exposure. During the summer and 5th intercostal spaces at the anterior axillary themselves. We aimed to describe compliance months of the study period, all environments line. Baseline demographic data including age, with these measures using a large, national tested temperatures in the “warm” range and sex, BMI, ISS and associated chest wall trauma cohort. Methods:Usinga6½-year sample all were out of “controlled room temperature” were collected from medical chart review. Nee- of 9-4-1 consenting EMS agencies using the range a majority of the time. Limitations: These dle thoracostomy failure was defined as chest ESO electronic health record (EHR), we calcu- observations only define the temperatures to wall thickness (CWT) of > 5cm, based on the lated compliance rates among transported 9-1- which the medications were exposed. Further length of commonly used needle decompres- 1 patients for the following measures: (1) some study would need to be conducted on the sion needles. Results: Atotal of 141 patients that type of glucose given to those with blood glu- effectsofthisexposure. met all inclusion criteria were identified. There cose under 60, (2) a blood glucose documented 117. Epidemiology And Outcomes Of were no significant differences in mean CWT for those felt to be in status epilepticus, and Anaphylaxis-Associated Out-Of-Hospital at any of the anatomic sites. CWT was simi- (3) a benzodiazepine given for those in felt to Cardiac Arrest lar between males and females. BMI > 30 was 130 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

associated with an adjusted odds ratio of 13.8 esized that the efficacy of DSD compared to street course at, or below, posted speed lim- (Confidence interval 4.8–39.8) for failure with control shocks (one vector, one device, shock its. The driver was blinded to the subject posi- a standard 5cm catheter needle decompression. size the same as each of the two DSD shocks) tion. Composite volume of motion was mea- Conclusions: In the increasingly obese general would depend on the time between the two sured at the T12-L1 body area. Statistical sig- population, needle thoracostomy with a stan- shocks. Furthermore, we hypothesized that the nificance was determined using t-test. Results: dard 5cm needle may be more prone to fail- potential for damaging a defibrillator during Nine healthy subjects participated, 66% were ure. Adult BMI > 30 is a significant risk fac- DSD would depend on the choice of shock vec- male. Comparing movement between LSB and tor for anticipated failure of needle tube decom- tors. Methods: To assess shock efficacy, defib- no LSB respectively, there was no statistical dif- pression. Alternative anatomic sites for nee- rillation pads were applied in lateral-lateral ference in three-dimensional volumetric move- dle decompression did not appear increase the (LL) and anterior-posterior positions in 10 anes- ment of the thorocolumbar spine (2 ± 0.6 mm3 anticipated success of the intervention. thetized pigs. Episodes of electrically-induced LSB vs. 4.7 ± 5 mm3 no LSB). The two posi- VF were treated with a shock of a block- tions that allowed the lowest mean volume of 119. Evaluating the Incorporation of a randomized therapy. Shock energy was chosen spinal movement were: head of the bed ele- Journal Club Series into Paramedic Initial to yield approximately 25% success for a single vated to 10 degrees and 30 degrees with head- Education LL shock. We compared LL stacked shocks (i.e., blocks adhered to the mattress (1.2 ± a failed LL shock was repeated) and seven DSD 1.5 mm3 and 0.9 ± 0.5 mm3, respectively). Con- Lauren Maloney, Paul Werfel, Robert Mar- shock intervals (Overlapping; 10, 50, 100, 200, clusions: In healthy volunteers thorocolumbar shall, Scott Johnson, Stony Brook University 500, 1000 ms apart), with n = 81 VF episodes spinal motion was limited in all groups and not Dept of Emergency Medicine Category of Sub- per therapy. To assess the potential for damag- contingent upon use of LSB. These data sup- mission: Student, Resident, Fellow ing a defibrillator, two sets of pads were applied port the assertion that the long spine board is in six different configurations (either approx- not superior for immobilization, and that more Background: Given Paramedic National Stan- imately parallel or approximately orthogonal investigation should be performed to evaluate dard Curriculum cognitive objectives, we defibrillation vectors). Ten 360 J shocks were optimal thoracolumbar immobilization. developed an 8-hour curriculum that guides delivered from one set of pads while the volt- educators and paramedic students (PS) through age across the second set of pads was measured. the scientific process and offers a simple way 122. Supraglottic Airway Utilization vs We compared the voltage coupling ratio (VCR): to find and evaluate research articles. We then Endotracheal Intubation Pre/Post ratio of the measured voltage to the deliv- evaluated its effect on PS perception of finding Deployment of the I-Gel LMA in a Large ered voltage. Results:ComparedtostackedLL and evaluating research articles, and their Ground and Air-Based EMS Service shocks, DSD shocks that were Overlapping, 10, interest in participating in future prehospital and 100 ms apart significantly increased effi- John Lyng, Michael Perlmutter, Alex Tremb- research studies. Methods: PS participated in cacy (p < 0.05), DSD shocks that were 50 ms ley II, Marc Conterato, Michaela West, North four 2-hour long journal club sessions. First, the apart significantly decreased efficacy (p < 0.05), Memorial Health Ambulance and Air Care Cat- educator provided PS with four types of articles and DSD shocks 200, 500, and 1000ms apart egory of Submission: Operations, Quality, and highlighted differences between formats. were not different. During DSD potential dam- Safety Systems, Disaster Next, PS used search engines to fact check age assessment, voltage of delivered shocks was references of a free open access article. Third, 1833±5 V and voltage across the second set of Background: Identify changes in invasive air- PS sent articles on a topic selected by the class pads ranged from 1.2 to 503 V; parallel vec- way management using supraglottic airways to the educator, who facilitated a discussion of tors resulted in significantly higher VCR com- (SGA) and endotracheal intubation (ETI) as several articles after a short statistics lecture. pared to orthogonal vectors (15.2 ± 0.6% vs. primary and secondary interventions follow- Finally, PS found an article on a topic of their 1.6±0.2%, p < 0.0001). Conclusions:Theeffi- ing transition from the King LTS-D to the i- choice and verbally presented as it as if telling cacy of orthogonal-vector DSD is highly depen- gel LMA in an EMS setting. Methods:Thisis their partner about it between calls. Before and dent on time between shocks and can increase, a retrospective observational study performed after the module, PS completed a survey with decrease, or not change compared to stacked in a US-based ground/air EMS performing demographic questions and a series of affective shocks on a single vector. Potential for defibril- 86,000 transports annually. Charts document- domain questions, with surveys linked using lator damage during DSD can likely be mini- ing an attempt at invasive airway placement unique identifiers. PS will receive a follow-up mized by choosing near-orthogonal defibrilla- over a 12 month period were abstracted for age, survey in one year. Results: A total of 21 PS tion vectors. gender, airway indication, type(s) of invasive participated. 81% were male, with an average airway device(s) attempted, number of place- age of 24. 43% were college graduates. Before ment attempts, and placement success. Two 121. Biometric Analysis of Thoracolumbar the module, 76% of PS could identify a research cohorts were defined: cohort “K” represent- Movement during Ambulance Transport article, 29% had a journal subscription, and ing King LTD and cohort “I” representing i- many read articles several times a month (38%) David Wampler, Ronald Stewart, Rena Sum- gel LMA. ETI was continuously available. Pri- or year (33%). Affective survey questions had mers, Lawrence Roakes, Mike Shown, Craig mary endpoint was number of airways success- five-point Likert scale responses that were con- Cooley, Chetan Kharod, Tasia Long, Brian fully managed using an SGA. Secondary end- verted to numeric responses (strongly disagree Eastridge, The University of Texas Health Science points included rate of use of invasive devices = 1, strongly agree = 5) and analyzed using Center at San Antonio Category of Submission: based on clinical indication and use of devices a paired t-test, with p < .05 for significance. Trauma as primary or secondary interventions. Descrip- After the module, PS had significantly more tive statistics were utilized. Results:Atotalof agreement that they could find research articles Background: Within the community of trauma 660 charts were abstracted, 259 cohort K and < (p .001) and are interested in attending a surgeons, emergency medicine physicians and 401 cohort I. Age (57.5 +/− 21.9y), and gen- journal club for their continuing education (p emergency medical services (EMS) providers der (63.5% male) were consistent across cohorts = .02). PS significantly disagreed more that responsible for the care of injured patients, there (p = 0.07 and 0.81, respectively). Acuity was patient care decisions should be based on is mounting concern that the long spine board similar across cohorts. SGAs were the primary personal experience instead of research based (LSB) does little to reduce spinal motion, and device in 1.9% of cohort K and 37.9% of cohort = evidence (p .01). All PS agreed the module that risk outweighs benefit. The purpose of this I, and the secondary device in 10.4% of cohort was a productive use and time and would study was to evaluate the movement of the K and 10.2% of cohort I. Success for first device recommend it to others. Conclusions:This thorocolumbar spine during ambulance trans- was ETI 84.0% and SGA 40% in cohort K, and cohort of PS demonstrated their ability to find, port, comparing different patient positions with ETI 80.1% and SGA 92.7% in cohort I. Final interpret, and communicate important findings and without LSB. We hypothesized that trans- successful device in cohort K was ETI 87.3%, in research articles, and had overall positive port on a mattress with the head of the bed SGA 11.1%, and in cohort I was ETI 54.6% trends in opinions about evidence-based elevated would limit thoracolumbar movement and SGA 44.7%. Successful airway manage- medicine. more effectively than a LSB. Methods:This ment was achieved using any invasive device was a randomized 10-treatment adult healthy at 94.2% in cohort K and at 98% in cohort I (p 120. Double-Sequential Defibrillation: volunteer crossover trial. Real-time 3D motion = 0.015). Conclusions: Deployment of the i-gel Efficacy and Risk of Defibrillator Damage analysis of the thoracolumbar region was mea- LMA improved invasive airway management Are Highly Dependent on the Choice of sured using a wireless motion tracking system. in this EMS service, achieving a 4% increase in Shock Timing and Shock Vectors Positions analyzed included: on LSB at zero and success, and a final 98% overall success rate. ten degree incline, and on EMS stretcher with Introduction of the i-gel resulted in an increase Tyson Taylor, Sharon Melnick, Fred Chapman, head elevated to 10, 30, 45, and 60 degrees. in use of SGAs as a primary device, and neu- Gregory Walcott, Physio-Control, Inc. Category All subjects were fitted with a rigid cervical tral effect on use of SGAs as a secondary device. of Submission: Cardiac collar (c-collar) and headblocks when on LSB. Despite that successful invasive airway man- Background: Double-sequential defibrillation Subjects on stretcher without LSB were fitted agement by any device improved following i- (DSD) is the use of two defibrillators for deliv- with a c-collar and were transported with and gel deployment, erosion of ETI skills is identi- ery of two near-simultaneous shocks in an without foam headblocks. Each subject under- fied as a potential collateral effect that requires attempt to terminate refractory VF. We hypoth- went simulated ambulance transport over a city surveillance. NAEMSP 2018 ANNUAL MEETING ABSTRACTS 131

123. I Love My Community Paramedic: (RMA), and field termination (FT) along with 126. Community Paramedic Point of Care Patients Report Overwhelming familiarity of protocols (FP) and phase useful- Blood Analysis: Validity and Usability Satisfaction with Community Paramedic ness (PU). Mean and median Likert scores for Testing of Two Commercially Available Program these categories were compared among phases Devices using the t-test and Mann-Whitney test, respec- Tia Radant, Paula Miller, Joseph Pasquarella, tively, with statistical significance set a pri- Ian Blanchard, Ryan Kozicky, Dana Dal- Ann Majerus, Jennifer Murphree, Stephen ori at < 0.05. Participants indicated the most garno, Stacy Goulder, Suzanne Snozyk, Bloomstrand, Aaron Burnett, Regions Hospital useful and instructional phase. Pre- and post- Karen Leaman, Susan Biesbrook, Lenore EMS Category of Submission: Operations, tests were given to evaluate changes in knowl- Page, Lyle Redman, Keith Spackman, Quality, Safety Systems, Disaster edge. Mean and median test scores were sim- Tyler Williamson, Eddy Lang, Christo- ilarly compared. The IRB deemed this study pher Doig, Gerald Lazarenko, Alberta Health Background: Patient satisfaction is a key exempt. Results: Statistically significant differ- Services/University of Calgary Category of indicator of healthcare quality. Community ences were found in all comparisons, except for Submission: Professional Paramedic (CP) is an emerging profession FT, FP, and PU from phase 1 to 2 and from and as such is there is limited data on patient Background: Community Paramedics (CPs) phase 2 to 3, and for MC and RMA from phase satisfaction with CP programs. Hypothesis: require access to timely blood analysis in the 2 to 3. For the former group, statistically signif- Patients enrolled in a 30-day post-discharge field to guide treatment. Point of care test- icant differences were found from phase 1 to 3. community paramedic program report high ing (POCT), as opposed to traditional labora- A statistically significant increase was found in satisfaction with both the program and the care tory analysis, may offer a solution, but lim- test scores (mean 50% to 65%, median 40% to provided by the CP. Methods: Inpatients with a ited research exists on CP POCT. Purpose: In 67%). Participants found phase 2 the most use- diagnosis of CHF were offered post-discharge the CP setting, to assess the validity of two ful and simulated calls the best way to learn home visits by a CP for up to 30 days after devices (Abbott i-STAT and Alere epoc) and PMC. Conclusions: A statistically significant discharge. Inclusion criteria required that the contrast their usability. Methods:InaCPpro- increase in Likert scores was found in all cat- patient was a local resident, not eligible for gramme responding to 6,000 annual patient egories from pre-training to completion of all home-health services upon discharge, diag- care events, a split sample validation of POCT phases. The study found a possible cumulative nosis of CHF, English speaking, and written, against traditional laboratory analysis for seven effect of phases 2 and 3 for FT and FP, sug- informed consent to home visits by a CP. The analytes (sodium, potassium, chloride, creati- gesting a benefit from the addition of simulated CP visited the patient in the home 1–2 times nine, hemoglobin, hematocrit, and glucose) was calls to review of PMC calls alone. The statisti- per week for 4 weeks following discharge. conducted on a consecutive sample of patients cally significant increase in test scores demon- At the final visit the patient was surveyed requiring blood analysis. The difference of pro- strated an increase in PMC knowledge from the to assess their satisfaction with the program. portion of discrepant results between POCT training. One limitation was the lack of a consis- Scores ranged 1–4, 1 being “very dissatisfied” and laboratory was compared using a two tent population due to EMR schedules. Further and 4 being “very satisfied.” Mean scores sample proportion test. Usability was anal- research should provide the training over one fromtheLikertscalewereanalyzedandare ysed by survey of CP experience, linear mixed day to ensure consistency. reported descriptively. Results: A total of 59 effects model of Systems Usability Scale (SUS) patients completed surveys regarding their adjusted for experience, expert heuristic eval- satisfaction with the program. Mean scores for 125. Effect of Transport Time Interval on uation of devices, device-logged errors, and each question were as follows: willingness to Neurological Recovery after coded observations of quality control testing. listen carefully to the patient (4.0), time taken Out-of-Hospital Cardiac Arrest in Results: Of 1,649 study period patient care to answer patient questions (4.0), amount of Patients without a Prehospital Return of events, 174 had a blood draw, with 108 events time spent with the patient (4.0), explaining Spontaneous Circulation (62.1%) enrolled from 73 participants. Partici- things in a way the patient could understand pants had a mean age of 58.7 years (SD16.3); Jeong Ho Park, Yu Jin Kim, Young Sun Ro, (3.95), instructions regarding medication and 49% were female. In 4 of 646 (0.6%) individ- Sola Kim, Sang Do Shin, Kyung Jun Song, So follow-up care (3.97), thoroughness of the ual comparisons, POCT reported a critical value Yeon Kong, Ki Jeong Hong, Sun Young Lee, examination (4.0), advice given on ways to stay but the laboratory did not; occurring more Department of Emergency Medicine, Seoul National healthy (3.94), and overall satisfaction level often in i-STAT (0.9%; 95%CI: 0.0%,1.9%) com- University Hospital Category of Submission: (4.0). 100% of patients responded they would pared to epoc (0.3%; 95%CI: 0.0%, 0.9%; p = Cardiac recommend the community paramedic service 0.323). There were no instances of the labo- to others. Conclusions: Patients provided Background: Longer transport can adversely ratory reporting a critical value when POCT overwhelmingly positive feedback on the CP affect the outcomes of out-of-hospital cardiac did not. In 88 of 1,046 (8.4%) individual com- program. Patient’s open responses included: “I arrest (OHCA) patients without return of spon- parisons the a priori defined acceptable differ- was glad that they were here the first day that taneous circulation (ROSC), and those effects ence between POCT and the laboratory was I got out of the hospital.” “When I got out of can be aggravated when resuscitation efforts exceeded; occurring more often in epoc (10.7%; the hospital I was just so messed up, I had all at the scene are insufficient. The aim of this 95%CI: 8.1%, 13.3%) compared to i-STAT (6.1%; = these drugs and stuff, and she went through study was to determine the association between 95%CI:4.1%, 8.2%; p 0.007). Eighteen of 19 them and got everything worked out. It made the transport time interval (TTI) and neurologic CP surveys were returned, with 11/18 (61.1%) a big difference; I was so overwhelmed at that outcomes in OHCA patients without ROSC. preferring i-STAT over epoc. The i-STAT had a time.” This study is limited by the small sample Methods: We analyzed 57,902 adult OHCA higher mean SUS score compared to the epoc < size. We hope to maintain these results as the patients with presumed cardiac etiology and (84.0/100 vs. 59.6/100; p 0.011). Fewer field program continues. without prehospital ROSC. The primary expo- blood analysis device-logged errors occurred in sure was TTI, which was categorized as short i-STAT (7.8%; 95%CI: 2.9%,12.7%) compared to 124. Evaluation of Educational Methods = (1–5 min), intermediate (6–10 min), and long epoc (15.5%; 95%CI: 9.3%, 21.7%; p 0.063). for Prehospital Medical Command (PMC) (ࣙ11 min). The primary outcome was good neu- A possible explanation may relate to usability Training for Emergency Medicine rological recovery at discharge (cerebral perfor- issues with the epoc cartridge and test menus. Residents (EMRS) mance category 1 or 2). Multiple logistic regres- Conclusions: CP programs can expect valid results from POCT in most instances, however Jeffrey Luk, Cristina Carpintero, Stephanie sion analysis was used, and the final model an important discrepancy between traditional Gaines, Amy Pound, University Hospitals Cleve- included an interaction term between TTI and laboratory did occur. Usability assessment sug- land Medical Center/CWRU School of Medicine scene time interval (STI). Results: Among the gests a preference for i-STAT. Category of Submission: Operations, Qual- patients, 40%, 36%, and 24% were classified as short, intermediate, and long TTI, respec- ity, Safety Systems, Disaster 127. Characteristics of Paramedic tively. Good neurological recovery occurred in Graduates Who Retest after an Background: PMC is a crucial part of EMR 1.0%, 0.6%, and 0.3% of the short, intermedi- Unsuccessful Attempt on a National training. This skill can be difficult to teach ate, and long TTI groups, respectively. Refer- Cognitive Examination in predominantly off-line prehospital systems, encing the short TTI group, the adjusted odds and training for PMC may not be standardized ratios (aORs) [95% confidence interval (CI)] of Ashley Larrimore, Rebecca Cash, Remle across programs. The purpose of this study was TTI for good neurological recovery was 0.58 Crowe, Madison Rivard, William Krebs, to evaluate a phased comprehensive PMC cur- (0.47–0.73) for intermediate TTIs and 0.30 (0.21– Jeremy Miller, Ashish Panchal, Department of riculum for EMRs. Methods: Setting: Tertiary 0.41) for long TTIs. In the interaction model, the Emergency Medicine, The Ohio State University academic medical center. Participants: EMRs. aOR of TTI for good neurological recovery was Wexner Medical Center Category of Submis- Design: Subjects were taught PMC in phases smaller in the 1- to 5-min STI group than in the sion: Operations, Quality, Safety Systems, ࣙ consisting of (1) lecture; (2) review of PMC calls; 6-min STI group. Conclusions: A longer TTI Disaster and (3) simulated PMC calls. A survey was adversely affected the likelihood of good neu- given pre-training and after each phase using rologic recovery among OHCA patients with- Background: Paramedic program graduates a Likert Scale to assess comfort with medical out prehospital ROSC. This negative effect was invest significant time and effort in complet- command (MC), refusal of medical assistance intensified when the STI was short. ing their training. However, some graduates are 132 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

unsuccessful on the national paramedic certifi- group using multivariable logistic regression by BLS practitioners since the dataset is unable cation examination on their first attempt. The with an interaction term between bystander to separate combined BLS-only and ALS-BLS proportion of paramedic graduates who do not CPR and community urbanization level (Rural response agencies. Further work is needed to retest, despite available attempts, is unknown. vs Urban). Results: Among 108,253 patients, understand the trends of CPAP/BiPAP use by The objective was to describe paramedic grad- 53,528 patients were included. 49.1% received BLS EMS professionals. uates who do not retest and their associated bystander CPR (12.8% without dispatcher characteristics. We hypothesized that few grad- assistance and 36.3% with dispatcher assis- 130. Association Between BMI and Return uates chose not to retest and retesting was not tance), and 50.9% received no bystander CPR. of Spontaneous Circulation in associated with specific candidate characteris- Good neurological recovery rate was 5.0% in Out-of-Hospital Cardiac Arrest tics. Methods: We conducted a cross-sectional bystander CPR with dispatcher assistance, Caitlin Howard, Jeremy Allen, David evaluation of the national paramedic certifica- 5.5% in bystander CPR without dispatcher Wampler, Hattie McAviney, Justin Smith, tion cognitive examination results for the class assistance, and 2.2% in no bystander CPR David Miramontes, Joan Polk, United States of 2013. This computer adaptive test terminates group. In the interaction model, the adjusted Army and UTHSCSA Category of Submission: when the 95% confidence interval surrounding OR of bystander CPR for good neurological Student, Resident, Fellow the estimate of the candidate’s ability is entirely recovery was different in urban areas [AOR above or below the passing standard. Test (95% CI): 1.38 (1.17–1.63) without dispatcher Background: Sudden cardiac arrest (SCA) con- length ranged from a minimum of 80 to a max- assistance and 1.64 (1.44–1.86) with dispatcher tinues to be the leading cause of death in the imum of 150 questions. Unsuccessful testers assistance] and rural areas [AOR (95% CI): 2.80 U.S. Current studies suggest that there is no were defined as candidates who had a grade of (1.33–5.92) without dispatcher assistance and strong correlation between BMI and resusci- fail or incomplete (did not finish the examina- 4.46 (2.28–8.74) with dispatcher assistance]. tation rates. The objective of this study was tion) on their first examination attempt. Grad- Conclusions: The effect of Bystander CPR and to evaluate what effect BMI has on the rate uates of military only training programs were DA-CPR was more prominent in rural areas of return of spontaneous circulation (ROSC). excluded. Chi-square tests, Wilcoxon Rank Sum than urban areas. Methods: This was a retrospective review of test, and two tailed independent t-test were an in-house cardiac arrest registry containing 129. A National Description of the Use of used to compare demographics and individ- details of each resuscitation attempted by a Continuous Positive Airway Pressure in ual performance on the examination between large, urban fire-based EMS system. Data was the Prehospital Setting successful and unsuccessful testers. Results:In analyzed from January 1, 2016 through August 2013, 11,090 paramedic graduates attempted the Rebecca Cash, Remle Crowe, Jeremiah Kins- 15, 2016. The BMI recorded was a subjec- national paramedic cognitive examination for man, Madison Rivard, Dave Bryson, Gamunu tive measurement obtained from the paramedic the first time with an overall pass rate of 73%. Wijetunge, Ashish Panchal, National Registry at the time of data collection. Patients were Paramedic graduates who failed were more of Emergency Medical Technicians Category of included in the study if the following variables likely to be maximum length testers (38%, N were available: age, gender, BMI, and outcome = Submission: Medical 1,148) than minimum length testers (29%, (no ROSC vs. ROSC). Patients were excluded = N 892). Most graduates who were unsuc- Background: The use of continuous and bilevel if age < 17, no age or gender recorded, no = cessful chose to retest (89%, N 2,697). There positive airway pressure (CPAP/BiPAP) is lim- BMI data available, or no outcome available. was no clinically significant difference in the ited to paramedics under the 2007 National Patients were divided into four groups based = median age (28 vs. 29 years, p 0.0156) or EMS Scope of Practice Model. However, state on the recorded BMI (under, normal, over, mor- race/ethnicity (white, non-Hispanic 88% vs. and local practices may vary and current bid). An ANOVA test was utilized to analyze = minority 89%; p 0.706) of students who chose national trends of CPAP/BiPAP use by other continuous variables and a χ2 test was used = to retest. Female students (86%, N 734) were EMS licensure levels is unknown. Our objec- to analyze categorical variables. Results:There = less likely to retest than male students (90%, N tive was to describe use and outcomes of were a total of 771 possible patients. 516 patients = 1,911, p 0.001). Conclusions: The majority of CPAP/BiPAP by EMS licensure level nationally. were included in the analysis. The mean age graduates who were unsuccessful on their first We hypothesized that basic life support (BLS) of the subjects was 63.08 + 17.96 years with attempt retested on the national paramedic cog- only agencies use CPAP/BiPAP with similar 319 males (61.82%). 64 (12.40%) patients were nitive examination with female graduates hav- patient outcomes compared to agencies with underweight, 224 (43.41%) patients were nor- ing lower retest rates. This study was limited by (ALS) capability. Meth- mal weight, 168 (32.56%) patients were over- the lack of graduate specific information con- ods: Using the 2012–2015 National Emergency weight, and 60 (11.63%) patients were mor- cerning their reasons for retesting. Future stud- Medical Services Information Systems (NEM- bidly obese. There was no statistically signifi- ies will need to focus on the individual charac- SIS) datasets, we evaluated all records with cant difference in outcome (no ROSC vs ROSC) teristics which affect whether graduates chose CPAP/BiPAP use documented by EMS pro- between the BMI categories (P = 0.37). Con- not to retest. fessionals in agencies with BLS-only response clusions: BMI did not have an association with versus a response with a combination of BLS rates of ROSC in this study. Our study did have 128. Interaction Effect between Bystander and ALS (ALS-BLS). Only 911 responses were limitations. First, the BMI was a subjective mea- Cardiopulmonary Resuscitation and included. Variables assessed included patient surement and not calculated. Second, the data is Community Urbanization Level on and response characteristics, additional pro- from a single system cardiac arrest registry and Outcomes after Out-of-Hospital Cardiac cedures performed, and cardiac arrest occur- may not be extrapolated to other systems. Arrest rences. Chi-square tests were used to evalu- 131. Paramedics Providing Palliative Care Jeong Ho Park, Young Sun Ro, Sang Do ate differences between BLS-only and ALS-BLS at Home: Management of Pain and Shin, Kyung Jun Song, Ki Jeong Hong, So responders. Results: There were 259,099 cases Breathlessness Yeon Kong, Dong Sun Choi, Gwan Jin Park, of CPAP/BiPAP use documented during the study period. Of these, 253,728 (98%) were per- Department of Emergency Medicine, Seoul National Brianne Robinson, Alix Carter, Judah Gold- formed by services with ALS-BLS responders. University Hospital Category of Submission: stein, Michelle Harrison, Marianne Arab, Dal- Most patients were 70 years or older (78%) Cardiac housie University Category of Submission: and 49% were male. The most common inci- Student, Resident, Fellow Background: Positive association between dent locations were residences (65%) and health bystander cardiopulmonary resuscitation and care facilities (20%). The proportion of patients Background: Palliative care is aimed at alleviat- outcomes of out-of-hospital cardiac arrest treated by BLS-only responders who suffered ing pain and distressing symptoms while offer- (OHCA) are reported. There are various dif- cardiac arrest after EMS arrival was signifi- ing support. Paramedics routinely respond to ferences of sociodemographic and EMS factors cantly greater (4% vs. 0.5% for ALS-BLS respon- palliative patients and can assist with symp- < between rural areas and urban areas. The aim of ders, p 0.001) with a concomitant increase tom relief. In Nova Scotia, a novel clinical this study was to investigate whether the effect in the provision of chest compressions (BLS- practice guideline was implemented enabling < of bystander CPR on outcomes after OHCA only: 4%, ALS-BLS: 1%, p 0.001). BLS-only paramedics to assist families with home med- differed by urbanization level of community. response agencies more frequently upgraded ications, collaborate with on-scene home care Methods: This study was a cross-sectional to lights and sirens during transport (7%) than teams, or to administer opiates through an < study using a nationwide EMS-based OHCA ALS-BLS responders (2%, p 0.001). Conclu- expanded EMS formulary with the goal to treat registry in Korea. We included adult witnessed sions: Use of CPAP/BiPAP by EMS agencies at home if the patient desired. Paramedics com- OHCA patients with presumed cardiac etiol- with BLS-only response occurred in 2% of cases. fort with the dose and range of opiates for ogy from 2013 to 2015. The primary exposure BLS-only responders documented more cardiac palliative care is increasing. Our objective was was bystander CPR categorized into 3 groups: arrest events after EMS arrival than ALS-BLS to describe paramedic medication administra- bystander CPR with dispatcher assistance, responders, although the reasons for this find- tion practices for the management of pain and bystander CPR without dispatcher assistance, ing require further evaluation beyond the scope breathlessness. Methods: We conducted a ret- and no bystander CPR. The endpoint was of this dataset including geographical location rospective review of 100 consecutive palliative good neurologic recovery at discharge. We and patient population served. This evaluation care responses from February 1, 2016 to June compared outcomes between bystander CPR likely underestimates the use of CPAP/BiPAP 30, 2016. An electronic query would fail to cap- NAEMSP 2018 ANNUAL MEETING ABSTRACTS 133

ture assistance with home medications; a man- most protocols have been revised in the last treatment modality for dehydration, emesis is a ual chart review including standard medication 3 years, it is unlikely that protocol revision tim- therapeutic barrier. In 2013, Maine’s statewide administration fields and the free-text narrative ing has been a barrier to ketamine adoption into Emergency Medical Services (EMS) proto- was conducted to fully capture the care pro- STPs. Further study is needed to examine the cols added oral ondansetron for paramedic vided. Descriptive analysis was conducted and barriers to introduction and indication expan- administration to children with nausea and results were reported with n and % or mean and sion of ketamine in STPs. vomiting, as unnecessary prehospital intra- standard deviation. Results: Study population venous (IV) catheter placement is associated included 94 unique patients; 6 patients had 2– 133. Manual Syringe Aspiration and with discomfort, prolonged scene time and 4 calls and the remaining had one. Paramedics Administration of Epinephrine by increased cost. Prehospital oral ondansetron administered medication to 58 (58%) patients, Emergency Medical Technicians for administration has not previously been eval- and of those 42 (72.4%) remained at home com- Prehospital Treatment of Anaphylaxis uated for clinical endpoints. Our objective pared to 17/42 (40.5%) with no medication. was to evaluate the impact of prehospital Most common CC was pain; despite this, only Andrew Latimer, Sofia Husain, Jonathan oral ondansetron administration to pediatric 36 (80%) pain patients received treatment and 6 Nolan, Vinod Doreswamy, Thomas Rea, patients on frequency of use, additional inter- (13.3%) had both pre- and post-treatment pain Michael Sayre, Mickey Eisenberg, University ventions, ED length of stay, rate of hospital scores. Only 12 (44.4%) breathlessness patients of Washington Department of Emergency Medicine admission and ED recidivism. Methods:We received medication. Paramedics assisted with Category of Submission: Student, Resident, conducted a simple interrupted time-series home medication 10 (17.2%), administered from Fellow analysis to assess the effect of oral ondansetron drug kit 45 (77.6%) and both 3 (5.2%). Mean availability on study endpoints. Pediatric oral morphine equivalent was 13 ± 7.5 mg. Background: In recent years, the costs of patients transported via EMS to our tertiary Contact with an OnLine Medical Physician epinephrine autoinjectors (EAIs) in the United care pediatric referral center ED who received (OLMP) occurred during 57 encounters, and States have risen substantially. In 2014, either oral or IV ondansetron in the prehospital was increased when medication was adminis- emergency medical services within a large setting for nausea or vomiting from 2011–2015 tered 46 (79.3%) compared to no medication 11 urban/suburban county in the United States were included. Pre- and post-oral ondansetron (26.2%). Conclusions: Medication administra- implemented the “Check and Inject” pro- protocol implementation groups were com- tion would be underestimated in an electronic gram to replace EAIs by teaching emergency pared using chi-square, Fisher’s exact or t-test query alone. Even with inclusion of assistance medical technicians (EMTs) to manually aspi- as appropriate. Results: A total of 48 patients with home medications, management of pain rate epinephrine from a single-use 1 mg/mL met inclusion criteria with a greater number and breathlessness may not be optimized. Pre- epinephrine vial using a needle and syringe treated in the post-protocol implementation and particularly post-medication pain scores followed by prehospital intramuscular admin- period (34 vs. 14). A statistically significant would confirm symptom control. Contact with istration of the correct adult or pediatric dose of increase in the proportion of patients receiving OLMP when paramedics were not going to epinephrine for anaphylaxis or serious allergic oral ondansetron in the prehospital setting was administer medication should increase admin- reaction. Treatment was guided by an EMT noted following protocol implementation (0% istration and non-transport through increased protocol that required a trigger and symptoms. vs. 47%, p = 0.002). This was associated with a comfort and confidence. We sought to determine if the “Check and significant decline in the proportion receiving Inject” program was safely implemented by prehospital IVs (100% vs. 65%, p = 0.010) and 132. Ketamine Indications in Statewide EMTs treating presumed prehospital anaphy- prehospital IV ondansetron (100% vs. 53%, p = Treatment Protocols laxis or serious allergic reaction. Methods:We 0.002). Significant changes in other prehospital conducted a prospective investigation of all (p = 0.521) or ED interventions (p = 0.741), Christie Fritz, Christina Loporcaro, David cases treated as part of the “Check and Inject” length of stay (p = 0.253), hospital admission Schoenfeld, Beth Israel Deaconess Medical Cen- program from July 2014 through December rates (p = 0.161), or 48-hour ED return visits ter/Harvard Medical School Category of Submis- 2016 in the suburban aspects of the County and (p = 0.254) were not observed. Conclusions: sion: Student, Resident, Fellow January 2016 through December 2016 within The results of this study suggest that the the major American city located within the availability of prehospital oral ondansetron Background: Ketamine was discovered in the county. All cases were prospectively collected 1960s, and since that time has been used increases the frequency of antiemetic use, using a custom quality improvement data decreasing the need for vascular access and for multiple indications including pain con- form completed by the first responding EMTs. trol, procedural sedation, induction, depres- improving patient comfort. An increase in other Two physicians completed a structured review interventions, hospital admissions, or return sion, and excited delirium/behavioral distur- of each EMS medical record to determine if bances. Ketamine has a more favorable hemo- ED visits was not observed. Despite concern the EMTs followed the “Check and Inject” that ondansetron may mask a medical or sur- dynamic profile than many of its alternatives protocol and determine if epinephrine was for the same indications. It can be adminis- gical emergency, this study suggests that pedi- clinically-indicated based on physician review. atric patients treated with oral ondansetron pre- tered through the intravenous, intraosseous or Results: Of the 411 cases eligible for analysis, intramuscular routes. The purpose of this inves- hospitally are not at increased risk of symptom- EMTs followed the protocol appropriately in masking and subsequent return ED visits. tigation is to describe the overall prevalence 367 (89.3%) cases. In the remaining 44 (10.7%) of ketamine in STPs and the indications for cases, the EMS incident report form failed 135. Use of a Community Paramedicine which it can be utilized. Methods: Cross sec- to document either a clear inciting allergic Program to Address High Utilizers of the tional study of STPs for inclusion of ketamine trigger or an appropriate symptom from the 9-1-1 System in any protocols. Protocol revision date was also protocol list. Physician review determined that captured. Results: Thirty-one out of fifty (62%) epinephrine was clinically indicated in 36 of the Thomas Grawey, Mario Colella, Steven Riegg, states issue ALS STPs, seven of which serve as 44 cases. Among the remaining 8 cases (1.9%) Michael Wright, Medical College of Wisconsin guidelines. 48% of STPs include ketamine as that did not meet protocol criteria and were not Category of Submission: Student, Resident, an approved medication in their pharmacopeia. clinically-indicated based on physician review, Fellow Ten states (32%) include ketamine for induc- none had a documented adverse reaction to the tion during rapid sequence intubation, and epinephrine. Conclusions: We observed that Background: The role of community five states (16%) allow ketamine for procedural EMTs successfully implemented the manual paramedics (CP) has been expanding over sedation. Six states (19%) include ketamine in “Check and Inject” program for severe allergic recent years. Many programs exist across the their pain control protocols. Eight states (26%) reactions and anaphylaxis in a manner that country, attempting to meet the unique needs have excited delirium protocols which include typically agreed with physician review and of the local community. The Milwaukee Fire the use of ketamine. One state also includes without any overt identified safety issues. Department (MFD) has created a CP program ketamine as an agent for shivering. 60% of states which addresses high utilizers of the 9-1-1 which include ketamine in their protocols only system, attempting to decrease unnecessary 134. Timely Treatment of Tiny Tummies: The allow its use for one indication. 75% of protocols use of resources and improve patient quality of Use of Oral Ondansetron in the have been revised since 2015 and all have been life. Objective: To determine if enrolling high Prehospital Environment revised within the past 5 years. Conclusions: utilizers of the 9-1-1 system in a one month Ketamine is a versatile medication with a vari- Kelly Meehan-Coussee, Abhijit Srun- community paramedicine program decreased ety of applications in prehospital care. Despite gavarapu, John Martel, Michael Bohanske, J. system usage. Methods: This is a retrospective this, less than half of STPs include ketamine Matthew Sholl, Tania Strout, Maine Medical chart review. Data from MFD’s program in in their pharmacopoeia, and the majority of Center Emergency Medicine Division of EMS, Tufts 2016 was reviewed. 9 out of 12 months had those that include it have limited indications. University Category of Submission: Student, patients enrolled in the program, varying from Ketamine is a hemodynamically stable option Resident, Fellow 2–8 patients per month. Data was available for pain control or induction for RSI, but a and analyzed based on month of enrollment in minority of states with STPs include ketamine Background: Nausea and vomiting are com- the program. The number of 9-1-1 calls from for these indications. Ketamine has had a recent mon emergency department (ED) complaints. the patients enrolled were reviewed with the resurgence in emergency medicine, although as While oral rehydration therapy is the preferred 6 months prior to participation compared to 134 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

6 months after the program was completed. opportunities addressing posttraumatic stress tent validity index (CVI) scores to eliminate Total hours of community paramedic contact and negative safety outcomes. items. The remaining items were revised for time was also monitored; 30 patients were prehospital use and rated by EMS profession- excluded because they dropped out of the 137. Prehospital Availability and Use of als for clarity, relevance, and feasibility. The program prior to completion. Results:Inall Medications for Managing Hazmat draft assessment tool was deployed for field 9 months of implementation there was a drop Emergencies testing with two paramedics to determine the in number of 9-1-1 use during the 6 months feasibility and frequency of item identification. Kubwimana Mhayamaguru, Amber Bel- after completion of the program. August par- Following descriptive analysis and structured lafiore, Eric Lederer, Carl Youngs, Robert ticipants saw the least change, where 5 patients interviews, a second field test was conducted French, Joshua Gaither, Kristina Waters, who required a total of 54.1 CP work hours saw with a revised tool. Paired crews completed Frank Walter, The University of Arizona Cat- adecreasefrom18to13runsovera6month the assessment independently on low acuity egory of Submission: Student, Resident, period (−28%). In July there was the largest patients whose home they entered. Pair agree- Fellow drop in 9-1-1 usage of 77% (48 to 11), during ment on the final tool was measured using which time 4 patients were enrolled and 43.8 Background: A minimal amount is known Cohen’s kappa. Results: Atotal of 87 items mea- contact hours were performed. In 2016 there about prehospital availability and use of med- suring extrinsic factors were identified. Round were a total of 47 patients enrolled in the pro- ications to treat hazardous materials (hazmat) one of content validity testing eliminated 33 ࣘ gram accounting for 337 calls pre-intervention emergencies. The purpose of this study was items (CVI 0.76); 22 items were condensed or − and 149 calls ( 56%) after 419.8 total hours of to identify the availability and use of hazmat removed due to redundancy. Round two elim- ࣘ CP care were performed. For every 27 minutes medications among paramedics with advanced inated another 6 items (CVI 0.70). Twenty- of care provided, one less 9-1-1 call occurred. hazmat training, practicing in prehospital set- eight items were included in the initial EMS ࣘ Conclusions: Participation in a community tings in the United States (U.S.). Methods: assessment and items with CVI scores 0.70 = paramedicine program established to decrease An email Qualtrics® survey was sent to U.S. (n 4) were eliminated. Twenty-two items 9-1-1 utilization cut use by 56%. Limitations paramedics who completed the Advanced Haz- were deployed for field testing. Round one of = include lack of information about nature of mat Life Support (AHLS®) Provider Course field testingn ( 12) revealed paramedics infre- 9-1-1 calls including which calls required from 1999–2017. The survey asked what spe- quently accessing the kitchen (41.6%), bath- hospital transport. A future study could look at cific hazmat medications were available to each room (0.0%), or bedroom (25%) and excluded cost savings provided by the program. respondent, how they were carried, and how room-specific items. Five crews completed 57 frequently they had been used. For analysis, paired assessments in round two using a nine- 136. Understanding How Transactional κ = responses were grouped into those medica- item tool. One item ( 0.8721) returned a Stress Relates to Stress Reactions and tions with hazmat indications only and those high level of agreement, whereas the remain- Safety Outcomes with multiple uses. Availability and use of each ing items showed low to moderate agreement (κ = 0.3322–0.5369). Conclusions: A nine-item, Elizabeth Donnelly, Paul Bradford, Cathie hazmat medication is reported using simple content-valid, prehospital falls risk assessment Hedges, Matthew Davis, Doug Socha, Peter descriptive statistics, including number (n)and tool was created using a standardized process. Morassutti, University of Windsor Category of percent (%). Hazmat medications were con- After two rounds of field testing, the tool is not Submission: Operations, Quality, Safety Sys- sidered to have been used if the surveyed yet highly reliable. It is hypothesized that the tems, Disaster paramedic gave them anytime in the last five years. Results: Of the 4,360 surveys sent, 784 low agreement is due to the variation in priori- Background: Increasing attention is being paid (18.0%) were completed. Of the completed sur- ties of providers on scene. Future efforts should to the impact of stress and fatigue on safety in veys, 279 (35.6%) paramedics had dedicated test the accuracy of extrinsic factor identifica- paramedicine. Specifically, empirical linkages hazmat medication kits and 505 (64.4%) had tion among secondary care providers only. have been established between fatigue, chronic hazmat medications carried with other medica- 139. Development of a Hypoxic Asphyxial work stress, critical incident stress, and safety tions. For those hazmat medications with haz- Model of Pseudo-Pulseless Electrical outcomes. However, the relationship between mat uses only, availability/use was: cyanide Activity in Swine transactional stresses, stress reactions like post- antidotes 463 (59.1%) / 36 (4.6%), atropine + traumatic stress, fatigue, and safety outcomes pralidoxime auto-injectors 376 (48.0%) / Norman Paradis, Sarah Crockett, Jeffrey (safety compromising behaviors, medication 5 (0.6%), pralidoxime multi-dose vials 122 / Gould, Christopher Kaufman, Karen Moodie, errors and adverse events, and injuries or expo- (15.6%) / 3 (0.4%), and methylene blue 103 Dartmouth-Hitchcock Medical Center Category sures) have not been assessed. There are two (13.1%) / 5 (0.6%). The availability/use of haz- of Submission: Cardiac types of transactional stress. Internal transac- mat medications with other uses was: atropine tional stresses are associated with the day to 513 (65.4%) / 63 (8.0%), calcium chloride 540 Background: Pulseless electrical activity (PEA) day provision of service (e.g., offload delays, (68.9%) / 83 (10.6%), calcium gluconate 247 is an increasingly prevalent initial rhythm in being placed on standby, dealing with dispatch, (31.5%) / 26 (3.3%), diazepam 498 (63.5%) / cardiac arrest, particularly with in-hospital res- inappropriate use of EMS, mandatory over- 49 (6.3%), lorazepam 262 (33.4%) / 18 (2.3%), piratory arrests. Pseudo-PEA (p-PEA), which time, and dealing with frequent service users). midazolam 619 (79.0%) / 29 (3.7%), ophthalmic often precedes true PEA, is characterized by a External transactional stress involves interact- topical anesthetics 254 (32.4%) / 50 (6.4%), and low-flow state in which cardiac contraction pro- ing with allied professions (e.g., law enforce- topical lubricating jelly 462 (58.9%) / 28 (3.6%). duces a non-palpable blood pressure, and is dif- ment, Base Hospital, ER Charge nurses, ER Conclusions: Among paramedics with AHLS® ficult to treat. We set out to develop a repro- Physicians, ER primary nurses, and fire fight- Provider training there is limited availability ducible, stable, and clinically relevant animal ers). The purpose of this study was to see if and use of hazmat medications. Although local model of p-PEA for testing novel treatments. there was significant variation in levels of trans- scope of practice, financial, and other geo- Hypothesis: Rapid induction of a hypoxic actional stress in paramedics that endorsed graphical considerations likely contribute to asphyxial state will result in a reproducible p- high levels of posttraumatic stress, fatigue, or these results, further work is needed to iden- PEA state sufficient for study of pathophysiol- reported negative safety outcomes. Methods: tify which medications should be available to ogy and therapy. Methods: A state of p-PEA An online survey was conducted with ten Cana- paramedics to optimize the cost benefit ratio of was induced via progressive hypoxia in twelve dian paramedic services with a 40.5% response stocking and using hazmat medications. domestic swine ∼32 kg with standard physio- rate (n = 717). T-tests were used to assess for sig- logical monitoring. Blood flow was measured nificant differences. Results: Analyses revealed 138. Validation of a Prehospital Falls Risk in the common carotid artery and jugular vein. high levels of internal and external transac- Assessment Tool FiO2 was reduced to 6% by increasing the frac- tional stress in those paramedics with high lev- tion of nitrogen in inspired gas. A target systolic Allison Infinger, Meghan Wally, Rachel Sey- els of posttraumatic stress (p < .001), those blood pressure (SBP) of 40 mmHg was used mour, Jonathan Studnek, Mecklenburg EMS who reported being fatigued (p < .001), those to mimic p-PEA. After resuscitation, the ani- Agency Category of Submission: Trauma who reported injuries or exposures at work mal was stabilized. This cycle of hypoxic p-PEA < [internal ambulance stress (p .05), external Background: Every 15 seconds an older adult and resuscitation was repeated until return of < ambulance stress (p .001), safety compro- will present to the emergency room with a spontaneous circulation could not be achieved. < mising behaviors (p .001), and medication fall related injury. Prevention programs have Results: p-PEA could be reliably created by < errors (p .05)]. Conclusions: These results demonstrated efficacy; however, health care hypoxic asphyxiation. In this model, p-PEAwas ± indicate that there are higher levels of transac- providers must be able to identify at risk characterized by a mean heart rate of 77 ± tional stresses between paramedics that report patients. This study aimed to develop a con- 16 bpm, mean aortic blood pressure of 23 ± pathological levels of posttraumatic stress, sig- tent valid and reliable assessment of environ- 6 mmHg, mean right atrial pressure of 14 ± nificant fatigue, and negative safety outcomes. mental fall risk performed in the prehospital 2 mmHg, mean carotid flow of 48 16 mL/min, ± These exploratory analyses indicate that trans- setting. Methods: First, we identified validated mean jugular flow of 10 5 mL/min, and mean ± actional stresses may influence the wellbeing of items for screening extrinsic factors from the lit- intracranial pressure of 24 3 mmHg. Time to paramedics. The ability to further break down erature. Then, a multidisciplinary expert panel achieve target systolic blood pressure was sig- and focus on the specific factors may offer completed two rounds of assessment using con- nificantly less in the second round, however NAEMSP 2018 ANNUAL MEETING ABSTRACTS 135

the physiological responses were similar for tiple factors can influence patient presenta- 184 (34.8%) seen in 2016 were also enrolled. both rounds. Conclusions: A reproducible, sta- tion rates during these events. Local emer- Of those 106 total patients enrolled, 58 were ble and clinically relevant porcine model of p- gency physicians and EMS provide medical men and 48 were women. While ranging in age PEA via hypoxic asphyxiation was developed. care at East Carolina University (ECU) foot- from 3 to 86 years, 95.2% (n = 101) were over Time to induction was reduced after multiple ball games with a stadium capacity of 51,082. 68 and the main diagnoses involved included insults. This model offers an improved method ECU football games are typically staffed by six COPD, CHF, dementia and cancer. The aver- for testing innovative therapies for p-PEA. EMS units placed around the field’s perime- age combined LOS with hospice services was ter, one field-dedicated EMS unit, and 2 Med- 71 days and 23.5% (n = 25) of the 106 patients 140. Characteristics of Acute Myocardial ical Treatment Areas staffed with four physi- used their full 6-month hospice benefit. Another Infarction Cases Coded as Low-Acuity at cians. Cooling tents are used as needed based 11.3% (n = 12) are still enrolled. The total num- Dispatch on weather forecasts for the game. Objective: ber of 9-1-1 responses for this cohort (prior This study aimed to quantify patient presenta- to hospice enrollment) had been 439. This fell Marie Gardett, Greg Scott, Chris Olola, tion rates and factors influencing patient pre- to 17 after enrollment (a 96.1% reduction in Meghan Broadbent, International Academies of sentation during ECU football games between related EMS utilization). Conclusions:Basedon Emergency Dispatch Category of Submission: 2008 and 2016. Methods: Aretrospective review this experience, it is concluded that community Cardiac of EMS field records and 9-1-1 incident numbers paramedic programs can play a very important Background: Identification of acute myocar- originating from the stadium on the dates and role in facilitating the care of hospice-eligible dial infarction (AMI) can be complicated by times of home football games from 2008–2016 patients and thus help to avoid unneeded EMS the wide variety of symptomologies or pre- was conducted. JMP Version 13 (Cary, NC) was system utilization for such patients. Appro- sentations. While the most common symp- used to conduct a bivariate correlation analysis priate education of front-line EMS profession- tom of AMI is chest pain, so-called “atypi- on the cumulative data set to determine rela- als, working in synchrony with a designated cal” presentations are in fact quite common tionships between external factors and patient CP, can reduce unneeded 9-1-1 utilization, but, and extremely variable, and AMI sometimes presentation as well as emergency department more importantly, facilitate the most appropri- presents with very mild-seeming symptoms (ED) transport rates per 10,000 attendees. Heat ate and expert care through hospice-partner such as flu-like chills and nausea, abdominal index, attendance, and kickoff times were the resources. pain, or lightheadedness. Correctly identify- main factors evaluated. RESULTS: Data from 143. Prehospital Provider Year of Hire ing mild-seeming presentations that actually 47 home football games with attendance rang- Correlates to Time Spent On-Scene in turn out to be AMIs can help ensure appropri- ing from 33,048 to 51,082 were included. The Emergent Trauma ate response and treatment. This study iden- heat index during the games ranged from 37.8 to 89.6 °F. Kickoff times ranged from 1200 to tified hospital-confirmed AMI cases coded as Clark Smith, Steven Hulac, Spencer Knierim, 2000 hours. Bivariate correlation analysis of low-acuity at dispatch to determine whether Zachary McDade, David Edwards, Denver heat index and patient presentation was cal- any common characteristics could help identify Health and Hospital Authority Category of Sub- culated as 0.432 (p < .05). This result sug- these cases in the future. Methods:Thiswasa mission: Trauma retrospective study utilizing emergency med- gests a positive correlation between heat index ical dispatch (EMD), emergency medical ser- and patient presentation rates. The correlation Background: The definitive prehospital man- vices (EMS), and hospital discharge datasets. between heat index and rates of ED transport agement of critically-injured blunt or penetrat- < The study sample included all cases that arrived was moderately positive at 0.316 (p .05). ing trauma patients is rapid transport to a to the hospital via EMS. Primary outcome mea- The bivariate analysis of attendance and kickoff trauma center. Retrospective studies of trauma sures were the numbers of hospital-diagnosed times with patient presentation and ED trans- registry data have indicated that prolonged on- AMIs categorized by patient age and gen- port rates showed little to no correlation with scene times may worsen mortality in the most der, Chief Complaint Protocol, and dispatch no statistical significance. Conclusions: Heat critically-injured patients. The preponderance determinant code; secondary measures were index values were shown to have a moderately of available research suggests that optimal man- comparisons between EMD- and EMS-recorded strong correlation with rates of patient presen- agement of these patients is the provision of symptoms. Descriptive statistics were used to tation at ECU football games. There was no basic stabilization measures while minimizing characterize the distributions of all ALPHA- correlation between attendance at the football time spent on-scene. The objective of our study level cases and of ALPHA-level AMIs, cate- games, kickoff times, and patient presentation was to investigate if prehospital provider date gorization by hospital discharge destinations, rates. of hire was associated with time spent on- and Chief Complaint. Results: A total of 8,007 scene in patients transported emergently with 142. Reducing 9-1-1 Over-Utilization ALPHA priority-level cases with correspond- traumatic injuries. Methods: We conducted a through a Targeted Community Paramedic ing hospital records were identified. Of these, data analysis of emergent transports of trauma Hospice Referral Program 40 (0.50%) were identified as AMIs. These patients by paramedics hired by our EMS ALPHA-level AMI cases fell into only five Chief Peter Antevy, Kenneth Scheppke, Juan Car- agency during the years 2006 through 2015. We Complaint Protocols (Sick Person, Falls, Uncon- dona, Susan Toolan, Sharon Maraj, Frank examined the on-scene times for these calls as scious/Fainting, Abdominal Pain/Problems, Babinec, Julie Corona, Paul Pepe, Memorial recorded through the agency’s computer-aided and Hemorrhage/Lacerations). Older age and Healthcare System Category of Submission: dispatch system, from January 2011 to June discharge to medical facility (rather than to Medical 2017. We compared the mean on-scene times home or self-care) were identified with AMI for paramedics over this period, aggregated by cases. The most commonly reported symptom Background: Over-utilization of 9-1-1 systems year of hire. We excluded calls in which the was a fall, especially ground-level fall in an is a nationwide problem that overburdens EMS provider indicated a specific delay or barrier older-age patient. Certain “sick person” char- agencies and often results in hospital transports to care in the electronic patient care report. acteristics were also somewhat associated with better suited for other dispositions. For exam- Results: During the study period, paramedics AMI diagnosis. Conclusions: Overall, the num- ple, EMS professionals often are called to attend from the included years of hire transported a ber of AMI cases assigned to the ALPHA pri- and transport patients who likely require out- total of 2,910 emergent trauma patients. The ority level is very low and is confined to of-hospital end-of-life care, yet still have unmet number of emergent trauma transports for very few Chief Complaint Protocols. In general, healthcare needs. The purpose of this study paramedics from each year of hire range from the ALPHA-coded AMIs in this study showed was to evaluate if a community paramedic (CP) 179 to 380. Paramedics with earlier years of hire characteristics consistent with missed or silent could successfully refer appropriate patients have lower average on-scene times than those AMIs widely described in other healthcare set- to local hospice partners and thereby dimin- hired later. Paramedics hired in 2006 average tings. ish EMS responses for those patients. Meth- 7.16 minutes on scene, while paramedics hired ods: Between April 1, 2015 and December 31, in 2015 average 9.14 minutes on scene. Linear 141. Heat Index Is the Main Factor 2016, front-line EMS crews, guided by estab- regression of this data yielded an R-squared Influencing Rates of Patient Presentation lished criteria, referred potential hospice can- value of 0.82. Utilizing a one-way between sub- at East Carolina University Football didates to a single designated CP who visited jects ANOVA, there was a significant effect of Games those patients at their residence then referred year of hire on average on-scene time at the p < those meeting specified hospice criteria toa 0.05 level [F(2,2900) = 4.713, p < 0.001]. Conclu- An Truong, Stephen Taylor, Roberto Portela, hospice partner (VITAS Healthcare) for enroll- sions: There was a distinct association between Kori Brewer, Brody School of Medicine at East ment. Demographics, diagnoses, length of stay paramedic year of hire and on-scene times in Carolina University Category of Submission: (LOS), and outcomes were collected for patients emergent transports of trauma patients. This is Student, Resident, Fellow enrolled. The associated 9-1-1 utilization, before the first study comparing providers’ years in Background: Mass gathering events are large and after enrollment, was tracked and mea- service to their on-scene times with critically gatherings of greater than 1000 people where sured. Results: The CP attended 320 poten- injured patients. Further research is needed to access to patients is difficult and response tial hospice patients over the 21-month period. determine if this trend is seen in other similar by emergency medical services (EMS) may be Of the 136 patients seen in 2015, 42 (30.9%) agencies and to investigate its impact on patient delayed. Current literature suggests that mul- were enrolled in hospice and, similarly, 64 of outcomes. 136 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

144. Benchmarking EMS Compass Trauma questionnaire assessing personal comfort lev- cies yielded similar results. Of note, multiple Scene Times and Traumatic Pain els and their knowledge and attitudes about EMS narratives revealed that paramedics trans- Management Performance Measures Using tourniquets and responding to traumatic emer- ported patients to a hospital-based ED instead a National Dataset gencies. Each training course included 20 min- of a FSED because the main hospital had more utes of didactic instruction on hemorrhage resources. Conclusions: The primary goal of Jeffrey Jarvis, Dustin Barton, Lauren Sager, control techniques, encompassing indications triage is “determining how best to get the right Nick Nudell, Williamson County EMS Cate- for tourniquets, and hands-on instruction with person to the right place at the right time using gory of Submission: Trauma tourniquet application on both adult and pedi- the right amount of resources”. The burgeon- atric mannequins. The primary outcome was ing of FSEDs highlights the significance of this Background: Minimizing scene times for willingness to use a tourniquet in response to critical concept. As FSEDs become more popu- patients with critical trauma has long been a traumatic medical emergency. Results: Of 236 lar, a burden is frequently placed on paramedics recommended. Additionally, pain from trau- participants, 218 met eligibility criteria. When to determine which patients are appropriate matic injuries is very common. Assessment initially asked if they would use a tourniquet for specific emergency departments. Our study and management of this pain has been iden- in real life 64% (140/218) responded “Yes”. Fol- demonstrated that paramedics have a reason- tified as a key clinical performance measure lowing training, 96% (194/203) of participants able ability to appropriately triage patients to by the EMS Compass initiative. There has responded that they would use a tourniquet in FSEDs and to predict the need for hospital been little work done using national data real life. Of participants who initially responded resources. to benchmark these measures. We sought to “No” (2%, 6/218), all responded “Yes” follow- describe the performance on these measures ing training. Before training, men were statis- 147. Outcome Impacts of Community using a large commercial dataset. Methods: tically more likely to respond “Yes” to using Bystander Defibrillation Versus Using anonymous data from 9-4-1 consenting tourniquets than women (80.9% vs. 57.1%, p Dispatcher-Assisted CPR (DA-CPR) in agencies, we analyzed 6 ½-years of data from = 0.003), but that difference resolved follow- Out-of-Hospital Cardiac Arrest at Public ESO Solution’s electronic health record (HER) ing training. When participants were asked Locations to calculate benchmarks for: (1) the percentage about their comfort level with using a tourni- of patients with trauma alert criteria as defined quet in real life, there was a statistically sig- Patrick Chow-In Ko, Shih-Chieh Huang, Yu- by the CDC trauma triage criteria for transport nificant improvement between their initial and Wen Chen, Hong-Yi Hsiao, Matthew Huei- to a trauma center who have a scene time post-training response (2.5 vs. 4.0, based on 5- Ming Ma, Chung-Liang Shih, National Taiwan under 10 minutes, and (2) of patients with any point Likert scale, p < 0.001). Conclusions:In University, College of Medicine, Department of traumatic injury, the proportion with at least this hemorrhage control education study we Emergency Medicine Category of Submission: one pain scale documented. For those with found that a short educational intervention can Cardiac an initial pain score >5, the proportion with improve layperson’s self-efficacy and reported a second score reassessing pain. Of patients Background: We compared the outcomes willingness to use a tourniquet in an emergency. from ALS agencies who had an initial score between a community-wide bystander defib- Significant gender differences exist in the stated >5, the proportion with decreased pain from rillation program and a DA-CPR program in willingness to respond in emergencies. Identi- the first to last pain score. We calculated both patients after out-of-hospital cardiac arrest at fied barriers to act should be addressed when the proportion and 95% Confidence Interval as public sites. Methods: A prospective 2-year designing future hemorrhage control public well as average, median and interquartile range community-wide observational database col- health education campaigns. Community edu- (IQR) for time-based measures. Results:Ofthe lected from a metropolitan OHCA e-Registry cation should continue to be a priority of the 66,414 critical trauma patients, 16,162 (24.3%, was studied, after a citywide bystander defibril- “Stop the Bleed” campaign. 24.0–24.7%) had a scene time less than 10 min- lation rescue program had been launched that utes. The average scene time was 16.4 min, IQR strategically provided publicly accessed AEDs 146. Can Prehospital Providers Correctly 14.7(10.2, 20.2). Of 2,166,680 trauma patients, (automated external defibrillators) in desig- Triage Patients to Freestanding 1,053,747 (48.6%, 48.6–48.7%) had a pain score nated locations that were also e-registered; and Emergency Departments? documented. Of 503,656 patients with initial a DA-CPR program had been run. The survival > scores of 5, 305,493 (60.7%, 60.5–60.8%) had Charles Hwang, Desmond Fitzpatrick, Jason outcomes of OHCA at pubic locations between a reassessment. Of the 310,737 patients of ALS Jones, University of Florida Department of Emer- the two program interventions were compared. > agencies with a score 5, 64,076 (20.6%, 20.5– gency Medicine Category of Submission: Outcomes included 2-hour sustained ROSC 20.8%) had an improvement in pain scores. Student, Resident, Fellow (return of spontaneous circulation) at hospital, Conclusions: We provide the first benchmarks survival to hospital discharge, and good CPC on critical trauma scene times and pain man- Background: Freestanding emergency depart- (Cerebral Performance Category Scale 1 or agement using a large national dataset. The ments (FSEDs) are equipped to care for most 2). All patient prehospital characteristics and results indicate additional efforts are needed, emergencies but do not have all the resources outcome relations were evaluated and adjusted both for assessing/documenting traumatic that hospital-based emergency departments by regression analysis. Results: The density of pain and in addressing it. Additionally, scene (EDs) offer. Emergency medical services (EMS) public AEDs distribution increased from 3.96 times on critical patients are rarely under the must routinely determine whether a FSED to 6.24 per square kilometers in the studied “platinum” 10 minutes, indicating either need is an appropriate destination. Inappropriate 2 years. Among a total of 6,356 OHCA, 627 for improvement or a more realistic goal. triage may increase morbidity and mortality patients occurred at public locations, including due to delay in definitive care. We sought 28 patients (male for 82%, witnessed arrest 145. Stop the Bleed: The Effect of to evaluate paramedics’ ability in determin- for 79%) received bystander aid by public Hemorrhage Control Education on ing whether a FSED is the most appropriate AEDs plus CPR rescue and 243 patients (male Laypersons’ Willingness to Respond destination. Methods: We conducted a retro- for 64%, witnessed arrest for 61%) received During a Traumatic Medical Emergency spective study of two county EMS agencies dispatcher-assisted CPR. For these 28 patients, and two FSEDs over more than 2 years. Both 53.6% (15/28) achieved prehospital ROSC Derek Brown, Elliot Ross, Theodore Redman, EMS agencies allow paramedic discretion in at scene or during transport, 71.4% (20/28) Julian Mapp, Kaori Tanaka, Chetan Kharod, determining transport destination; both proto- achieved sustained ROSC after resuscitation Craig Cooley, David Wampler, SAUSHEC Mil- cols read, “Any patient potentially requiring at hospital, 57.1% (16/28) achieved survival- itary EMS & Disaster Medicine Fellowship Cat- admission in the paramedic’s best judgment to-discharge and noticeably all those 16 (100%, egory of Submission: Student, Resident, (Ex. elderly, weakness, dizziness, dialysis, etc.) 16/16) survival-to-discharge patients achieved Fellow will be EXCLUDED and not considered eligi- excellent neurological outcome of CPC 1 (CPC Background: The “Stop the Bleed” campaign ble for transport to a FSED.” The primary out- Scale 1). Their outcomes were significantly advocates for non-medical personnel to be come was whether paramedics can correctly better [71.4 vs. 43.6%, OR: 3.2 (95%CI: 1.4–7.6) trained in basic hemorrhage control. How- identify patients that can be cared fully at a for sustained ROSC; 57.1 vs. 25.9%, OR: 3.8 ever, it is not clear what type of education FSED without additional resources. We sought (95%CI: 1.7–8.5) for survival of discharge; or the duration of instruction that is required to identify the percentage of patients brought 57.1 vs 16.9%, OR: 6.6 (95%CI: 2.9–14.9) for to meet that condition. The objective of this by EMS to FSEDs that were discharged with- good CPC; and 100 vs. 65.1% for good CPC study was to determine the impact of a brief out additional hospital-based services. Results: among survival-to-discharge] compared with hemorrhage control educational curriculum on Between January 1, 2015 and February 6, 2017, those 243 patients by dispatcher-assisted CPR the willingness of laypersons to respond dur- 1,247 EMS patients had a selected destination rescue. In 28 patients by bystander defibrilla- ing a traumatic emergency. Methods:This of FSED. We excluded patients that did not tion rescue only one man without prehospital education initiative was conducted between arrive at their selected FSED destination, left ROSC still achieved survival-to-discharge and SEP 2016 and MAR 2017, and subjects were before FSED disposition, or were transferred good CPC. Conclusions: For OHCA patients at recruited from multiple community groups in from the FSED to unaffiliated hospitals. A total public locations, we found that a community- a large metropolitan area. Individuals with for- of 1,184 patients were included for analysis, and wide bystander defibrillation program were mal medical certification were excluded. Par- 885 (74.7%) did not require additional hospi- associated with excellent neurological outcome ticipants completed a pre- and post-education tal resources. Comparing the two EMS agen- of CPC 1 and survival to hospital discharge that NAEMSP 2018 ANNUAL MEETING ABSTRACTS 137

were significantly higher than those associated certification. The prevalence of common sleep tilation via BVM was able to maintain a physio- with dispatcher-assisted CPR program. disorders is reported using descriptive statis- logic ETCO2 only 48.7% of the time. There was tics. The association between sleep disorder significant variability, which resulted in inter- 148. Randomized Trial of a Shear screening result and safety outcomes was tested mittent hypoxia, as well as significant hyper- Reduction Surface in Ambulance using multi-level mixed effects logistic regres- ventilation. Prior research has linked these Transport sion models which accounted for clustered events to increased morbidity and mortality. responses. Models controlled for individual Further studies to compare similar data against Kathleen Berns, Ann Tescher, Lucas Myers, and agency-level risk factors, including age, mechanically ventilated patients is warranted Patrick Koehler, Kip Salzwedel, Heather gender, body mass index, exercise frequency, before changes to practice can be made. McCormack, Marianne Russon, Josh Bur- years of experience, shift schedule, work at mul- ton, Christine Lohse, Jay Mandrekar, Evan tiple jobs, and annual call volume. Results: 151. Development and Validation of Call, Scott Zietlow, Mayo Clinic Category of Responses were obtained from 2,992 fire-based Reality-Based Training Scenarios Submissions: Operations, Quality, Safety EMS providers employed at 65 departments. Simulating Violent EMS Encounters Systems Most were male (93%), full-time employees Mallory DeLuca, Donald Garner, Jr., Remle (99%), who worked 24 hour shifts (77.2%). One Background: Shear is a known risk factor in Crowe, Rebecca Cash, Madison Rivard, Jeffer- in three was obese (33.2%). Nearly half (45.1%), pressure injury development such as decubitus son Williams, Ashish Panchal, Jose Cabanas, screened positive for at least one sleep disorder. ulcers. The purpose of this study is to examine Wake County EMS Category of Submission: Over 1/3 (33.9%) screened positive for obstruc- the effectiveness of an anti-shear mattress over- Professional tive sleep apnea, 7.5% screened positive for lay (ASMO) in reducing shear/pressure and insomnia, and 10.1% screened positive for shift increasing comfort on an ambulance stretcher. Background: Emergency Medical Services work disorder. More than 2/3 (71.6%) reported Methods: This was a randomized, cross-over (EMS) providers are often exposed to violence sleeping less than 7 hours per night on aver- design. Thirty adult volunteers in 3 BMI cat- during patient encounters. Traditional EMS age and 33.8% had excessive daytime sleepi- egories served as their own controls. PRE- training may not adequately address appro- ness. After controlling for potentially confound- DIA shear/pressure sensors were applied to priate responses to potentially threatening ing variables, positive sleep disorder screening the sacrum, ischial tuberosity (IT), and heel. situations. Our objective was to develop and was independently associated with more than The stretcher was placed in sequential 0°,15°, validate scenarios to evaluate EMS providers’ twice the odds of an occupational injury (OR and 30° elevations, with and without ASMO. response to threatening situations. We hypoth- 2.04; 95% CI 1.48–2.81), motor vehicle crash (OR The ambulance travelled over a closed course esized that provider recognition and perception 2.10; 95% CI 1.12–3.93), and near-crash (OR 2.27; achieving 30 mph, with 5 complete stops at each of threatening situations would not differ given 95% CI 1.94–2.66). Conclusions: Sleep disorders head of bed elevation for a total of 900 trials. different patient presentations or aggressors. are highly prevalent among EMS providers. Subjects rated discomfort on a 0–10 scale after Methods: Using an iterative process, EMS Sleep disorder screening may help to identify each series of 5 runs. Results:Peaksheardif- physicians, EMS educators and law enforce- providers who are vulnerable to adverse safety ference between surfaces was −0.89, indicating ment training staff developed four simulation outcomes. that after adjusting for elevation, sensor loca- scenarios to assess provider responses to tion, BMI, starting pause peak shear levels were threatening situations. Each scenario involved 150. Effectiveness of Manual Ventilation 0.89 Newtons (N) lower for ASMO compared patient presentations and distractors that sim- in Intubated Helicopter EMS Transported with standard surface (p = 0.057). Compared ulated common high-stress EMS encounters. Trauma Patients with 0°, elevations of 15° and 30° increased The scenarios were standardized for timing < < (8 minutes) and distinct phases of escalation these levels by 2.41N (p 0.001) and 3.44N (p Timothy Lenz, Brett McLachlan, Craig Bil- (e.g., entrance of distractor, physical contact 0.001), respectively. Using the sacrum as the ref- brey, Keith Mausner, Medical College of Wiscon- with patient, physical contact with crew), erence, IT and heel had increased shear levels of sin Category of Submission: Trauma 2.54N (p < 0.001) and 1.01N (p = 0.079), respec- with the same 51 data elements collected. The tively. Peak pressure difference between sur- Background: Helicopter EMS agencies are fre- scenarios used actors in an immersive, realistic, faces was −1.69, indicating pre-run peak pres- quently called to prehospital settings to trans- video-recorded environment. Role players sure levels were 1.69 mmHg lower for ASMO port intubated patients to definitive care at a and evaluators attended a week-long course compared with standard surface (p = 0.070). trauma center. There is no current evidence to standardize simulation performance and Discomfort was lower on ASMO than standard to inform the decision of ventilation in this assessment. Providers were told that they were surfaceat0° and 30° (p = 0.004, p = 0.014). population. Current practice varies by group participating in a “patient care scenario” but Both surfaces had increased discomfort mov- from hand-operated bag-valve-mask (BVM) to otherwise blinded to the purpose of the simu- ing from 0° to 30° (p = 0.005 and 0.039, respec- mechanical ventilation. Our goal was to evalu- lation. Each provider participated in a single tively). Conclusions: ASMO reduced levels of ate the effectiveness of manual BVM ventilatory scenario as a member of a two-person team. The shear, pressure and discomfort. During trans- support in our population of severely injured evaluator to participant ratio was 1:1. Charac- port, attention should particularly be given to trauma patients. We hypothesized that man- teristics were compared using chi-square tests. the heels and head of bed elevation. ual control of ventilation will provide adequate Results: A total of 272 EMS providers were support to maintain a physiologic end-tidal car- evaluated across the four scenarios: domestic = = 149. Sleep Disorders Are Common Risk bon dioxide (ETCO2). Methods: This research abuse (n 94, 35%), possible overdose (n = Factors for Occupational Injury represents a prospective, observational, proof 44, 16%), deceased mother (n 68, 25%), and = of concept study. Over a seven month period intoxicated homeless person (n 66, 24%), with Matthew Weaver, Jason Sullivan, Conor < of data collection (June 2015 to December 2015) 3% missing data across elements. There were O’Brien, Salim Qadri, Charles Czeisler, Laura and across the three distinct bases of our flight no differences in participant characteristics Barger, Brigham and Women’s Hospital and = program, twenty patients were enrolled. Inclu- by scenario: certification levels (p 0.96), sex Harvard Medical School Category of Submis- = = sion criteria for the study was limited to trau- (p 0.28), and years of EMS experience (p sion: Operations, Quality, Safety Systems, matic mechanisms and patients endotracheally 0.86). Most providers felt their scenario was Disaster = intubated on scene and transported by heli- realistic (n 219/265, 83%) and this rating did not differ across scenarios (p = 0.08). Overall, Background: The rate of occupational injury in copter. Excluded were any interfacility trans- 63% (n = 170/269) of providers stated that EMS is high and crashes are common. Fatigue ports, non-scene calls, and any patient intu- if this scenario had occurred in real life, they has been identified as an important risk fac- bated with a supraglottic device. ETCO2 mon- would have felt threatened, with no difference tor. Sleep disorders are common, often over- itoring was accomplished with a ZOLL ProPac across scenarios (p = 0.31). Conclusions:We looked contributors to fatigue. We sought to programmed to collect data at 30 second inter- created and validated four realistic scenarios examine the prevalence of common sleep dis- vals for the duration of the flight. Additional for prehospital providers that simulated threat- orders and their impact on occupational safety. information on demographics and mechanism ening patient encounters with standardized Methods: A nationwide cross-sectional study was also collected. As a descriptive pilot study, phases of escalation and data collection points. collected data from 66 fire departments across there were no considerations of power; we Future research should focus on evaluating the US who participated in a workplace-based enrolled all patients during the study period the characteristics of threatening encounter sleep disorders screening and education pro- who met the inclusion criteria. Results:The phases that alert providers to the potential for gram. Participants were screened for common subject group of 20 trauma patients was used violence. sleep disorders using reliable and valid screen- to collect data for over 500 cumulative minutes of manual ventilation. The percentage of cumu- ing questionnaires and asked a series of ques- 152. Paramedics Providing Palliative Care lative time spent with adequate oxygen satura- tions about adverse safety outcomes which at Home: An Evaluation of Paramedic tions (ࣙ90% Sp02) was 83.6%. The percentage occurred in the past month. The cooperation Comfort and Confidence in Providing of cumulative total time spent with adequate rate was 58.6%. For this secondary analysis, Palliative Support the dataset was limited to participants who ETCO2 (35–45 mmHg) was 48.7%, with 34.6% reported their primary responsibility as med- of time spent under this range and 16.7% above Alix Carter, Judah Goldstein, Marianne Arab, ical care and listed an EMT-Basic or higher this range. Conclusions: Manual control of ven- Michelle Harrison, Wilma Crowell, Katherine 138 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

Houde, Jan Jensen, Mireille Lecours, James pital complications (cardiac arrest, oxygena- the effectiveness of IO vs IV access in cardiac Sullivan, Carolyn Villard, Kathryn Downer, tion or ventilation failure, emesis, and docu- arrest and other low perfusion states such as Dalhousie University Category of Submission: mented air leaks) and where hospital outcome shock in a prospective manner. Operations, Quality, Safety Systems, Disas- data were available, the incidence of aspira- ter tion on radiologic studies (compared with chi 155. Type of Airway Device Does Not Affect square tests). We secondarily compared prehos- Physiologic Markers In Patients Background: Paramedics are called for crisis pital oxygenation and ventilation parameters, Undergoing Mechanical CPR: The and symptom management for patients receiv- in-hospital ventilator days, ICU days, hospital Prehospital Airway and Mechanical CPR ing palliative care. To address the mismatch days, and in-hospital death, using descriptive Evaluation Study between EMS current care and the patient’s statistics. Results: Of 137 cases meeting inclu- Torben Becker, Arjun Prabhu, Aric Bern- goals of care, a new program was implemented sion, N = 93 (68%) were male, and average age ing, Clifton Callaway, Francis Guyette, Chris- in two provincial EMS systems. Prior to pro- was 50 years (+/−18). Median initial PIP was tian Martin-Gill, Torben Becker, University of gram launch, all paramedics were trained in 30 cmH2O (IQR 24–40). In patients with PIP ࣙ Florida Category of Submission: Cardiac the Learning Essentials Approach to Palliative 30 cmH2O at any time (N = 74, 54%) vs. PIP Care (LEAP) Mini for Paramedics. We eval- < = 30 cmH2O (N 63, 46%), final prehospital Background: Mechanical chest compression uated paramedic comfort and confidence to vital parameters were SpO2 99.5 (IQR 96–100) (MCPR) devices and manual chest compres- deliver palliative or end of life care. Methods: vs. 98.5 (IQR 95–100) and ETCO2 35 (IQR 32–41) sions achieve similar survival for patients with A prospective, cross-sectional electronic sur- vs. 33.5 (IQR 29–38). Prehospital complications out-of-hospital cardiac arrest (OHCA). How- vey was delivered before and 18 months after = occurred in 11 (8%) vs. 10 (7%) (p 0.68). Of ever, recent data suggest supraglottic airway training and program launch. A total of 1,255 ࣙ 87 patients with in-hospital data with PIP 30 devices (SGA) during MCPR may impair ven- paramedics received an email invitation. Partic- = < = cmH2O (N 46) or 30 cmH2O (N 41), inci- tilation compared with an endotracheal tube ipants scored questions on comfort and confi- = dence of aspiration was N 11 (23.9%) vs. N (ETT). In this study, we tested whether mark- dence on a 4-point Likert scale, and attitudes = = 5 (12.2%) (p 0.16). Median ventilator days ers of oxygenation, ventilation, and perfu- on a 7-point Likert scale. Scores are reported were 4 (IQR 1–10) vs. 3 (IQR 1–11.5), ICU days sion differed between OHCA patients receiving as Median (IQR). Wilcoxon ranked sum tested were 5.5 (IQR 2–16) vs. 3 (IQR 2–19), and hos- MCPR with SGA and OHCA patients receiving before and after differences. Open-ended ques- pital days were 8 (IQR 3–22) vs. 7.5 (IQR 2–27). MCPR with ETT. Methods: We retrospectively tions were thematically analyzed by one author. = = N 19 (40.4%) vs. N 13 (31.7%) died. Conclu- reviewed prehospital and in-hospital electronic Results: Pre-launch, 235 (18.9%) responded;105 sions: Although confounders such as aspiration health records from three Emergency Medi- were primary care paramedics (PCP) (44.7%). prior to airway placement may exist, these data cal Services (EMS) agencies from January 1, Post-launch, 267 responded (21.3%), 118 by suggest that patients receiving mechanical ven- 2014 to December 21, 2016. We included all (44.2%) PCPs. Paramedic comfort to provide ࣙ tilation via the King-LTD with PIP 30 cmH2O patients with OHCA who underwent MCPR palliative care scores improved: pre = 3(IQR1) have similar incidence of prehospital and in- and who had their airway managed with an to post = 3(IQR1)(p= 0.00009), where 4 = very hospital complications. ETT or SGA. The primary outcome was intra- comfortable. Comfort to provide palliative care arrest end-tidal carbon dioxide (etCO2) mea- without transport increased: pre = 3 (IQR 1) vs. 154. The Effect of IV vs. IO Access in surements. We also examined ventilation rates, post = 3(IQR1),p=< 0.000001). Confidence in Prehospital Cardiac Arrest ROSC Rates vital signs upon return of spontaneous cir- having the right interventions tools to deliver culation (ROSC), as well as vital signs, lactic palliative care increased from: pre = 2(IQR1) Colby Redfield, Stephen Suarez, Jessica acid values, and venous or arterial blood gas to post = 3(IQR0)(p=<0.000001); for care Daniels, Cristina Sanchez, Heidi Siples, results in the emergency department (ED). We without transport to hospital: pre = 2(IQR1)to Kim Landry, Leon County EMS Category of also recorded rates of ROSC and survival at post = 3(IQR1),p=<0.000001). Respondents Submission: Cardiac 24 hours, 30 days, and 90 days. Results:Of strongly agreed that all paramedics should be 140 patients who received MCPR, valid data able to provide good basic palliative care: 7 Background: The prevailing standard of care in were available for 126 patients. Of included [IQR 6, 7]) and that a patient with an incur- prehospital emergency medical services is that patients, 84 (66.7%) had an ETT placed, and 42 able illness should receive palliative care: 6 [IQR either intravenous (IV) or intraosseous (IO) are (33.3%) had a SGAplaced. Twenty-eight (22.6%) 4, 7]). Thematic analysis revealed paramedics acceptable routes for obtaining vascular access achieved ROSC. In-hospital data were available feel delivering palliative care is rewarding, and delivery of resuscitation medications and for 13 (10.3%) patients. There were no group although additional experiential training, con- volume expanders in cardiac arrest patients. differences in etCO2 values during arrest, vital tinued expansion of the role of PCPs and addi- Our local EMS agency’s current cardiac arrest signs upon ROSC or ED arrival, or arterial or tional medications were recommended. Con- protocol allows for either IV or IO access to be venous partial pressure of oxygen, partial pres- clusions: The palliative care training and addi- placed without preference. Objective: To eval- sure of carbon dioxide, pH and lactic acid lev- tional resources resulted in improved comfort uate the effectiveness of IV access versus IO els in the ED. There were no group differences and confidence. Paramedics strongly agree with access, in terms of Return of Spontaneous Cir- in ROSC or survival at 24 hours, 30 days, or paramedic administration of palliative care, cite culation (ROSC), for patients suffering from 90 days. Conclusions: We detected no differ- palliative care as an important and rewarding cardiac arrest. Methods: Quality Improvement ence in markers of oxygenation, ventilation or part of their job, and identified recommenda- retrospective review project examining cardiac perfusion and no differences in survival for tions for further training and scope. arrest data with a single ACLS EMS agency with average call volume of 37,000 calls annually. We OHCA patient managed with either an ETT or 153. Complications with Use of a examined a four year period from 2013 to 2016. SGA in combination with MCPR. Transport Ventilator with a King-LTD Cardiac Arrest patients were identified from a 156. The Use of Airway Simulation Based on Peak Airway Pressure Quality Assurance Database. Exclusion criteria Scenarios to Augment Systemic Quality included trauma arrest, pediatrics, pregnancy, Leonard Weiss, Gabriel Diamond, Thomas Improvement Initiatives in a Fire-Based and obvious signs of death. Method of vascular EMS Agency Segerson, Justin Talarico, Francis Guyette, access was determined by reviewing the report Christian Martin-Gill, Department of Emer- and placed into an excel spreadsheet along with Eric Cortez, Tyler Smith, Andrew Little, Rich gency Medicine, University of Pittsburgh School of ROSC determination. Results: A total of 1,028 Latham, William Krebs, James Davis, David Medicine Category of Submission: Medical patient care reports were examined from Jan- Keseg, Ohio Health Doctors Hospital Category Background: Our prior pilot data demon- uary 1, 2013 to December 31, 2016. There were of Submission: Operations, Quality, Safety strated that mechanical ventilation during crit- 230 patients where resuscitation was not initi- Systems, Disaster ical care transport using the King Laryn- ated due to obvious signs of death. A total of 46 Background: Airway simulation for prehospi- geal Tube Disposable airway (King-LTD) was patients were excluded as trauma related car- tal providers has several benefits, including associated with peak inspiratory pressures diac arrests and 31 patients excluded due to provider exposure to low-frequency procedures (PIP) above the manufacturer recommended 30 age less than 18 years. A total of 721 patients and identification of systemic quality improve- cmH2O in almost half of cases. In the current remained after applying the exclusion criteria. ment concerns. The objective of this study was study, we aimed to determine prehospital and A total of 361 cardiac arrest patients had an IV to analyze two airway simulation scenarios in-hospital complications associated with use placed with a ROSC in 148 (41.1%). Atotal of 360 during a two-hour paramedic airway course. of King-LTD when PIP with mechanical venti- cardiac arrest patients had an IO placed with a We hypothesized that the simulation scenarios lation is above or below 30 cmH2O. Methods: ROSC in 80 (22.2%). IV use during cardiac arrest would identify areas of focus for future quality We retrospectively reviewed all King-LTD uses hadimprovedROSCwhencomparedtoIOuse < improvement initiatives. Methods:Thiswasa with mechanical ventilation in a large multi- (p 0.001). Conclusions: In this small retro- prospective evaluation of paramedics in an all state critical care transport service from Decem- spective review, there is a correlation between advanced life support (ALS) fire-based emer- ber, 2006 through November, 2015. Cases of dis- higher ROSC rates and IV access versus IO gency medical services (EMS) system during continuation of ventilatory efforts with King- access. Limitations include small sample size, two simulated airway scenarios in a hospital- LTD or missing PIP data were excluded. Pri- single EMS agency and retrospective nature of based simulation center. During each session, mary outcomes were the incidence of prehos- study. Future studies should further evaluate NAEMSP 2018 ANNUAL MEETING ABSTRACTS 139

teams of paramedics (4–6 individuals) man- cobalamin. Patients in cardiac arrest comprised 159. Descriptive Analysis of Patients aged one trauma patient and one acute decom- 36.8% of the patients studied and were excluded Administered Naloxone by Prehospital pensated heart failure patient. Trained EMS from subjective adverse reactions. For the Providers agency instructors and simulation center per- remaining patients, one was observed to have sonnel using a standard scoring sheet with nausea and another with post-administration Eric Cortez, Kaitlin Bowers, Judd Shelton, predefined data points evaluated teams. The seizure. An increase in blood pressure was Andrew Little, Robert Lowe, Sam Kotran, Ohio primary outcome was successful endotracheal noted in 42.4% of the patients, with a change in Health Doctors Hospital Category of Submis- intubation. Secondary outcomes included sev- systolic measurements between 1–106 mmHg sion: Medical eral pre-intubation and post-intubation assess- with a mean change of 13.9 mmHg (median Background: Emergency medical services ment and management steps. Descriptive statis- 7 mmHg, SD = 17.6 mmHg) and change in dias- (EMS) providers are administrating naloxone tics were reported as medians with interquar- tolic measurements between 1–77 mmHg with more frequently and at higher doses. The tile ranges (IQR) and proportions. Results: a mean change of 19 mmHg (median 10 mmHg, objective of this study was to analyze patients A total of 375 paramedics participated in 61 SD = 24.8 mmHg). Of these patients, 7.9% expe- that received naloxone by EMS providers. We trauma scenarios and 74 heart failure scenarios. rienced a clinically significant increase in blood hypothesized that a proportion of prehospi- The median number of self-reported successful pressure that resulted with a value greater than tal patients were administered naloxone in intubations in the previous six months was 1 180/110 mmHg. Conclusions: The administra- the absence of apnea. Methods:Thiswasa (IQR 0–2). Successful intubation was achieved tion of hydroxocobalamin was associated with retrospective study of patients that received in 59 (97%) of the trauma scenarios and 73 a low incidence of previously reported adverse prehospital naloxone between October 1, 2015 (99%) of the heart failure scenarios. End-tidal reactions when given in the prehospital setting and March 31, 2016. All patients adminis- capnography confirmation was performed in 60 for the treatment of suspected cyanide toxicity. tered naloxone and transported to emergency (98%) of the trauma scenarios and 73 (99%) of Limitations for this study include its retrospec- departments (EDs) within the study’s health- the heart failure scenarios. Preoxygenation was tive nature and its lack of hospital patient out- care system were included. Patients were performed in 60 (98%) of the trauma scenar- comes. excluded if they were transported to EDs ios and 72 (97%) of the heart failure scenarios. outside of the healthcare system. The primary Basic airway maneuvers (repositioning, suc- 158. BIS: Bispectral Index Monitoring for outcome was the presence of prehospital apnea tioning) were performed in 13 (21%) of trauma Patients During Out-of-Hospital Cardiac before naloxone administration. Secondary scenarios and 31 (42%) of heart failure scenar- Arrest outcomes included the proportion of patients ios. In the heart failure scenario, allergies were Ralph Frascone, Jeffrey Anderson, Joseph diagnosed with opioid overdose in the ED, and reviewed in 10 (13.5%) encounters, and endo- Pasquarella, Nicholas Loken, Sandi Wewerka, the presence of prehospital unresponsiveness, tracheal tube dislodgement was recognized in Regions Hospital EMS Category of Submission: miosis and hypoxia (< 94% pulse oximetry). 57 (77%) encounters. Conclusions:Thisstudy Cardiac Data points were defined a priori and a stan- found high intubation success rates during the dardized data sheet was utilized. Data were simulated scenarios, while other tasks, such as Background: Progress in the treatment of reported as percentages, and medians with basic airway maneuvers and reviewing aller- OHCA has resulted in a need to rapidly deter- interquartile ranges (IQR). Results:Atotal gies, were performed at lower than expected mine the likelihood of neurological viability in of 350 patients were included. The median rates. Developing quality improvement initia- patients during CPR. End tidal (Et) CO2 lev- age was 45 years (IQR 31–56), and 61% were tives is challenging for low-frequency proce- els have been used as a measure of circula- males. The most common naloxone doses were dures. This study exemplifies the utility of tion during CPR, however, EtCO2 is not predic- 2 mg (54%), 4 mg (26%), and 6 mg (7.2%). airway simulation in helping to help guide tive of neurological recovery. Based upon stud- Of 347 patients with available prehospital quality improvement initiatives for large EMS ies in our animal laboratory, we hypothesize physical exam findings, apnea was present in agencies. that measuring processed electroencephalogra- 27%, unresponsiveness in 56%, miosis in 51%, phy (EEG) during CPR can be used together 157. Incidences of Adverse Reactions and hypoxia in 17%. Final ED diagnosis was with EtCO2 to determine if there are signs of Secondary to the Administration of available for 284 patients, and 128 (45%) were brain electrical activity that may predict neuro- Hydroxocobalamin for Suspected Cyanide diagnosed with opioid overdose. Conclusions: logically intact recovery from a cardiac arrest. Poisoning in the Prehospital Setting In this study, a proportion of EMS patients The primary research question was to deter- received naloxone in the absence of apnea and Albert Arslan, Doug Isaacs, Pamela Lai, mine if EEG activity alone or in combina- other signs of opioid toxicity. Furthermore, Matthew Melamed, Glenn Asaeda, David tion with another non-invasive measurement, over half of the patients were not diagnosed Prezant, Fire Department City of New York and EtCO2, could be used to predict the return with opioid overdose in the ED. This data Northwell Health EMS Fellowship Category of of spontaneous circulation (ROSC). Methods: highlights several important considerations Submission: Student, Resident, Fellow This is a multi-agency, prospective, proof-of- for EMS naloxone administration: indications concept, prehospital, cohort study to deter- (obvious opioid toxicity vs. undifferentiated Background: The objective of this study was mine the relationship between EtCO2 and BIS. overdose), endpoints of therapy (reversal to assess the incidences of adverse reactions Paramedics from three agencies were trained in of apnea vs. confusion), need for re-dosing secondary to the prehospital administration of the application of BIS. Sensors were applied as (potent opioid toxicity vs. non-opioid overdose hydroxocobalamin to patients with suspected early as possible during resuscitation. BIS was with partial response), and effects of naloxone cyanide poisoning after exposure to smoke recorded until the patient achieved ROSC or administration in the setting of medical or inhalation. Exposure to fires involves a high was pronounced dead. The BIS monitor trans- traumatic emergencies. Limitations include a morbidity and mortality, in part by the cellu- forms the EEG waveform into a dimensionless high number of missing ED diagnoses, and lar asphyxiant cyanide - a byproduct of the percent ranging from 0 (complete cerebral sup- exclusion of patients transported to other combustion of synthetic materials. Hydroxo- pression) to 100 (fully awake and alert). Data hospitals. cobalamin, one of the most common antidotes, was analyzed using descriptive statistics and combines with cyanide to form a nontoxic unadjusted logistic regression. Results:Forty- 160. Can Grip Technique and Bag Size metabolite. Since 2009, our department has two patients with BIS measures were enrolled. Improve Volume Delivered with a administered hydroxocobalamin in 239 cases, (ROSC) was achieved in 13 patients (31%). Nei- Bag-Valve-Mask by EMS Providers? creating one of the largest prehospital case ther BIS at initiation of CPR (p = 0.513) or series for a single agency. Methods:Thisisa BIS nadir (0.975) was significantly associated Melissa Kroll, Jyotirmoy Das, Jeffrey Siel- retrospective analysis of adverse reactions in with ROSC. 29/40 (73%) died prior to or dur- ger, Washington University/ Barnes-Jewish Hospi- patients who were administered hydroxocobal- ing transfer to the ED. BIS measures at initi- tal Category of Submission: Medical amin in the setting of suspected cyanide poi- ation of CPR (p = 0.973) or at nadir (0.285) Background: Emergency Medical Services soning by review of patient care reports as well were not significantly associated with mortal- (EMS) professionals rely on the bag-valve-mask as hydroxocobalamin-specific questionnaires. ity. 2/11 patients who survived the ED transfer (BVM) to provide life-saving positive pressure Patients were separated into two study popu- had BIS measures that fell below 5%. Similarly, ventilation in the prehospital setting. Multiple lations: those in cardiac arrest, and those that among 40 patients with available data, ETCO2 emergency medicine and critical care studies were experiencing respiratory failure, altered at initiation of CPR or at nadir did not sig- have shown that lung-protective ventilation mental status, seizures, coma, or hypotension nificantly predict ROSC outcomes (p0 = 0.995; protocols reduce morbidity and mortality. A of unknown etiology. Patients received 1.25– pnadir = 0.416) or mortality (p0=0.772; pnadir recent study has shown that the volumes typi- 5 grams of hydroxocobalamin intravascularly. = 0.532). Using ETCO2 <5% as a stopping rule cally delivered by EMS professionals with the Adverse reactions recorded included erythema, only would have achieved 91% sensitivity for adult BVM are often higher than recommended nausea, seizures, headaches, allergic reactions, survival, as one patient who survived ED trans- by lung-protective ventilation protocols. Our or increased blood pressures. Results: A total fer had ETCO2 readings <5 during monitoring. primary objective was to determine if a group of 239 patients, with ages ranging from 1– Conclusions: In this small study, neither BIS of EMS professionals could reduce the volume 99 years and a median age of 52 years, of whom nor ETCO2 monitoring are predictive of ROSC delivered by adjusting the way the BVM was 58% were male, were administered hydroxo- or survival through ED transfer. held. Secondary objectives included (1) if the 140 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

adjusted grip allowed for volumes more consis- agent; 60 (15.3%) patients met the revised Paul Banerjee, Paul Pepe, Amninder Singh, tent with lung-protection ventilation strategies hypoglycemia decision tool for non-transport. Latha Ganti, Polk County Fire Rescue Category and (2) comparing volumes to similar grip Of these, 8.3% were transported to hospital of Submission: Pediatric strategies used with a smaller BVM. Methods: and all were discharged from ED with no A patient simulator of a head and thorax was additional management for hypoglycemia; Background: To determine which factors had used to record respiratory rate, tidal volume, 6.7% had repeat access to paramedics/ED care the strongest association with good outcomes peak pressure, and minute volume delivered for hypoglycemia and none were admitted. after pediatric out-of-hospital cardiac arrest by participants for 1 minute each across six The sensitivity of the hypoglycemia decision (POHCA) since 2010 when clinical practice different scenarios: three different grips (using tool was 93.3%, specificity 17.8%, PPV 25.0%, guidelines became more aligned with those the thumb and either three fingers, two fingers, NPV 90.0%. Conclusions: Demonstrating high used for adults. Methods: Conducted in a or one finger) with two different sized BVMs sensitivity and NPV, this tool is potentially large EMS urban/surburban jurisdiction that (adult and pediatric). Trials were randomized safe to rule out transport to hospital following uses a comprehensive Utstein-style database, by blindly selecting a paper with the scenario paramedic care for prehospital hypoglycemia. all POHCA cases encountered over 5 calen- listed. A convenience sample of EMS providers Further research is needed to prospectively dar years (January 1, 2012 through December was used based on EMS provider and research validate the tool and evaluate its impact on 31, 2016) were analyzed for associated out- staff availability. Results: We enrolled 50 prehospital and healthcare systems. come correlations following full implementa- providers from a large, busy, urban hospital- tion of the latest (2010) international guide- based EMS agency a mean 8.60 (SD = 9.76) 162. Fall Risk Inventory by Paramedics lines for childhood basic and advanced life sup- years of experience. Median volumes for each Predicts Future Hospitalization and ED port. The analysis was used to identify current scenario were 836.0mL, 834.5mL, 794mL for the Utilization by Elders predictors for return of spontaneous circula- adult BMV (p = 0.003) and 576.0mL, 571.5mL, tion (ROSC), hospital admission (HA) and sur- Ryan Carter, Joanne McGovern, James Dziura, 547.0mL for the pediatric BVM (p < 0.001). vival to successful hospital discharge (SURV). Fangyong Li, Geliang Gan, David Cone, Across all three grips, the pediatric BVM pro- Logistic regression models of traditional predic- Sandy Bogucki, Yale University Category of vided more breaths within the recommended tors were performed using JMP 12.0 for Mac. Submission: Medical volume range for a 70kg patient (46.4% vs 0.4%; Results: Of 133 consecutive POCHA cases stud- < ied, the interquartile range (IQR) for response p 0.001) with only a 1.1% of breaths below Background: One-third of community- intervals was 16 to 47 minutes (range: 0– the recommended tidal volume. Conclusions: dwelling elders fall each year. Previous 490) and the majority presented with asys- The study suggests that it is possible to alter the work showed that more than half of elders tole. As traditionally predicted, shorter times volume provided by the BVM by altering the who fall and activate EMS for “lift assists” from arrest to EMS arrival were associated (sig- grip on the BVM. The tidal volumes recorded without transport will activate EMS again nificantly) with ROSC, HA and SURV (all p with the pediatric BVM were more consistent within 30 days. Objective. To evaluate whether < 0.0001) whereas bystander-witnessed arrest with lung-protective ventilation volumes. several parameters assessed by a research cases (only 13%) were not (p = NS). Still, in paramedic at a scheduled home visit predict 95% of cases, the arrest was identified by a 161. Retrospective Refinement and ED visits and hospitalizations within 90 days bystander prior to EMS arrival and, contrary Validation of a Hypoglycemia Decision in elders at risk for falls. Methods:Forthis to previous studies (with lower reported fre- Tool for Paramedics prospective study, informed consent to track quencies of bystander CPR), chest compres- future healthcare utilization was obtained, and sions were performed by bystanders in 59% of Julie Sinclair, Michael Austin, Shannon participants were enrolled via three pathways: cases. The earlier CPR was provided by EMS Leduc, Zachary Cantor, Richard Dionne, 9-1-1 activation for lift assist, ED visit, or personnel was itself (significantly) associated Penny Price, Justin Maloney, Andrew Reed, self-referral. Participants had scheduled home with ROSC, HA and SURV (all P < 0.0001), but Andrew Willmore, Valerie Charbonneau, visits by research paramedics, who assessed some form of treatment before EMS arrival was Christian Vaillancourt, Regional Paramedic home safety and fall risk (a 15-item survey of provided in 54% of cases and such actions were Program for Eastern Ontario Category of yes/no questions adapted for field use from strongly associated with ROSC, HA and SURV Submission: Medical a previously validated instrument), balance, (p < 0.0001 for all 3 outcomes) whereas AED and medical disability, and by a visiting nurse, Background: Hypoglycemia symptoms are placement (50% of cases) was not. Conclusions: who evaluated home health needs. Subsequent often treated by paramedics in the prehospital Although “witnessed arrest” cases and AED healthcare utilization within 90 days after the environment. Some evidence suggests that placement were not identified as contribut- visiting nurse evaluation was identified by not all patients require transport to hospital ing factors in this subpopulation of cardiac querying electronic hospital records. A mul- following successful reversal of symptoms. We arrests (likely reflecting infrequent ventricular tivariate analysis was performed, including sought to refine and validate a decision tool dysrhythmia etiologies), as expected, shorter several of the research paramedics’ assess- derived to identify patients that could safely elapsed intervals from the moment of arrest to ments plus race, sex, medication count, history be assessed, treated, and not transported to EMS arrival; performance of CPR prior to EMS of prior healthcare utilization, and enrollment hospital following paramedic care for hypo- arrival; and, most importantly, any treatment pathway with the dependent variable being glycemia. Methods: We conducted a health provided before EMS arrival, all resulted in sig- ED or hospital admission within 90 days. record review of paramedic call reports and nificantly higher rates of ROSC, hospital admis- Results: Of 2,265 participants, 1,512 com- emergency department (ED) health records sion and survival beyond hospital discharge. over a 6-month period (July 1, 2015–December pleted their research paramedic and visiting 31, 2015). Prehospital records were queried to nurse appointments, with at least 90 days 164. Adherence to Quality CPR Principles identify all adult patients with a prehospital of subsequent observation. The median age During the EMS to ED Handoff in reading of <72 mg/dl (4.0 mmol/L) excluding was 77, with 69% female, 19% black, and 11% Simulated Pediatric Cardiac Arrest cardiac arrests and terminally ill patients. Hispanic. 390 (25.8%) had an ED or hospital We used standardized case report forms to admission within the 90-day time period. In the Ariel Cohen, Jen Anders, Jordan Duval- collect data. We defined short-term adverse multivariate analysis, significant independent Arnould, UCSD Category of Submission: events as admission to hospital, repeat access predictors of 90-day healthcare encounters Pediatric included history of prior encounter (adjusted to paramedics/ED care, or death, occurring < Background: The aim of this study is to quanti- within 72 hrs of the initial prehospital hypo- OR 2.94, p-value 0.0001), medication count (1.06, 0.0001), and fall risk (0.91, 0.0002). In tatively evaluate adherence to 2015 AHA guide- glycemic event. The hypoglycemia decision lines for quality CPR during the transition of tool incorporates the following variables: on an analysis using the same variables with the single outcome of 90-day hospitalization, patient care from EMS to ED. We hypothe- insulin, not on corticosteroid/oral diabetic sized that quality would be compromised dur- agent, no seizure disorder or cardiovascular these factors remained significant independent predictors, with similar adjusted odds ratios. ing this complicated period; as measured by disease, and given CHO/protein. We per- pauses in chest compressions. Methods:We formed descriptive, logistic regression analysis Conclusons: This study demonstrates that the fall risk inventory, along with medication simulated the handoff and resuscitation of a and test characteristics of the decision tool. pediatric patient in a tertiary pediatric ED Results: There were 392 included patients count and history of previous encounter, is an independent predictor of future healthcare uti- using EMS and hospital volunteers. This was with the following characteristics: mean age a pilot study conducted over two, four hour 57.5 [range 18–97], male 55.9%, diabetic 72.5%, lization and hospitalization within 90 days. The field-adapted fall risk inventory is a simple tool sessions, where as many simulations as pos- on insulin 60.2%, oral diabetic agents 10.7%, sible were run. Simulation began with entry >1 paramedic encounter 18.6%; 247 (63.0%) for paramedics to enhance the EMS assessment of patients at risk of falls. of the prehospital gurney in the ER hallway were transported to hospital and 57 (14.5%) and continued through first 10 seconds of ded- were admitted; 34 (8.7%) had repeat access to 163. Factors Associated with a Good icated compressions from ER staff on emer- paramedic/ED care. A significant association Outcome Following Pediatric gency department bed. CPR recording defib- was found between these patient characteris- Out-of-Hospital Cardiac Arrest in the rillators collected CPR data (chest compres- tics and short-term events: renal disease, liver Years Following the 2010 Resuscitation sion pauses (sec), rate (cc/min), depth (in) and disease, homelessness and on chemotherapy Guidelines CC fraction (CCF, %) throughout the scenario. NAEMSP 2018 ANNUAL MEETING ABSTRACTS 141

Qualitative assessment was performed using 166. Paramedics’ Perceptions of Focused paramedics were recruited for this study. The video recording and post-simulation partici- Point of Care Cardiac Ultrasound paramedics completed a 60-minute educational pant surveys. The primary outcome was num- intervention on FOCUS which included a ber of pauses in chest compression longer than John Reynolds, Juan March, Roberto Portela, lecture followed by a hands-on practicum 10 seconds. Secondary outcomes include analy- Steven Taylor, Bryan Kitch, Department of Emer- concentrated on using the parasternal long sis of depth and rate of compressions and qual- gency Medicine, Division of EMS, Brody School of axis and subxiphoid views only. An emer- itative feedback from participants about poten- Medicine, East Carolina University Category of gency medicine trained physician educated tial for errors. Results: A total of 16 simulated Submission: Student, Resident, Fellow in basic ultrasound skills delivered the edu- resuscitations were analyzed, with a total of cational intervention to the paramedics. The Background: Focused point of care cardiac 16 minutes of CPR. Only two simulations, each paramedics were given a brief overview and ultrasound (FOCUS) has been used success- had a total of one pause longer than 10 sec- training of ultrasound knobology, and then fully in screening for many life threatening onds. Average depth of compressions ranged asked to perform FOCUS using only the emergencies such as cardiac standstill, pericar- from 0.5–1.2 in. Average rate ranged from 107– parasternal long axis and subxiphoid views. dial effusion, and others. There has been lim- 146 cc/min, with the majority of compressions Participants were then graded using the Car- ited research on paramedics’ ability to per- being above 120cc/min. Conclusions: Simu- diac Ultrasound Structural Assessment Scale form FOCUS, but none looking at their per- lated CPR during EMS to ED handoff did not (CUSAS). CUSAS is a 6-point graded scale that ceptions. The goal of this study was to evalu- have an issue with prolonged pauses. How- evaluates visualization of the cardiac structure. ate paramedics’ perceptions of FOCUS before ever, the majority of the resuscitation did not A CUSAS score of 6 is given when multiple and after an educational intervention. Meth- meet quality goals/2015 Pediatric BLS Guide- chambers are visualized. A CUSAS score of 3 is ods: A prospective study was performed in a lines for depth and rate of compressions. Limi- given when there is only partial visualization suburban/urban setting with a population of tations include that this was a simulated resus- of the ventricle. A CUSAS score of 1 is given 180,000 and 26,000 EMS calls annually. Over citation scenario and only one size mannequin when no chambers are visualized. Results: a six month period a convenience sample was used. Future studies observing real-time All 27 paramedics were able to view the heart of fire-based paramedics were recruited. The resuscitation should evaluate the validity of this during the practicum. When performing the paramedics attended a 60 minute ultrasound pilot study findings to possibly guide efforts to parasternal long axis view 27 of 27 paramedics lecture and practicum. An emergency medicine improve resuscitation quality. (100%) received a CUSAS score of 6 (multi- trained physician educated in basic ultrasound ple chambers visualized). In contrast, when skills delivered the educational intervention to 165. Factors Associated with Pediatric performing the subxiphoid view 0 of 27 (0%) the paramedics. The paramedics completed a 5 Interfacility Transfer from Emergency received a CUSAS score of 5 or 6, p < 0.001, 5 of question survey both before and after the edu- Departments 27 (19%) paramedics received a CUSAS score of cation, regarding their perceptions of prehos- 4 (multiple partial chambers including one ven- pital ultrasound. A Chi-square test or Fischer Ali Aledhaim, Jon Mark Hirshon, Jennifer tricle) and 22 of 27 (81%) paramedics received Exact test was used to determine statistical sig- Fishe, Jennifer Anders, University of Maryland a CUSAS score of 3. Conclusions: Our pilot nificance. Results: All 27 (100%) paramedics Department of Emergency Medicine Category of study suggests paramedics with only limited completed the pre-survey, education interven- Submission: Pediatric education can be taught to successfully perform tion, and the post-survey. Pre-survey only 2 of a FOCUS using the parasternal long axis view, Background: In regionalized health systems, 27 paramedics felt they had a significant knowl- but have difficulty using the subxiphoid view. pediatric patients often require interfacility edge regarding FOCUS, while in the post- transfer (IFT) from an initial emergency care to survey that number increased to 13 of 27, p < 168. Increasing Cardiac Arrest Survival a second acute care facility to reach definitive 0.001. Pre-survey 4 of 27 paramedics felt com- through a Novel Dispatcher CPR care. IFT is associated with patient safety risks, fortable performing and reading a FOCUS dur- Instruction Program delays in definitive care, and increased cost. ing a cardiac arrest compared to 23 of 27 post- < EMS triage tools to guide pediatric destination survey, p 0.001. Pre-survey 8 of 27 paramedics Brittany Farrell, E. Brooke Lerner, M. Ric- choice should be developed to reduce the need agreed that the cost of FOCUS justifies the ben- cardo Colella, Kenneth Sternig, Lesley Simley, = for IFT. Objective: To determine factors associ- efits as compared to 21 of 27 post-survey, OR Christine Westrich, Charles Cady, Medical Col- ated with the likelihood of pediatric ED patients 8.3, 95% CI: 2.4–28.4. Almost half (13 of 27) of lege of Wisconsin Category of Submission: Car- undergoing Interfacility Transfer (IFT). Meth- the paramedics thought that FOCUS performed diac ods: This study encompassed 3 years (2010– by paramedics during cardiac arrest would be 2012) of Maryland HCUP ED visit data. We easy to perform based on the pre-survey, com- Background: Out-of-hospital cardiac arrest included patients 0–17 years of age with a dis- paredto24of27onthepost-survey,OR= (OHCA) survival rates remain low as do charge or transfer disposition. The analysis was 8.6, 95% CI: 2.1–35.6. Pre-survey the majority bystander CPR rates. When a dispatcher pro- limited to visits classified as “emergent” and the of paramedics (19 of 27) already believed that vides CPR instructions to a bystander who 20 most common Diagnosis Categories (DxC) they should have access to prehospital ultra- performs compressions the odds of survival associated with IFT. Factors assessed included sound, and in the post-survey that number increase. However, many communities do DxC, age, gender, race, and insurance type. The increased to 25 of 27, p < 0.08. Conclusions: not provide this lifesaving intervention, often likelihood of IFT from the ED was evaluated by This study suggests that without previous edu- citing the barriers of limited personnel and weighted multivariate logistic regression mod- cation paramedics were not comfortable using funding. Objective: To describe the implemen- eling design. Results: For the three-year period, ultrasound and believed FOCUS was not cost tation of a novel centralized dispatcher CPR 146,995 pediatric ED patients were diagnosed effective. Yet, after a brief educational inter- instruction program that serves seven PSAPs with one of the top 20 DxC emergent conditions; vention, paramedics’ perceptions significantly in a single county and compare bystander 10,143 underwent IFT. All factors assessed were changed. CPR rates before and after implementation. statistically significant with varying effect sizes. Methods: As of April 22, 2016, seven munic- The largest difference was seen between the top 167. Paramedics Can Successfully Perform ipal public safety answering points (PSAPs) 20 DxC medical (11.5% IFT) vs. trauma con- Cardiac Ultrasonography Utilizing the that did not previously provide dispatcher ditions (3.2% IFT, p < 0.001). Age was associ- Parasternal Long Axis Approach instructions implemented this novel pro- ated with incremental increases in transfer rate. gram. Using a simple 30-minute self-directed John Reynolds, Juan March, Roberto Portela, Compared to 0–4 yo, the ORs of IFT were 1.35, video, 84 PSAP dispatchers were trained to Steven Taylor, Bryan Kitch, Department of Emer- 2.48, and 3.54 for 5–9 yo, 10–14 yo, and 15–17 yo, utilize a two-question protocol to identify and gency Medicine, Division of EMS, Brody School of respectively (p < 0.001). In the adjusted logis- transfer suspected OHCA cases to a central Medicine, East Carolina University Category of tic model, pediatric patients with medical con- communication center. At this center, a trained Submission: Student, Resident, Fellow ditions were 4.6 (4.41–4.85) times more likely to communicator delivered CPR instructions be transferred than patients with trauma condi- Background: Focused point of care cardiac to the caller. Training of the 26 central com- < tions (p 0.001). African-Americans were 22% ultrasound (FOCUS) has been used success- municators was accomplished with a 2-hour less likely to undergo IFT than Caucasians. Pri- fully in screening for many life-threatening in-person didactic session followed by a 2-hour vate insurance and self-pay had a higher OR emergencies such as cardiac standstill, peri- practice session. We compared pre and post = of transfer than Medicaid, 1.08 (p 0.002), cardial effusion, and others. There has been countywide EMS medical record data through < and 1.51 (p 0.001), respectively. Conclusions: limited research on paramedics’ ability to December 2016 using descriptive statistics. We For pediatric medical patients, IFT from ED perform FOCUS, but none specifically com- also collected and analyzed data from record- to another acute facility for admission is more paring paramedics’ ability to utilize different ings of communicator-to-caller interactions. common than for trauma. EMS triage tools to cardiac views. This study aimed to determine Results: 169 calls were transferred to the cen- guide destination choice for pediatric medi- if paramedics can perform FOCUS utilizing tral dispatch center. Of those, 106 needed CPR cal patients may help reduce this discrepancy. two different views. Methods: A prospective instructions. Of those, 56 callers performed Additionally, racial and insurance disparities study was performed in a suburban/urban compressions before EMS arrival (52%). The 63 exist for pediatric IFT from EDs. setting with a population of 180,000 and 26,000 non-OHCA calls were for a variety of ailments EMS calls annually. Twenty-seven fire-based ranging from severe to mild and the number 142 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

of non-OHCA calls decreased over time (May den of preventable injuries and readmissions on tion to seek illicit substances. The major health 44%; Dec 29%). 11 victims survived to hospital frontline providers and health care systems. concern of opioid abuse, respiratory depres- discharge, for a 19% survival rate; previously, sion, is treated mainly with Naloxone, which the countywide survival rate was 10%. The 170. Am I awake? Lack of Sedation counteracts opioids at the receptor level. It is countywide bystander CPR rate increased Protocols for Intubated Patients during thought by many EMS personnel that people from 19% to 24%. Approximately 109 OHCA Transport in Statewide Treatment experiencing resuscitation with Naloxone will calls were not transferred for instructions, Protocols continue to abuse opioids. Methods:This work continues to increase the rate of OHCA retrospective chart review examined electronic Christina Loporcaro, David Schoenfeld, Beth calls transferred. Conclusions: Implementing patient care reports provided by the Three Israel Deaconess Medical Center/Harvard Medical a novel centralized dispatcher CPR program Rivers Ambulance Authority (TRAA). All School Category of Submission: Student, Res- increased the rate of bystander CPR. Using a encounters in which Naloxone was adminis- ident, Fellow central communication center for instructions tered between November 1, 2010 and October allowed us to train and maintain a smaller Background: In our constantly evolving health- 31, 2016 by TRAA or other bystanders were group of communicators, leading to less cost care system the transfer of intubated patients examined. The number of encounters each and more experience for those communica- between facilities is an ever more common patient had during this date range was used to tors, while limiting the burden on the PSAP occurrence. While there is a paucity of litera- analyze a general recurrence rate of opioid use. dispatchers. ture regarding the impact of adequate sedation Results: The increase in number of individuals in the out of hospital environment, intensive experiencing more than one Naloxone related 169. Qualitative Study of Emergency care unit (ICU) studies have shown significant event annually did not differ significantly from Medical Technician and Patient χ = outcome measures such as ICU length of stay what was expected over the 6-year range, 2 Perspectives on the Transport Plus = is associated with inadequate patient sedation. 9.81, p 0.08. However, the number of patients Program The purpose of this study was to describe cur- falling into this category increased more than triple throughout the study. Conclusions:The Hayley Neher, Ksenia Gorbenko, Nadir rent protocols for sedation of intubated patients results of this study suggest that the number Tan, Diana Grigoriou, Hugh Chapin, Lynne during interfacility transfer (IFT), as well as of recurrent patient encounters involving the Richardson, Ula Hwang, Kevin Munjal, Icahn the use of standardized sedation assessment administration of Naloxone has increased. School of Medicine at Mount Sinai Category of scoring to guide sedative medication admin- While the extent of the increase of recurrence Submission: Student, Resident, Fellow istration. Methods: Cross sectional study of STPs utilizing a standardized review to eval- is much less than initially believed by EMS Background: “Transport PLUS” is an educa- uate sedation protocols for intubated patients personnel, additional future studies to cor- tional intervention in which Emergency Med- and the use of standardized sedation assess- rectly identify the impact of recurrent patient ical Technicians (EMTs) are trained to use a ment scores. Protocol revision date was also encounters may show significant results to checklist to perform discharge instruction com- captured. Results: Thirty-one out of fifty states assist combating addiction. prehension assessments and home fall safety (62%) issue ALS STPs. Of those thirty-one 172. Pharmacologic Opioid Alternatives assessments for older adult patients trans- states, only one (3%) has a protocol for seda- for Pain Control in Statewide Treatment ported home following hospitalizations. Pre- tion of intubated patients. No STP incorpo- Protocols viously reported preliminary findings demon- rates or references any sedation scoring tool to strated high rates of patient acceptance and help guide sedative administration or aid in Christie Fritz, Christina Loporcaro, David removing fall hazards following the interven- patient assessment. 75% of protocols have been Schoenfeld, Beth Israel Deaconess Medical Cen- tion. In this qualitative study, we endeavored revised since 2015 and all have been revised ter/Harvard Medical School Category of Submis- to identify potential barriers to success and within the past 5 years. Conclusions: Although sion: Student, Resident, Fellow refine the existing checklist and other modifi- there is little in the prehospital literature regard- able aspects of the program in order to max- ing patient outcomes with respect to inade- Background: There has been an increasing imize its effectiveness. Methods: This qual- quately sedated patients, self-extubation, exces- focus on reducing opioid use across health- itative study consisted of two homogenous sive agitation on hospital arrival and vital sign care in light of the opioid epidemic. There focus groups led by an experienced facilita- abnormalities are complications well known to are multiple pharmacologic options for treat- tor with Transport PLUS trained EMTs and providers. This study demonstrates that cur- ing pain in the prehospital setting includ- potential older adult patients to assess bar- rent STPs do not provide paramedics with the ing ketamine, nitrous oxide, acetaminophen, riers and opportunities for improving the tools to optimally assess and sedate intubated ibuprofen, ketorolac and aspirin. The major- program. Three independent analysts coded patients in the out of hospital environment. ity of states issue statewide treatment proto- anonymous transcripts for themes, compared While sedation plans may be developed with cols (STPs) that are either mandatory, or serve for consistency, and resolved disagreements medical control prior to transfer, a protocolized as a guide for medical directors. The pur- through discussion. Results:TrainedEMTsand approach to sedation scoring and medication pose of this investigation is to describe the potential patients found the program valuable administration may be beneficial. This repre- extent to which STPs include alternatives to but uncovered a number of potential barri- sents a serious deficiency in our ability to pro- opioids for pain control. Methods: Cross sec- ers to success and suggested improvements. vide high quality care to intubated patients in tional study of STPs, utilizing a standardized Themes identified by both groups included the out of hospital environment. In the future, review of pharmacopeia in pain control proto- concerns for patient privacy and the impor- we hope to develop and validate a prehospital cols. Protocol revision date was also captured. tance of obtaining buy-in from both patients sedation scoring model and associated protocol Results:Thirty-twooffiftystates(64%)issue and providers. Trained EMTs also suggested for the management of intubated patients in the STPs; 78% are mandatory; 38% of STPs limit improving phrasing of items on the checklist out of hospital environment. pain management to opioid medications only; and optimizing delivery of educational infor- and 62% of STPs provide for pharmacologic mation. Patient focus group suggested ways to 171. Prevalence of Recurring Patient alternatives to opioids for pain management. enhance comprehension. Suggested improve- Encounters that Require Administration Pharmacologic alternatives for pain control are ments included emphasis on situational aware- of Prehospital Naloxone: A Retrospective variable across STPs and include Nitrous oxide ness during EMT training, building rapport, Chart Review (50%), ketamine (19%), Tylenol (25%), ketoro- question order, normalizing safety measures, lac (25%), Ibuprofen (16%), and aspirin (6%). Thomas Dykstra, Jen Knapp, Patrick Dugan, and explaining the reasoning behind includ- A total of 75% of protocols have been revised Rhees Nickel, City of Fort Wayne, EMS Founda- ing and excluding specific items on the check- since 2015 and all have been revised within tion Chair Category of Submission: Student, list. Conclusions: The Transport PLUS program the past five years. All ALS statewide treat- Resident, Fellow was well received by both EMTs and patients. ment protocols have explicit orders for opiates We found a high degree of agreement between Background: A significant proportion of in their pain control protocols. Conclusions: the two groups in identified barriers to suc- patients responded to by EMS personnel for The opiate epidemic in the U.S. has led to an cess. Adjustments in EMT training and support- opioid overdose will continue to abuse opioids increased focus on the use of alternatives to ive materials, including checklists and hand- after treatment and resuscitation, leading to narcotic medications in healthcare. Pain man- outs, were made based on suggestions obtained subsequent overdoses in the future that require agement is an important part of prehospital during the focus group interviews. Training additional treatment. The aim of this study is to care, however many states do not provide phar- was specifically enhanced to emphasize qual- identify the prevalence of recurrent encounters macologic alternatives to narcotic medications. ity, consistency, communication skills and tech- that require the administration of Naloxone to While no studies have identified prehospital nique. Documents were enhanced to be more reverse opioid overdose. The trend of opioid narcotic administration as a cause of or contrib- visually appealing, easier to understand, and abuse within the United States has continued utor to the opiate epidemic, we should strive promote better flow throughout the encounter. to increase despite efforts to decrease their to reduce the use of narcotics when appropriate A randomized controlled trial to assess effec- accessibility. To deter this issue, stricter guide- alternatives exist. Despite the majority of STPs tiveness of the program is already underway. lines regarding the prescription of medicinal undergoing protocol revisions within the last If successful, our program will reduce the bur- opioids has led many individuals with addic- two years which is during the ongoing opiate NAEMSP 2018 ANNUAL MEETING ABSTRACTS 143

epidemic, STPs have not fully incorporated Background: Following the guidelines of ria were low-energy mechanism of injury, pen- alternatives to opiates for pain control. This rep- dispatch-assisted CPR (DACPR) may enhance etrating pelvic injuries, pregnancy, and inabil- resents a significant opportunity to improve our bystander CPR rate after OHCA. Registry of ity to secure binder due to patient size. Com- STPs to include alternatives to narcotic medi- quality measurement for DACPR has never munity consultation to meet the requirements cation for the management of pain, and do our been explored. We designed a nationwide of Exception from Informed Consent was con- small part to help combat the opiate epidemic. quality registry for DACPR performance and ducted prior to study implementation. EMS Further study is needed to better understand innovated a structured format of measurement. crews were randomly assigned a sealed kit at the barriers to adoption of non-opiate phar- Methods: A nationwide Google Forms based the start of each shift containing either a com- macologic treatment or adjuncts for pain treat- online e-registry system covering over twenty mercial binder (intervention) or towels (com- ment. administrative regions and more than twenty parison), indicating standard of care. Prehospi- millions of population was designed and tal providers were blinded to the contents until 173. The Heavy Lift: Impact of a Regional launched for DACPR performance and qual- it was opened after identifying a patient meet- Bariatric Transport Program ity measurement at individual case level for ing inclusion criteria. Outcomes included skin non-traumatic OHCA patient. Audio records of complications, hospital and ICU admissions, Gerald Wydro, Larry Loose, Alvin Wang, individual EMS call were reviewed for perfor- angioembolization, surgical control of bleeding, Department of Emergency Medicine, Aria Jefferson mance rating. System data inputted could be transfusions, and 30-day readmission and mor- Health Category of Submission: Operations, immediately retrieved as feedback to each cor- tality. Results: A total of 30 patients with sus- Quality, Safety Systems, Disaster responding administrative region. Recognition pected pelvic fractures were enrolled from June Background: Obesity is an epidemic in this of cardiac arrest by call communication, CPR 2016 to April 2017. Fourteen (46.7%) patients nation and provides serious challenges to EMS Instructions upon the recognized OHCA, and were randomized to the binder group; six for care and transport. Many systems have chest compression upon the recognized OHCA (42.9%) had pelvic fracture diagnoses compared identified the problem, but few provide a solu- were the three major categorical performance to four (25.0%) in the comparison group. The = tion to their providers. Alternatively, EMS sys- indicators, and each operational time interval patient population was majority male (n 19, tems should create a solution that is deploy- of call-to-recognition, call-to-instruction, and 63.3%) and averaged 31.5 years. Of the twenty- able, cost effective, and provides safe digni- call-to-compression were evaluated. Each three patients (74.2%) admitted to the hospital, fied transport. We describe the characteristics of categorical performance indicator (Y-axis) was 11 (47.8%) were admitted to the ICU. Only 3 a regional Bariatric Support Unit (BSU) trans- paired with its operational time interval (X- (9.6%) patients required angioembolization, 2 port system dispatched via the 9-1-1 system for axis) as a set of quality index for diagrammatic (6.5%) surgical control of bleeding, and 3 (9.6%) bariatric patients. Methods: Descriptive anal- comparison in our design. We used regression a transfusion. One (3.2%) patient required read- ysis of a regional BSU transport system in analysis for statistical analysis. Results:A mission and died within 30 days. There were no our suburban EMS system served by 17 agen- total of 6,078 audio records for OHCA EMS serious adverse events. Conclusions: This pilot cies covering an area of 622 sq. miles with a calls across 18 regions were centralized into test demonstrates that prehospital providers population of over 620,000. Requests for EMS the nationwide DACPR Quality Registry are able to implement a randomized trial, service exceed 53,000 annually and are han- in 6 months (minimal 40 to maximal 1,625 including identification of eligible patients, dled via a single 9-1-1 center. The BSU trans- cases/region according to its population). maintaining the randomization scheme and port system utilizes three specially equipped Regional recognition rate significantly varied assignment to treatment, and handoff to the < ambulances (bariatric stretchers, lifts, ramps, from 10.0% to 88.1% (p 0.01; averaged clinical and research teams at the receiving and winches) strategically located throughout 60.4%, SD 21.2%). Instruction rate varied from hospital. < the county. The BSU ambulances rendezvous 41.3% to 93.1%% (p 0.01; averaged 77.4%, with the on scene EMS unit and assist with SD 14.9%). Compression rate varied from 176. Descriptive Analysis of Patients < transport of the patient and crew to the hos- 45.2% to 88.4% (p 0.01; averaged 75.3%, SD Transported via Ground and Air Critical pital. Results: There were 121 requests for 12.8%). Averaged regional call-to-recognition Care Teams on Extracorporeal Membrane BSU transport during the 12 month period time, call-to-instruction time, and call-to- Oxygenation (ECMO) of review with 108 (89%) ending in transport compression time were 58 (SD 21), 92 (SD Matthew Sztajnkrycer, Ryan Sherden, to the hospital. The average weight of trans- 48), and 174 (SD 71) seconds. The designated Meghan Lamp, Kathleen Berns, David Clay- ported patients was 419 lbs. Of BSU requests, diagrammatic comparisons may indicate the pool, Mayo Clinic Category of Submission: 66 (55%) were dispatched ALS, with less than administrative regions of better performance Medical half receiving an ALS intervention. The most located at the upward and leftward dimension, and the ones of unsatisfied performance located common complaint type was Acute Extremity Background: Despite improved portability and at the downward and rightward dimension Pain (19%). Twenty Four patients (20%) used ease of cannulation, few U.S.-based medical (diagrams will be illustrated). Conclusions: the system more than once. Average on-scene transport services currently transfer patients We successfully innovated and launched time increased by 150% for patients transported on ECMO. The purpose of the current study a nationwide DACPR quality e-registry via BSU (30 minutes) compared to our system was to perform a descriptive analysis of a showing a wide variety of regional perfor- average on-scene time (12 minutes). Patient and cohort of patients transported via air or ground mance needing improvement. The designated EMS crew satisfaction was high with the BSU while on ECMO. Methods: Retrospective case diagram may easily indicate and compare system and there were no reported injuries to series of patients transported by a single crit- the individual performance across the joint patients or EMS providers during the review ical care transport provider to a single ter- regions. period. Conclusions: A regional BSU transport tiary care facility between January 1, 2014 and system provides a cost effective, safe and dig- May 31, 2017. Patients were included if trans- 175. Pilot Randomized Control Trial of nified means of transport of bariatric patients ported while on ECMO. T-test and Fisher’s Pelvic Binder Compared to Standard Care during EMS response. While more than half of Exact Test were performed for statistical analy- in Prehospital Patients with a Suspected cases were dispatched ALS, the most common ses. Results: Twenty-five patients met inclusion Pelvic Fracture complaint was Extremity Pain. No practitioners criteria, of which 16 (64%) were male. Mean age used unconventional modes of transportation ± Jonathan Studnek, Allison Infinger, Meghan was 43.4 17.6 years (range 1–68 years). Six- for transporting a patient to the hospital dur- Wally, Sarah Pierrie, Malcolm Leirmoe, teen patients were transported on VA-ECMO, ing this period; 20% of patients utilized the sys- Joseph Hsu, Rachel Seymour, Mecklenburg while 9 were transported on VV-ECMO. Three tem more than once. On-scene times were sig- EMS Agency Category of Submission: Trauma patients were transported by ground critical nificantly increased however no adverse events care team, while 9 were transported by rotor were reported. Background: Pelvic ring fractures are associ- wing and 13 were transported by fixed wing. ated with high morbidity and mortality, how- Mean transport time was 60.8 ± 28.4 minutes. 174. Nationwide Quality E-Registry for ever, pelvic stabilization and hemorrhage con- The most common indications for ECMO were Dispatcher-Assisted Cardiopulmonary trol has not been rigorously tested. The primary respiratory failure/acute lung injury (48%) and Resuscitation (DACPR) of Out-of-Hospital objective of this study was to determine the fea- cardiogenic shock (28%). Four patients received Cardiac Arrest (OHCA) – The Design for sibility of conducting a randomized controlled ECMO as extracorporeal life support (ECLS) for Structured Measurement trial comparing a commercially available pelvic refractory cardiac arrest. No patient died dur- Patrick Chow-In Ko, Mei-Fen Yang, binder to standard care in prehospital patients ing ECMO initiation or transport. Two patients Kah--Meng Chong, Hui-Chih Wang, Chien- with a suspected pelvic fracture. Methods:This required fluid boluses for low blood flow, while Hsin Lu, Chih-Hao Lin, Yen-Bing Chen, prospective study collected data from an EMS 5 received blood transfusion for cannulation- Yen-Ho Yang, Ming--Shian Lee, Wen-Chih agency - which serves a population of nearly related blood loss. The most common interven- Chou, Chih-Chiang Cheng, Wen-Long Chen, 1 million and transports approximately 114,000 tions in transit were sedation, muscle relax- National Taiwan University, College of Medicine, patients per year - and a level 1 trauma center. ation, and heparinization. Survival to hospi- ࣙ Department of Emergency Medicine Category Eligible patients were those 18 years with a tal discharge was 48%, with improved survival = of Submission: Operations, Quality, Safety high-energy mechanism of injury and prehospi- amongst younger patients (p 0.52). Mortality Systems, Disaster tal suspicion of pelvic fracture. Exclusion crite- for patients on VA-ECMO was 62.5%, compared 144 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

with 33.3% for those on VV-ECMO (p = 0.35). 178. Pediatric Bypass: Characteristics and STEMI criteria in the most recent AHA/ACC In patients receiving ECLS, 50% survived to Effects on EMS Resources STEMI guidelines as a result of low specificity. discharge; both had refractory VF/VT arrests. We hypothesize that LBBB has led to a high No difference in survival was noted based Jennifer Fishe, Kevin Psoter, Kyle Fratta, Carla number of false positive activations in our sys- upon early (40%) versus late (50%, p = 0.70) Tilchin, Jennifer Anders, University of Florida tem and can safely be removed from our STEMI ECMO initiation. Conclusions: In our patient College of Medicine - Jacksonville Category of criteria. Methods: We conducted a one-year cohort, transport on ECMO was not associated Submission: Pediatric retrospective analysis of prehospital STEMI with significant adverse event or mortality. VA alerts. Hospital records were reviewed for ED Background: Regionalization of pediatric ECMO for cardiopulmonary support was asso- physician interpretation of EKG findings of care decreases pediatric service availability ciated with worse final outcome. ECLS sec- ST-elevation, LBBB, or neither of these criteria at community hospitals. However, pediatric ondary to VF/VT arrest was associated with (nondiagnostic). Primary outcomes were cath regionalization’s effects on EMS operations better survival to discharge compared with lab activation and intervention. Secondary are unknown. This study describes pediatric other dysrhythmias. The current data suggest outcomes analyzed were presence of initial transport characteristics, focusing on bypass that transportation of ECMO patients is safe, elevated troponin. We excluded patients with patients. Methods: This retrospective study and initiation of ECMO need not be delayed missing records. Results: A total of 107 STEMI examined all transports ages 0–17 years from pending transfer. Alerts were transported over the study period, three geographically diverse EMS agencies with records available for 102 patients. Of (urban, suburban, and rural) over a 12-month patients identified as EMS STEMI Alerts, 45.1% 177. Does Prehospital Mode of Arrival period. Those agencies only pediatric destina- went to cath, and 36.3% received coronary Influence Women’s Decisions to tion protocol is the CDC Trauma Triage Tree. intervention. Rates of cath lab activation and Participate in Research? Scene response, destination facility, and sur- coronary intervention were significantly higher rounding facility locations were geocoded, and in patients with an ED physician interpretation Madeline Karafanda, Martina Anto-Ocrah, each facility assigned a category denoting pedi- of ST-elevation compared to those with LBBB Vivian Lewis, Todd Jusko, Jeff Bazarian, atric service availability. Bypass was defined as (71% vs. 9%, OR 22.03, CI 9.77–49.68, p < Edwin van Wijngaarden, Courtney Jones, transport to any facility other than the nearest. 0.0001). One patient with LBBB received emer- Department of Environmental Health, University of Results: The three agencies transported 12,223 gent cath with stenting after testing revealed Rochester Medical Center Category of Submis- pediatric patients during the study period, elevated troponin. Secondary analysis of this sion: Medical and 8,039 (66%) bypassed the nearest facility patient’s EKG showed that he did not have (80% to a higher level of pediatric care, and Background: Advances in medicine require Sgarbossa criteria. Conclusions: The majority 20% to an equivalent or lower care level). voluntary participation in research. This of EMS STEMI alerts did not require emergent Over half of urban (71%), suburban (60%), and requirement however, may compromise study cardiac catheterization. More false positive rural (59%) agency pediatric transports were generalizability, as it is often unclear how alerts were due to nondiagnostic EKGs rather bypasses. The majority of children bypassed refusals and participants differ. Further com- than LBBB. It appears that removal of LBBB to a higher level of care were transported to plicating the matter is the National Institutes as criteria for STEMI activation can safely pediatric trauma/specialty facilities (55%), of Health (NIH) requirement, that proposed lower STEMI alert numbers. Future protocols followed by regional pediatric facilities (24%), research studies address any possible dispar- will direct EMS to transport patients with and comprehensive pediatric facilities (21%). ities in gender. Investigators have explored LBBB and anginal symptoms to a PCI-capable The top five EMS clinical impressions were the barriers and facilitators for research par- center without designating the patient as a pain, other, seizure, traumatic injury, and no ticipation. Few, however, have focused on STEMI alert. Further efforts will be aimed at apparent illness/injury. Patients bypassed to how prehospital factors, specifically mode decreasing the number of false positive alerts the same or lower care level were transported of Emergency Department (ED) arrival, may through EMS education. influence the recruitment of female subjects in to community (51%), trauma/specialty (30%), research studies. We explored how prehospital comprehensive (12%), and regional facilities 180. Is Door-to-needle Time Reduced for mode of arrival (ambulance vs non-ambulance) (7%). The top five impressions were pain, other, EMS Transported Stroke Patients Routed affects research participation, sampling female no apparent illness/injury, traumatic injury, Directly to the CT Scanner on ED Arrival? subjects only. We hypothesize that women and asthma. For bypass patients, median EMS arriving via ambulance will be less willing transport distance was 6.2 km (25–75th per- Bryan Sloane, Nichole Bosson, Jeffrey Saver, to participate in research, compared to those centiles: 3.2–10.8) and median driving time was Nerses Sanossian, Marianne Gausche-Hill, arriving as walk-in/ambulatory patients. 15.8 minutes (25–75th percentiles: 10.8–21.9), Harbor-UCLA Medical Center Category of Sub- Methods: From January 9 to July 8 2017, we representing an additional median 2.9 km mission: Medical collected data on 373 women presenting for (25–75th percentiles: 1–6.4) and 6.8 minutes (25–75th percentiles: 3.1–12.6) from the closest Background: To evaluate if a protocol to route care in the ED of a Level 1 Trauma Center. EMS-transported stroke patients directly to the All subjects were required to have GCS ࣙ13 facility. Median transport distance was 2.8 km (25–75th percentiles: 1.6–4.6) and median driv- CT scanner on ED arrival reduces door-to- and/or deemed capable of providing informed needle time (DTN). We hypothesized a reduced consent (following standard protocol and/or ing time was 8.6 (25–75th percentiles: 6.2–11.9) for patients transported to the closest facility. DTN compared to initial routing to an ED provider approval). Refusals were compared bed. Methods: This is a retrospective analy- to participants based on variables abstracted Conclusions: This study demonstrates high pediatric bypass rates, which coupled with sis from a large regionalized stroke system. from the medical record. Comparisons were EMS utilize the modified Los Angeles Prehos- made between groups using 2-tailed inde- increased transport distances and times, affect χ EMS resource allocation by occupying vehicles pital Stroke Screen (mLAPSS) and transport all pendent t tests or 2 tests, as appropriate. suspected acute stroke patients to one of 46 Results: Ambulance users comprised a third and crews for longer runs. Future work will = determine each bypass’ appropriateness to Approved Stroke Centers (ASC). Some ASC of the sample (33.5%, n 125) and non- route EMS directly to CT. ASC report patient users represented 66.5% (n = 248). The mean inform both EMS operations and pediatric + − destination decisions. treatment and outcomes to a registry, from age was 28.5( / 7.9), with no statistical which data were abstracted from May 2015 differences between ambulance users and through April 2016. Adult patients transported non-users (p = 0.4). Compared to non-users, 179. Removal of Left Bundle Branch Block from Prehospital ST-Elevation Criteria by EMS and treated with intravenous throm- a significant proportion of ambulance users bolytic therapy (IV tPA) were included. The pri- (41.6% vs. 14.1%, p < 0.001), were involved in Decreases Number of Unnecessary Cath Lab Activations mary outcome was median DTN at hospitals motor vehicle crashes, and sought care within with CT routing protocols compared to hos- 24 hours of their injury. Over a quarter of Rachel Semmons, Elizabeth Mannion, pitals with ED routing. Secondary outcomes ambulance users (versus non-users) refused Andrew Thomas, Quinn Frier, Jason Wilson, were door-to-imaging time, hospital length of to participate in research (28.8% vs.19.4%, p Cory Thomas, Tampa Fire Rescue, University stay, and modified Rankin Scale at discharge. = 0.039). Ambulance use was associated with of South Florida Category of Submission: A subgroup analysis of patients with positive a 69% increased odds of refusal to participate Cardiac mLAPSS was planned a priori. Outcomes were in research (95% CI: 1.02, 2.78). Reasons for compared with Hodges-Lehmann’s median dif- refusing included “disinterest in research”, Background: Prehospital identification of ference. Results: EMS transported 6315 patients time constraints” and “discomfort with con- STEMI allows decreased time to PCI. False for suspected stroke and 797 (13%) were treated sent process/nature of study”. Conclusions: positive prehospital STEMI Alerts may waste with IV tPA, 143 at hospitals with CT rout- As hypothesized, ambulance transport to resources through unnecessary cath lab acti- ing and 654 at hospitals with ED routing. the ED is associated with increased odds vation as well as pose risks to patients. Our Patient characteristics were similar between of research refusal. Future studies should current prehospital STEMI Alert Criteria groups; overall 420 (53%) were male, 500 (62%) explore if this finding is unique to females includes ST-segment elevation >1mm in two or White race, and 189 (24%) Hispanic ethnicity. only, and tailor ED-based research recruitment more contiguous leads and/or presumed new Median NIHSS was 12 (IQR 8–19) in the CT efforts, with ambulance mode of arrival as a left bundle branch block (LBBB) in the presence routing group and 11 (IQR 5–19) in the ED rout- consideration. of anginal symptoms. LBBB was removed from ing group. Positive mLAPSS and EMS notifi- NAEMSP 2018 ANNUAL MEETING ABSTRACTS 145

cation occurred respectively in 63% and 96% Kim,JeongHoPark, Department of Emergency hospital providers (15%) identified themselves in the CT routing group and 66% and 86% Medicine, Seoul National University Boramae Med- as having prior military/Tactical Combat Casu- in the ED routing group. DTN was not dif- ical Center Category of Submission: Trauma alty Care/law enforcement training that had ferent between groups, median DTN 59 min- familiarized them with wound packing and utes (IQR 45–78) for CT routing and 54 (IQR Background: Trauma and Injury Severity Score hemostatic dressings. 81.5% of all respondents 40–73) for ED routing, median difference 4.5 (TRISS) has been used to predict mortal- (n = 145) did not believe that wound packing (IQR 0–9). There were no differences between ity of trauma patients and to perform qual- was authorized to perform as part of local or the groups in terms of secondary outcomes or ity improvement of trauma care system. In State EMS protocols, when in fact the procedure within the mLAPSS-positive subgroup. Con- advanced countries, functional outcome includ- was not mentioned in any such regulations. 64% clusions: In this regional stroke system, hospi- ing disability is recently emphasized as a qual- (n = 114) providers believed that hemostatic tals with protocols for routing EMS-transported ity indicator for trauma care system. The goal dressings would be more effective than a reg- stroke patients directly to CT did not have of this investigation is to develop modified ular gauze roll when used for wound pack- reduced DTN compared to hospitals without model of Trauma Related Injury Severity Score ing; those with prior familiarization were more such protocols. These results are limited by the to predict Disability (TRISS-D) for acute trauma likely to think this was true. (92.5% for those fact that the actual routing of each patient is not patients. Methods: We used emergency med- with prior familiarization vs. 58.9% without. χ2 known. ical services based severe trauma database of statistic = 11.69, p = 0.002 ). On a ranked scale the Korea Centers for Disease Control. We of 0 to 100 indicating comfort level using hemo- 181. Withdrawn enrolled severe trauma cases transported by static dressings/wound packing, individuals fire department from January to December 2013 with prior familiarization were more likely to 182. Association between BMI and in 10 provinces across Korea. We calculated rate a higher comfort level (mean score of 89 for Prehospital Selection of Advanced Airway revised trauma score (RTS) and injury sever- those with prior military/LEO/TCCC training in Out-of-Hospital Cardiac Arrest ity score (ISS) for enrolled cases. We devel- vs. 64 without, t-value 5.9, p < 0.00001). Conclu- oped modified TRISS model predicting severe Caitlin Howard, David Wampler, Jeremy sions: Current civilian EMTs and Paramedics disability and worsening disability using age Allen, Hattie McAviney, Justin Smith, David are interested and motivated to utilize hemo- index (0–14, 15–54, 55– years), RTS and ISS. Miramontes, Joan Polk, United States Army and static dressings and wound packing techniques, TRISS-D model 1 added injury mechanism cat- UTHSCSA Category of Submission: Student, but most require additional training to increase egory divided by blunt or penetrating injury. Resident, Fellow comfort with these interventions. Prior military, TRISS-D model 2 added presence of severe tactical combat casualty care or law enforce- Background: Obesity is associated with diffi- head injury when abbreviated injury scale (AIS) ment training appears effective in increasing cult prehospital endotracheal intubation. The of head is from 3 to 6. We developed coeffi- confidence. Civilian EMS protocols may need objective of this study was to examine the asso- cients of each TRISS-D model for severe dis- to explicitly reference wound packing to ensure ciation between patient BMI and the selection ability and worsening disability. Severe dis- providers are aware that they can utilize this of advanced airway by prehospital providers ability was defined when Glasgow outcome skill. during out-of-hospital cardiac arrest (OHCA). scale (GOS) at hospital discharge was 1,2,3. Methods: This was a retrospective review of If the difference of GOS at hospital discharge 185. Transport Determinates for an in-house cardiac arrest registry containing and GOS before trauma incident is 1 point or Continuing Care Residents Assessed by an details of each resuscitation attempted by a more, we defined the case as worsening dis- EMS Urgent Response Team: A large, urban fire-based EMS system. Advanced ability. We assessed discriminative power of Retrospective Observational Study airway selection was at the discretion of the each model by Area Under the ROC Curve resuscitation team. The BMI recorded was (AUC) value. Results: A total of 14,791 patients Kevin Lobay, Robyn Palmer, Lorissa Mews, a subjective measurement obtained from the were enrolled. 3,757 cases were severe disabil- Robert Sharman, Brian Boswell, Priya Jaggi, paramedic at the time of data collection. Data ity and 6,018 cases were worsening disability. University of Alberta Department of Emergency was analyzed from January 1, 2016 through AUC value of TRISS-D model 1 and model 2 Medicine Category of Submission: Opera- August 15, 2016. Patients were included in the for severe disability was 0.948(95% Confidence tions, Quality, Safety Systems, Disaster study if the following variables were available: Interval (CI): 0.944–0.952) and 0.950(95% CI: Background: Alberta Health Services (AHS) age, gender, BMI, and initial airway attempted 0.946–0.954), respectively. AUC value of TRISS- Emergency Medical Services (EMS) in the (supraglottic vs ETT). Patients were excluded D model 1 and model 2 for worsening disability City of Edmonton recently introduced an if age < 17, no age, gender, or BMI recorded, was 0.810(95% Confidence Interval (CI): 0.803– “EMS Continuing Care Urgent Response Team” or an airway other than supraglottic or ETT 0.817) and 0.816(95% CI: 0.809–0.823) respec- (ECCURT) to support continuing care resi- was used. Patients were divided into 4 groups tively. Conclusions: We developed modified dents by providing urgent care on-site, thereby based on the BMI (under, normal, over, mor- TRISS model for functional outcome like severe reducing unnecessary patient transfers to emer- bid). A subcategory analysis of endotracheal disability and worsening disability of acute gency departments. ECCURT is comprised of intubation method (direct laryngoscopy (DL) trauma patients. TRISS-D model for severe dis- Advanced Care Paramedics and Nurse Prac- vs video laryngoscopy (VL)) was also exam- ability showed excellent discriminative power titioners, and is dispatched via a dedicated ined. ANOVA was utilized to analyze con- with AUC value higher than 0.9. AUC value consult line and/or 9-1-1. Various patient tinuous variables and a χ2 test was used to of TRISS-D model for worsening disability was characteristics are tracked within our inter- analyze categorical variables. Results: A total higher than 0.8. nal database including age, diagnosis, Goals of 474 patients were included. Mean age for of Care Designation (GCD), and Canadian the population was 63.56 + 17.65 years with 184. Most Civilian Prehospital Care Triage Acuity Scale (CTAS) score. Objectives: 293 males (61.81%). Most patients were classi- Providers Require Additional Wound This study will provide an analysis of vari- fied as normal BMI (209 patients, 44.09%) or Packing Training and Protocols ous ECCURT patient characteristics, and deter- over BMI (156 patients, 32.91%). The ETT was mine whether age, GCD and CTAS score are more frequently utilized as the initial airway Mark Liao, Daniel O’Donnell, Thomas Lar- correlated with frequency of transport to hos- of choice in under BMI vs morbid BMI (P = daro, Indiana University Category of Submis- pital. Methods:Thisisasix-monthretrospec- 0.03). Compared to normal BMI, more over BMI sion: Student, Resident, Fellow tive, observational study of patient data. All and more morbid BMI had a supraglottic air- Background: Civilian EMS agencies are increas- new patients assessed between January 1, 2016 way selected as the initial airway (P = 0.03 ingly interested in adopting hemostatic dress- and June 30, 2016 were included. Multiple and P = 0.009, respectively). Subgroup analysis ings and wound packing for treating difficult- regression analysis was performed to deter- of laryngoscopy method used for endotracheal to-control or junctional hemorrhage. However, mine whether a statistically significant correla- intubation was not significant between the BMI baseline civilian provider training of hemo- tion exists comparing age, GCD and CTAS score groups (P = 0.80). Conclusions:Wefoundthat static dressings and wound packing is vari- with transport frequency. Results: A total of 471 paramedics tended to favor endotracheal intu- able. We conducted a survey of prehospital (83%) of 567 new patients assessed by ECCURT bation with lower BMI patients. There was no care providers in a large metropolitan EMS during the study period had established GCDs difference noted between BMI and DL vs VL. agency that did not equip hemostatic dressings in place; 521 (92%) of our patients had a CTAS Limitations included that the BMI was not cal- or provide wound packing training to evalu- score assigned; 131 (23%) of our patients were culated and we only looked at the initial airway ate baseline provider knowledge and comfort transported to hospital. All patients with a GCD attempt, which may not have been the conclu- level of these techniques. Methods: A total of of C2 (specifically requesting no transfer to hos- sive airway. 178 prehospital providers (68% of whom were pital) were managed by our team on-site. Mul- 183. Development of Modified Trauma and paramedics) completed an online survey. This tiple regression analysis reveals a statistically Injury Severity Score Model to Predict survey queried their prior training, understand- significant correlation of age, GCD, and CTAS = Disability for Acute Trauma Patients ing of local EMS protocol, knowledge of hemo- score with transport frequency (F statistic 3.26 static dressing efficacy vs. regular gauze for E-11). P-values for each variable are: age = 0.92; Ki Jeong Hong, Sang Do Shin, Kyoung Jun wound packing and comfort level performing GCD = 0.05; CTAS = 5.08 E-12. Conclusions: Song, Young Sun Ro, So Yeon Kong, Tae Han wound packing. Results: Only 27 civilian pre- Although patient age appears not to be strongly 146 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

correlated with transport frequency indepen- patients receive appropriate prehospital care. utes and 27,613 miles in the urban jurisdic- dently, GCD and CTAS score may be quite use- Objective: The objective was to describe the tion; 91,002 minutes and 77,831 miles in the ful predictors for Community Care EMS Teams quality of online medical control in a Cana- suburban jurisdiction; and 5,248 minutes and when selecting patients who can be managed dian EMS system and use the study findings to 7,605 miles in the rural jurisdiction. HEMS use on-site without transport to hospital. develop a quality improvement program which for pediatric transport was zero in the urban will enhance the outcome of online medical con- county, 0.1% in the suburban county and 4.8% 186. Early Double Sequence Defibrillation trol. Methods: A retrospective review of writ- in the rural county (p < 0.001). The mean trans- Improves Outcomes in Refractory ten and audio records of online medical con- port time per patient varied significantly at Ventricular Fibrillation trol interactions from April 1, 2016 to March 10.6, 15.2, and 21.6 minutes, respectively (p < 31, 2017. Audio recordings were assessed by a 0.001). Mean road transport miles per patient Matthew Harris, Ronald Klebacher, Joshua single reviewer to evaluate predetermined cri- was 4.6, 13.0, and 31.3 miles, respectively (p Schwarzbaum, Andrew Parrish, Michael Carr, teria which gauged the efficiency of commu- < 0.001). On a population basis, EMS utiliza- Andrew Torres, Navin Ariyaprakai, Amundep nication that occurred during each interaction. tion for pediatric transport was 0.493, 0.494, and Tagore, Eric Wasserman, Bauter Robert, Mark Results: There were 454 online interactions in 0.445 minutes per pediatric citizen and 0.214, Merlin, Newark Beth Israel Medical Center Cate- the fiscal year, 14 cases were excluded as audio 0.716, and 0.381 road miles per pediatric citi- gory of Submission: Cardiac was unavailable and 27 could not be retrieved zen per year, respectively (p < 0.001). Conclu- Background: Refractory ventricular fibrilla- due to technology failure at the dispatch level. sions: EMS resource use for pediatric transports tion (RVF) has been defined as VF that per- Therefore 413 cases were assessed. Three hun- is noteworthy and varies significantly between sists after 5 standard attempts at defibrillation dred thirty-eight patches (81.8%) were manda- urban, suburban, and rural jurisdictions. This (SD), though no uniform definition exists. Its tory provincial patch points with 289 (85.5%) study provides essential benchmarks for future incidence has been estimated at 0.5–0.6 per regarding patients in cardiac arrest. Analge- development of pediatric direct transport pro- 100,000 population. Double sequence defibrilla- sia administration made up 30.7% of the non- tocols. tion (DSD) has emerged as a possible treatment mandatory calls, and all resulted in medica- 189. Assessment of Emergency Medical for RVF to improve rates of ROSC. Methods: tion orders. In 100% of patches additional infor- Services Provider Research Literacy and A retrospective chart review of patients greater mation was requested by the oversight physi- Involvement than 17 years with RVF, defined as VF persis- cian and in 131 (31.7%) patches no request was made by the paramedic. The average length tent after 3 standard defibrillations (SD), after Lauren Maloney, Robert Marshall, Henry of patch was 0:02:03 (SD = 0:01:07) and the the implementation of a quality project allow- Thode Jr, Adam Singer, Scot Johnson, Stony paramedic had to wait on average 0:01:11 (SD ing paramedics to perform DSD in patients Brook University Department of Emergency = 0:00:44) before talking to an oversight physi- with RVF. After 3 SDs, 2 sets of defibrilla- Medicine Category of Submission: Student, cian. Conclusions: Implementing standardiza- tion pads were placed on the patients with Resident, Fellow RVF. Two rapid sequence defibrillations at 360 tion of information handover will allow for Joules were delivered. No limit was placed on patch calls to be more efficient and ensure all Background: For a needs assessment for future the number of DSD shocks provided. We com- pivotal information is communicated. This will continuing medical education classes and pared patients who received DSD to those who allow oversight physicians to make informed rollout of prehospital clinical research, a survey received SD. Our primary outcome was ROSC. clinical decisions optimizing the care provided was developed to gather data on provider We performed descriptive statistics, and asso- to patients. To further enhance the medical con- attitudes towards evidence-based medicine ciation and correlation between variables with trol provided by oversight physicians it would (EBM), participating in clinical research, and ANOVA and Chai-squared. Results:Weidenti- be beneficial to determine the most effective informed consent. Methods: A 35 question fied 280 patients with RVF, 229 (82%) received way to provide EMS training to these physi- survey was distributed to 71 employees of SD only and 51 (18%) received DSD. Compar- cians. Also, as all requests for analgesia were a university-based EMS system. Surveys ing the SD group vs. DSD group: Mean Age granted, implementing a medical directive with included demographic and experience items. 67.7 years vs. 66.8 years (p < 0.001), Male gen- increased paramedic autonomy for pain control Responses to various statements were graded der 76.2 % vs. 72.5% (p < 0.001), and mean would be warranted. on a 5-point Likert scale from “strongly dis- weight (kg) 89.3 vs. 90.1 (p < 0.001). There were agree” to “strongly agree” and analyzed with 188. Quantifying EMS Resource Allocation fewer witnessed arrests in the control group Chi square tests. Results: Of 54 analyzable for Pediatric Transports (61.6% vs. 80.4%). Time to 1st shock was the surveys, 81.5% respondents were paramedics ± ± identical (14.7min 9.5 vs 14.7min 10.1), and Jennifer Anders, Jennifer Fishe, Kevin Psoter, and 18.5% were EMT-Bs. 78% of respondents in those who received DSD, mean time to first Carla Tilchin, Kyle Fratta, Johns Hopkins Uni- were male. Mean age was 39 with an average DSD was 33.6 minutes. The rate of ROSC was versity School of Medicine Category of Submis- 18 years of EMS experience. 61% held college higher in the control arm compared to therapy sion: Pediatric degrees, 48% subscribed to medical journals, arm, though this was not statistically significant and read articles a couple times a week (20%), (31.4% vs. 23.5%) (p value = 0.26). Of the 32/51 Background: Regionalization of pediatric care month (32%), or year (35%). At least 95% of patients with ROSC in DSD arm, average time decreases available pediatric services at com- providers agreed about the importance of pre- to 1st DSD was lower (32.7 min vs. 35.01). These munity hospitals. Therefore, some children hospital EBM and their responsibility to stay patients had similar numbers of primary shocks should bypass closer hospitals for direct trans- current with medical advances. Paramedics (4.42 vs. 4.78) but required fewer DSD (2.8 vs. port to pediatric specialty facilities. Future were more likely than EMT-Bs to disagree that 3.47). Conclusions: The management of RVF tools assisting EMS with transport destination EMS protocols are updated promptly. 37% remains challenging. While the achievement of choices must balance EMS resource allocation agree that patient care decisions should be ROSC was higher in the non-DSD group, the with direct transport’s benefits. To do so, the based on research evidence and not personal difference did not meet statistical significance. current burden of pediatric transport on EMS experience, (45% males vs. 8% females). 65% Those who received DSD earlier had higher agencies must be quantified to provide a bench- of those surveyed disagreed with limiting the rates of ROSC than those with more delay, and mark for future systems changes. Objective: rights of an individual to better the care of a required fewer DSD attempts. The objective of this study was to describe the large group, and disagreement was higher in baseline EMS services utilization for pediatric females than males (92% vs. 57%), respectively. 187. Prehospital Online Medical transport in three geographically diverse juris- A total of 96% agreed with an option to read Oversight (Promo) an Analysis of the dictions (urban, suburban, and rural). Methods: research articles for CME; those without a Interaction between Emergency Room This study examined a 12-month retrospective college degree were more likely to disagree. No Physicians and Paramedics cohort of pediatric (0–17 years) EMS transports significant relationship between age, educa- from three Maryland counties. All agencies use tion, provider level, or experience existed with Jason Prpic, Alicia Violin, Sylvie Michaud, the same patient care protocols, EMR, and Heli- frequency of reading research articles. A total Nicole Sykes, Paul Myre, Health Sciences North copter EMS (HEMS) system. Each patient trans- of 65% disagreed that spending an additional Centre for Prehospital Care Category of Submis- port location, actual transport times, demo- 5 minutes after a call to complete clinical trial sion: Operations, Quality, Safety Systems, graphics, and clinical variables were abstracted paperwork would be a burden; those who read Disaster from the EMR. The response scene and destina- articles a couple times a year or never were tion hospital locations were geocoded to calcu- more likely to agree. A total of 44% disagreed Background: In Ontario, paramedics operate late road driving distance. Each agency’s base- with enrolling a critical patient in a trial if mainly under off-line medical direction, they line EMS utilization for pediatric transport was delayed consent is obtained, with a significant use online medical control when it is mandatory then estimated using transport miles and min- relationship to age; younger respondents were according to provincial medical directives or if utes. Results: The three counties transported less likely to disagree than other age groups. a patient presents with a condition that does not a total of 12,223 pediatric patients during the Conclusions: In this cohort of prehospital fit into their protocols. Literature that encom- 12-month period (urban n = 6,033, suburban personnel, evaluating medical research and passes the interaction that occurs between over- n = 5,987, and rural n = 243). Total EMS uti- involvement in future prehospital clinical trials sight physicians and paramedics is limited even lization for pediatric transport was 63,631 min- was overall well received. though this interaction is critical to ensure NAEMSP 2018 ANNUAL MEETING ABSTRACTS 147

190. Can Heart Rate Variability Risk ETCO2 and EBRI between high quality CPR 193. Impact of the Implementation of a Stratify Patients with Undifferentiated period and low quality CPR period. Pear- Critically Ill Patient Bundle of Care on Non-Traumatic Chest Pain? son’s correlation coefficient was calculated to the Performance of Key Medical assess correlation between EBRI and ETCO2. Interventions for Respiratory Distress Juan March, Carmon Russoniello, Nicholas Results: Experiment was performed in five Patients by Paramedics in the Field Murray, Walter Robey, East Carolina Univer- female porcine (44.6 ± 2.8kg). EBRI and EtCO2 sity Department of Emergency Medicine Division of was obtained according to quality of CPR Mark Pinchalk, Mark Tomassi, Roth Ronald, EMS Category of Submission: Cardiac received. Delta EBRI obtained during high Jeffery Reim Jr., James Dlutowski, Simon quality CPR was significantly higher than delta Taxel, Thomas Goode, City of Pittsburgh EMS Background: Previous research suggests that EBRI of lower quality CPR (HQ: Median 0.17, Category of Submission: Professional heart rate variability (HRV), also known as R to (0.04–0.30), LQ: Median −0.18 (−0.05–−0.32), R variability, can be used to risk stratify patients Background: Medical intervention patient care p =< 0.01). EBRI had statistically moderate with known acute coronary syndromes. The bundles have been advocated as a process based positive correlation with ETCO2 (r = 0.56). HRV spectrum contains two major components. system to improve patient care and outcomes Conclusions: In porcine cardiac arrest model, One component of HRV is the high frequency using evidence based guidelines. We sought EEG-based Brain Resuscitation Index was (0.18–0.4 Hz) component, which is synchronous to evaluate the effect of the implementation of successfully obtained during resuscitation and with respiration and is identical to respiratory a Prehospital “Crashing Patient” Critical Care had statistically moderate correlation with sinus arrhythmia. The second is a low fre- Bundle on the performance of key prehospital ETCO2. quency (0.04–0.15 Hz) component that appears intervention for patients presenting with respi- to be mediated by both the vagus and car- ratory distress. Methods: A “Crashing Patient” diac sympathetic nerves. This study examined 192. Social Connectedness and Coping bundle of care addressing key interventions whether heart rate variability can be used to risk Styles in EMS Workers and Their for critically ill patients was implemented in stratify patients presenting with undifferenti- Association with Burnout and Perceived an urban Advanced Life Support (ALS) EMS ated non traumatic chest pain. Methods:This Stress system from 2012–2014. After full implemen- exploratory study was performed at a percu- Lori Boland, Pamela Mink, Jonathan Kamrud, tation of the care bundle, retrospective Patient taneous coronary intervention capable tertiary Jessica Jeruzal, Russell Myers, Charles Lick, Care Report (PCR) review was conducted of teaching hospital with 900 beds and an Emer- Andrew Stevens, Allina Health Emergency Med- PCRs with a chief complaint of “Respiratory gency Department (ED) with an annual census ical Services Category of Submission: Profes- Distress” for the first calendar quarter after of 120,000. A convenience sample of adult sional implementation (July–September 2014) and patients presenting to the Emergency Depart- compared to PCRs for the most recent quarter ment with a chief complaint of non-traumatic Background: To assess social connectedness (April–June 2017). Rates of EKG & end tidal chest pain were enrolled. HRV was captured and coping styles among emergency medi- carbon dioxide (EtCO2), vascular access and using a physiological status monitor (PSM) cal services (EMS) providers and explore their CPAP application were compared for all respi- affixed to the chest for a 5–10 minute period association with occupational burnout and per- ratory distress cases. For the subset of patients during the patient’s ED stay. High risk patients ceived stress. Methods: A 167-item electronic who received Albuterol for bronchospasm, the were identified by either a positive troponin, survey was distributed to employees of a large rates of administration of Methylprednisolone, positive stress test, positive cardiac catheteri- ambulance service that provides 9-1-1 response Magnesium Sulfate and 1:1000 Epinephrine zation, ST elevation on EKG, or death within in Minnesota. The survey included the Maslach were compared between the two time intervals. 30 days. A low frequency/high frequency Burnout Inventory (MBI), Cohen’s 4-item Per- Results: There were 905 respiratory distress ratio of less than 1.0 was used as the cutoff. ceived Stress Scale (PSS), the Brief COPE Inven- PCRs in the 2014 interval and 885 in 2017. Data analysis was performed with a Fischer tory, and the Berkman-Syme Social Network In 2017 there were improvements in EKG Exact test. Results: A total of 26 patients were Index (SNI). Burnout was defined as a high monitoring from 32.6% to 45.9% (p < 0.0001) of enrolled. All six patients identified as high risk score on the emotional exhaustion (ࣙ27) or cases, EtCO2 monitoring from 7.1% to 17.3% (p had a LF/HF ratio of less than 1.0; sensitivity depersonalization (ࣙ13) subscales of the MBI. < 0.0001), vascular access from 37.2 to 45% (p = 100%. Furthermore, all 20 patients who were The COPE inventory assesses an individual’s = 0.0009) & CPAP use from 6.5% to 10.8% (p = determined to be low risk had an HF/LF ratio > tendency to use 14 coping styles in response 0.0013). 408 of the patients received Albuterol 1.0; specificity = 100%, p< 0.0001. Conclusions: to stressful situations, with scores ranging for bronchospasm in 2014 compared to 306 in This pilot study suggests that heart rate vari- from 2 (low use) to 8 (high use). Results: 2017. In this subset there were improvements in ability with a LF/HF ratio < 1.0 may be used to Responses were received from 217 providers the administration of Methylprednisolone from rapidly risk stratify patients with undifferenti- (54% response); the mean age was 40, 60% 24.4% in 2014 to 52% (p < 0.0001), Magnesium ated non traumatic chest pain. Further studies were male, and 55% had an EMS tenure of Sulfate from 12.5% to 19.9% (p = 0.0091) & in the prehospital environment with a larger 10+ years. The prevalence of burnout was 18% 1:1000 Epinephrine from 3.2% to 6.8% (p = sample size are needed to determine if HRV can and the mean PSS score was 4.8 (SD=3.2). The 0.0318). These care improvements were associ- be used by EMS to rapidly risk stratify patients SNI characterized respondents as socially iso- ated with a decrease of the rate of cardiac arrest with undifferentiated non traumatic chest lated (15%), moderately isolated (33%), moder- after EMS contact for medical patients in the pain. ately integrated (29%), and socially integrated system from 12% to 9.1% (NS). Conclusions: (24%), and the prevalence of burnout in each The implementation of a prehospital critical 191. Correlation of EEG-Based Brain group was 38%, 19%, 16%, and 7%, respec- (“crashing”) patient bundle of care resulted Resuscitation Index and End Tidal Co2 in tively. After adjustment for age, gender, EMS in a significant performance improvements in Porcine Cardiac Arrest Model tenure and marital status, providers charac- accomplishing key interventions for respira- tory distress patients. Patient care bundles may Dongsun Choi, Hee Jin Kim, Taehan Kim, terized as socially isolated were more likely have significant utility to improve patient care Ki Jeong Hong, Young Sun Ro, Kyoung Jun to experience burnout than those who were = = and safety in the prehospital setting. Song, Hee Chan Kim, Shin Sang Do, Seoul socially integrated (OR 6.4; 95%CI 1.3– National University Hospital, Department of Emer- 32.2). Decreased social connectedness was asso- 194. Tracking Violations of Newly gency Medicine Category of Submission: Car- ciated with increased mean PSS score: socially = = Implemented Behavioral Emergency diac integrated 3.8, moderately integrated 5.0, moderately isolated = 4.8, and socially isolated Treatment Protocol Background: Evaluation and monitoring of = 6.0 (p for trend = 0.03). Commonly used Timothy Lynch, Christie Fritz, David brain viability is important during resuscitation coping strategies included planning, positive Schoenfeld, Beth Israel Deaconess Medical of cardiac arrest. We developed non-invasive reframing, and active coping, while substance Center/Harvard Medical School Category of EEG-based brain resuscitation index (EBRI) abuse, behavioral disengagement, and denial Submission: Student, Resident, Fellow and evaluated correlation EBRI and end-tidal were infrequently used. Higher use (scores = CO2(ETCO2). Methods: A crossover animal 6,7,8) of religion, use of emotional support, and Background: In September 2014, Massachusetts experimental study using porcine cardiac use of instrumental support to cope were asso- statewide EMS protocols authorized the use of arrest model was designed. After 1 minute ciated with a lower prevalence of burnout. Con- haloperidol and/or a benzodiazepine for man- of untreated ventricular fibrillation, alter- versely, higher scores on the coping subscales agement of behavioral emergencies. The newly nation of high quality CPR (compression of self-blame, food, and substance abuse were adopted protocol allows for medication admin- depth 5 cm and compression rate 100/min) associated with increased burnout and were < < istration with contraindications of age 18, his- and low quality CPR (compression depth correlated positively with PSS scores (all p tory of seizures, or prolonged QT interval. Geri- 3 cm and compression rate 60/min) was 0.002). Conclusions:EMSproviderswhoare atric dosing was reduced by 50%. The new pro- performed for every 50 seconds in 10 phases. socially isolated or who frequently use the cop- tocol was implemented following a standard EBRI was calculated from selected single EEG ing strategies of self-blame, food, or substance training module. The purpose of this investiga- channel which have the lowest noise. Mixed abusemaybeatincreasedriskofburnoutand tion is to describe the frequency and type of pro- model analysis was conducted to compare the stress, however the temporality of these charac- tocol violations observed during the implemen- differences of hemodynamic parameters, teristics remains unclear. tation of a new protocol, with the goal of help- 148 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

ing to better understand the types of errors, so Self Transport, 639/Referred to ETHAN Clinic- 197. Review of Emergency Medical Services as to improve implementation of future treat- Cab or Self Transport, 839/Patient Declined (EMS) Transports to a Freestanding ment protocols. This will help to determine Clinic Referred wants ED Visit-Cab or Self Emergency Department (FSED) what further training if any is needed and plan Transport, 340/Referred to Patient Care Physi- for future protocol roll out difficulties. Meth- cian/Alternate Clinic-Cab or Self Transport), Matthew Chinn, Brittany Farrell, M. Riccardo ods: Retrospective chart review of calls occur- traditional transport 15% (1497/Referred for Colella, Medical College of Wisconsin Category ring between October 1, 2014 and June 30, 2015, EMS Transport to ED-Ambulance) and miscel- of Submission: Operations, Quality, Safety in which the new behavioral emergencies pro- laneous 8% (274/Patient Declined to speak with Systems, Disaster tocol was utilized. Cases were reviewed for ETHAN MD, 130/Unable to Complete Due to Background: Freestanding emergency depart- protocol violations and the type of violation Technical Issues, 230/Referred for Home Care ments (FSED) are an area of expansion in was recorded. Results: There were a total of 56 Instructions Only, 31/Patient Refused EMS healthcare. Despite rapid growth, there is a min- calls during the study period that utilized the Transportation, 120/Other). The mean study imal amount of literature regarding the appro- new behavioral emergencies protocol includ- age was 44 years (range 1–99 years), 54% were priate triage of patients to these facilities by ing the administration of haloperidol. Proto- female and no patient adverse events were emergency medical services (EMS) providers. col deviations were identified in 29% (95%CI reported. Conclusions: In this system’s popula- Purpose: The study seeks to review and develop 18–42%) of cases. The most common error was tion, telehealth alternate transport and/or des- a list of objective markers for improving EMS protocol violations at 17%(95%CI 9–26%), with tination dispositions significantly reduced low- field triage to a FSED through evidence-based 13% (95%CI 6–24%) having a seizure history acuity ambulance transports and ED visits. Fur- recommendations. Methods: Patient data was of or reported seizure and 4%(95%CI 1–13%) ther studies are warranted to develop guide- retrospectively reviewed from the EPIC elec- pediatric administrations. 9%(95%CI 4–20%) of lines for uniform reporting of prehospital care tronic medical record system of all patients haloperidol administrations were not reduced depositions based on the Physician telehealth brought in to a single FSED by ambulance dur- for geriatric use. While not required by the pro- model. ing a six month convenience period. A report tocol, OLMC was contacted in 14% (95%CI 7– was generated to abstract patient demograph- 27%). Conclusions: Standard Treatment Proto- 196. Novel Measure to Capture ics, medical information, and disposition. Miss- cols allow for rapid implementation of care by Transactional Stress in Paramedic ing data fields were then manually entered. prehospital providers, without the need to con- Services Ambulance services were all previously given tact OLMC. Little is known about the type and Elizabeth Donnelly, Paul Bradford, Cathie a list of FSED capabilities and guidance on frequency of errors observed when adopting a Hedges, Matthew Davis, Doug Socha, Peter bypass for major trauma, STEMI, and stroke new protocol and this analysis can provide use- Morassutti, University of Windsor Category of care, amongst others, in accordance with best ful insight to help better tailor training for new Submission: Operations, Quality, Safety Sys- practice guidelines upon facility opening. Data protocol implementation. Additionally, unnec- tems, Disaster was analyzed using an unpaired t-test. Results: essary calls to OLMC were observed, suggest- There were 138 patients brought to the FSED ing a lack of familiarity or confidence with the Background: In the past few years, there has for the six month period of September 2016– new protocol. This investigation demonstrates been an increase in awareness of the challenge February 2017 by 12 ambulance services. A total potential risks in new protocol implementation of managing work related stress in EMS. Extant of 105 patients were discharged home directly and we recommend further study to develop research has liked different types of chronic from the FSED and 20 were transferred to a full- best practices for training and implementation and critical incident stress to stress reactions service hospital for admission or specialty care; of new clinical protocols. like posttraumatic stress. However, there is no 7 were admitted to a psychiatric facility; 6 were tool to capture the transactional stresses that are 195. Emergency Physicain Telehealth admitted to a skilled nursing facility. There associated with the day to day provision of ser- Dispositions of Low-Acuity 9-1-1 Patients was a statistically significant difference in age vice (e.g., dealing with offload delays or manda- between patients discharged home and those Michael Gonzalez, David Persse, Guy Gleis- tory overtime) and interacting with allied pro- transferred to a full-service hospital (52.69 years berg, Karen DuPont, Andrew Kincannon, fessions (e.g., emergency department staff) or vs. 71.75 years; p = 0.0011). There was no statis- Houston Fire Department Category of Submis- allied agencies (e.g., law enforcement). The pur- tically significant difference between these two sion: Medical pose of this study was to develop and validate a groups in initial FSED pulse rate, respiratory measure which captured transactional stresses rate, systolic blood pressure, or temperature. Background: Every day within the United in paramedics. Methods: An online survey was There was a trend towards a longer length of States low-acuity patients are transported to conducted with ten Canadian Paramedic Ser- stay in the FSED for patients transferred to a = emergency departments (ED) for primary care. vices with a 40.5% response rate (n 717). Fac- full-service hospital (183.51 min vs. 236.25min; American College of Emergency Physicians and tor analysis was used to identify variation in p = 0.0865). Conclusions: The data reflects that National Association of EMS Physicians believe responses related to the latent factor of trans- older patients are more likely to require transfer not all patients require ALS care and in these actional stress. The scale was validated using and possibly admission after initial treatment at circumstances, alternate transport and desti- both exploratory and confirmatory factor analy- a FSED. The FSED initial vitals were not good nation may be appropriate. EMS patient dis- ses. Results: The sample of transactional stress predictors of the need for transfer; the use of ini- positions are traditionally determined by the questions was split to allow for multiple anal- tial vitals as a surrogate for prehospital vitals is = = medic assessment along with off-line medical yses (EFA n 360/ CFA n 357). In the a limitation. Further research is needed to eval- direction. At present, literature regarding pre- exploratory factor analysis, principal axis fac- uate other possible indicators that may be used hospital physician telehealth patient disposi- toring with an oblique rotation revealed a two- to triage patients to the most appropriate emer- = tions are limited. The aim of this study was factor, twelve item solution, (KMO .832, x2 gency department. to measure and report prehospital Emergency = 1440.19, df = 66, p < .001). Confirmatory Telehealth and Navigation (ETHAN) mobile- factor analysis also endorsed a two factor, 12 198. Variability of California Local EMS integrated patient dispositions for alternate item solution, (x2 = 130.39, df = 51, p < .001, Agencies’ Pediatric Respiratory Distress transportation and/or destination. Methods: CFI = .95, TLI = .93, RMSEA = .07, SRMR Protocols and Their Corresponding Level This retrospective study was conducted on con- = .06). Results supported two groups of six- of Evidence secutive EMS patients triaged by telehealth item factors that captured transactional stress emergency physicians in a major metropoli- in the provision of service. The factors, clearly Jennifer Farah, J. Joelle Donofrio, Nicholas tan urban fire-based EMS system from Decem- aligned with transactional stress issues internal Aldridge, University of California, San Diego ber 2014 through May 2017. Once on scene, to the ambulance and transactional stress rela- Category of Submission: Student, Resident, EMS completes a patient assessment together tionships external to the ambulance. Both sub- Fellow with ETHAN inclusion/exclusion criteria. If scales demonstrated good internal reliability (α Background: We sought to compare Califor- eligible, the medic transfers the ePCR and = .843/α = .768) and were correlated (p ࣘ .01) nia local EMS agencies’ (LEMSA) protocols contacts the Physician, who interviews the with a convergent validity measure. Conclu- and review evidence-based guidelines on the patient via real-time video/voice conferenc- sions: This study successfully validated a two- treatment of three main pediatric respiratory ing and determines the appropriate disposi- factor scale which captures stress associated complaints by presentation: asthma (wheez- tion. Those cases where the ETHAN proto- with the day to day provision of EMS and the ing), bronchiolitis (wheezing <24 months), and col was employed were abstracted from the interaction with allied professions. The devel- croup (stridor). Methods: In 2016, publicly ePCR system. Descriptive statistics describe opment of this measure of transactional stresses available protocols from 33 California LEMSAs study characteristics and a 95% confidence further expands the potential that paramedics, were itemized and reviewed in the following interval was calculated for telehealth disposi- Paramedic Services, employers, and prehospi- categories: wheezing, wheezing <24 months, tions. Results: During the study period 10,042 tal physicians may understand the dynamics and stridor. Descriptive statistics were used to patients met the ETHAN criteria. Among this that influence provider health and safety. As compare these protocols. Literature reviews, group of telehealth dispositions; alternate trans- a result, there may be greater opportunities including the American Academy of Pedi- port and/or destination 77% (95% CI 76–78%) to intervene holistically to improve paramedic atrics’ (AAP) current treatment guidelines, (5942/Referred to ED by ETHAN MD-Cab or health and well-being. were used to create level of evidence (LOE) NAEMSP 2018 ANNUAL MEETING ABSTRACTS 149

tables for asthma, bronchiolitis, and croup. Of responses (DE 9.5 ± 7.2, CC8.4 ± 4.7, p = 201. Association of Case Volume Per note, steroids were included only in the litera- 0.54). More patients in the DE cohort received Ambulance Station with Outcome of ture review, as California LEMSAs do not cur- multidisciplinary care conferences (37% vs. Out-of-Hospital Cardiac Arrest (OHCA) rently use steroids prehospital. The evidence- 8%, p = 0.02) and primary care linkage (53% based tables were compared to California local vs. 15%, p = 0.008), while case management Tae Han Kim, Sang Do Shin, Kyoung Jun EMS agency protocols. Results: Among the staffing alone was more prevalent in the CC Song, Ki Jeong Hong, Young Sun Ro, So Yeon 33 LEMSAs, wheezing protocols had the least cohort (77% vs.. 47%, p = 0.041). Quarterly Kong, Seoul National University Hospital, Depart- amount of variability with only two of the EMS responses declined to 6 ± 5.7 after ment of Emergency Medicine Category of Sub- six treatments, ipratropium (15/33) and neb- 3 months, 6.4 ± 6.6 after 6 months, and 3.9 ± mission: Operations, Quality, Safety Sys- ulized epinephrine (3/33), having >2 LEM- 4.5 after 9 months of enrollment. Clients in tems, Disaster SAs with variability. The most common wheez- the third quarter averaged a six call decrease Background: Sufficient case volume for emer- ing treatments included albuterol (33/33) and compared to baseline (1.8–10.2, p = 0.011). gency medical service may be important for IV/IM epinephrine (33/33). The least common Nine were disenrolled due to death, reloca- retention of resuscitation skills and proce- treatments included nebulized epinephrine and tion, or reduction in EMS calls. Conclusions: dures during prehospital management of Out- magnesium (2/33). Current evidence strongly These preliminary findings indicate that of-Hospital Cardiac Arrest (OHCA). We eval- supports the use of albuterol, ipratropium, MIH direct engagement and care coordina- uated association of case volume per ambu- epinephrine, magnesium, steroids, and nonin- tion yield a reduction in 9-1-1 utilization. lance station with outcome of OHCA. Meth- vasive positive pressure ventilation (NIPPV) in This study was limited by a small sample ods: Nationwide data of all adult OHCA dur- the asthmatic child. Only three agencies dif- size and lack of randomization, but strongly ing 2013 to 2014 was retrospectively analyzed. ferentiated wheezing in children <1yearof indicates that additional investigation is All ambulance station was stratified in to 4 age, referencing this as possible bronchioli- warranted. groups according to annual average number tis. All three included albuterol and NIPPV of OHCA treated by EMS teams dispatched as their recommended treatments but did not 200. Urban Law Enforcement Naloxone from each ambulance station. Multivariable include nebulized hypertonic saline, nebulized Deployment for Treatment of Suspected logistic regression model was conducted to epinephrine, steroids or suctioning. For chil- Out-of-Hospital Opioid Overdoses: A Pilot evaluate effect of increased case volume per dren <24 months, albuterol and steroids are Program an ambulance station on survival outcome of no longer strongly recommended based on Eric Cortez, David Keseg, James Davis, Ken- OHCA. Results: From 2013 to 2014, total of new AAP guidelines. Stridor had the highest neth Kuebler, Ashish Panchal, Ohio Health Doc- 47,637 OHCAs were treated and transported protocol variability, with no treatment having tors Hospital Category of Submission: Opera- by EMS teams from 1,205 ambulance stations uniform use among agencies. The most com- tions, Quality, Safety Systems, Disaster nationwide. Mean annual number of OHCA mon treatments included IV/IM epinephrine dispatched from each ambulance station was (24/33), NIPPV (29/33), and humidified mist Background: Law enforcement (LE) naloxone 19.8 cases. Overall survival to discharge rate (18/33). The least common treatments were programs aimed at early recognition and was 5.5% with 2.9% of discharge with favor- nebulized epinephrine (12/33) and suctioning treatment of opioid overdoses have increased. able neurological outcome. Survival was high- (4/33). For stridor, evidence supports the effi- Implementation is often challenged by emer- est in groups with largest case volume (7.2% in cacy of all formulations of epinephrine. Conclu- gency medical services (EMS) engagement, group 4(largest case volume) vs. 3.3% in group sions: There is wide variation among California which may impact adoption and overall 1(smallest case volume)). Adjusted odds ratio LEMSAs in their management of pediatric res- success. The objective of this study was to of largest case volume per ambulance station piratory distress. Recent changes to treatment analyze the implementation of a naloxone pilot for predicting survival was 1.46(95% CI 1.26 – guidelines have likely created the discordance program at a large urban LE agency supported 1.70). Conclusions:CasevolumeofOHCAper between current treatment practices and LOE by local EMS providers. We hypothesized that ambulance station might be associated to sur- tables. Timely evidence-based updates will with direct training and interaction with EMS vival outcome of EMS treated OHCA. Appro- likely benefit prehospital agencies’ treatment providers, LE adoption would be high. Meth- priate prehospital EMS dispatching strategy protocols. ods: This prospective pilot program was con- according to case volume should be further ducted between May 2016 and December 2016. 199. Early Impact of an Emerging Mih studied. LE officers, investigative personnel, and sup- Program for 9-1-1 High Utilizers port personnel underwent training by the city’s 202. Resource Utilization and Clinical fire-based EMS providers. LE training included Jon Ehrenfeld, Ashley Clayton, Catherine Outcomes of Older Adult EMS Patients identifying the symptoms of opiate overdose, Counts, Michael Sayre, Seattle Fire Department with Traumatic Brain Injury Who Were and administration of naloxone if opioid over- Category of Submission: Operations, Qual- Transferred to a Level I Trauma Center ity, Safety Systems, Disaster dose was suspected and respiratory depression was present. LE personnel were deployed with Courtney Jones, Vasisht Srinivasan, Jeremy Background: Vulnerable, medically complex 2 mg naloxone doses administered intranasally Cushman, Julius Cheng, Timmy Li, Suzanne patients comprise a disproportionate share of with a mucosal atomizer device. At the end of Gillespie, Martina Anto-Ocrah, Nancy Wood, responses in an urban, fire-based EMS sys- the study period, LE personnel completed a Heather Lenhardt, Ann Dozier, Jeffrey Bazar- tem. A social worker-based Mobile Integrated survey concerning their training and experi- ian, Manish Shah, University of Rochester, School Healthcare (MIH) program was designed ence with naloxone administration. LE clinical of Medicine and Dentistry Category of Submis- to intervene using either direct engagement performance was monitored for each naloxone sion: Trauma (DE) or indirect care coordination (CC). We administration. Outcomes included patient hypothesized that sustained outreach would survival at the time of EMS arrival, and the Background: Traumatic brain injury (TBI) is reduce 9-1-1 activations and engage more results of the post program survey. Results: a substantial source of death, disability, and appropriate services. Methods: We used A total of 124 LE officers underwent naloxone healthcare utilization among older adults. computer-aided dispatch and electronic health training with 31 (25%) LE officers administer- Older patients are frequently under-triaged records to identify housed individuals with ing naloxone to 58 suspected overdose patients. by EMS to community hospitals and require ࣙ3 EMS responses in the previous quarter. Thirteen (42%) administered naloxone to more subsequent transfer to a trauma center for The social worker then assigned enrollees to than one patient. Fifty-six (97%) of the patients further care. However, a minimal amount the DE or CC cohort based on previous call received a single 2 mg dose of naloxone, is known regarding the provision of care volume, current services, vulnerability, and and 2 (3%) of the patients received two 2 mg and patient outcomes at the final receiving case management history. We recorded medical doses of naloxone. Of the treated patients, hospital. We aimed to describe trauma center and social services in place, existing case 98% (57/58) patients survived to EMS arrival. care among geriatric transfer patients with managers or providers, services and referrals The post program survey demonstrated that TBI. Methods: We conducted a secondary initiated, ongoing 9-1-1 utilization, and reason 82% of LE officers felt they received adequate analysis on a sub-cohort from a prospective for disenrollment when applicable. Groups naloxone training, 90% felt that the program multi-center study focusing on ambulance and were compared by chi-squared and t-tests. promoted timely and safe use of naloxone, emergency department (ED) care of injured Results: During the baseline quarter, EMS and 90% felt prepared to handle issues on older adults transported via ambulance. The responded 389 times to 45 patients. Twenty- scene. Conclusions: This study suggests that current analysis focused on patients trans- eight were female, the median age was 64 urban LE agencies partnered with EMS may ferred to the region’s Level I trauma center (IQR 56–71), 29 were Caucasian, and 12 were successfully implement naloxone administra- from another hospital. The trauma center African American. All were medically and tion programs for suspected opioid overdoses. for the present study serves a nine county socially complex, with a mean of >4 medical or Limitations to this study include the lack of catchment area of over one million people. social comorbidities per patient. Nineteen were patient-centered outcomes, and the significant Transfer paperwork from the originating assigned to DE and 26 to CC. In the baseline number of LE officers that did not administer hospital was reviewed and a detailed medical quarter the cohorts had a similar number of naloxone. record abstraction was conducted, including 150 PREHOSPITAL EMERGENCY CARE JANUARY/FEBRUARY 2018 VOLUME 22 / NUMBER 1

computed tomography (CT) findings, proce- 204. Change in the Utilization of cardiac arrest. Secondary outcomes included dures, length of stay (LOS), and ED disposition. Emergency Care after Establishment of changes in vital signs and shock index (SI). We used descriptive statistics to characterize Emergency Centre in Yaoundé, Cameroon: We performed descriptive statistics on demo- the study sample including proportions and A Before and After Cross-Sectional graphics, biometrics and derived the mean, confidence intervals. Results: There were 205 Analysis median and standard deviations for continuous patients transported by EMS to a community variables of both the interventional and con- hospital who were subsequently transferred So Yeon Kong, Sang Do Shin, Young Sun Ro, trol group. RESULTS: PDE was administered to the Level I trauma center. Thirty had con- Yun Jeong Kim, Joong Sik Jeong, Dae Han Wi, 75 times in the two-year study period. 22 of firmed abnormalities on head CT (14.6%). The Seoul National University Hospital Category of those were peri-intubation (treatment group). mean age was 78 years (range: 55–91), 57% Submission: Medical Mean age in PDE was 69 years vs. 72.4 years female,andthemostfrequentmechanismof in control group (P = 0.23). When comparing Background: In effort to address the shortage of injury was falls (93%). Median length of stay pre- and post-intubation vital signs of patients emergency medical care in Cameroon, Yaoundé at the trauma center was 13.5 days (range: receiving PDE, we found significant increases Medico-Surgical Emergency Center (CURY) 0–230), with 8 patients staying one day or in mean HR, SBP, DBP, MAP, and SI (P < was established in June, 2015 in Yaoundé, less. CT findings included subdural hematoma 0.001). In the control group SBP, DBP, MAP, Cameroon. To evaluate its impact on the com- (60%), subarachnoid hemorrhage (50%), and SI, and RR all achieved a statistical significant munities of Yaoundé, we assessed the changes intraparenchymal hemorrhage (36.7%). Five decrease of the mean (P < 0.001). The mean in utilizations of emergency medical care since patients required neurosurgical intervention dose of epinephrine was 10 micrograms (range the establishment of CURY. Methods: In 2014 (17%), eight required ICU admission (27%), 10–80mcg); 19.7% of peri-intubation patients in the first survey was conducted on randomly two were discharged from the ED (7%), and the control group went into cardiac arrest. Only selected 619 households (3,358 individuals) liv- two transitioned to inpatient hospice (7%). 4.5% of patients in the treatment group went ing in six health districts of Yaoundé. In 2017 Conclusions: In our sample, geriatric patients into cardiac arrest. This did not reach statistical the second quantitative survey was conducted with TBI who were subsequently transferred to significance. Conclusions: PDE used in the on 634 households (3,466 individuals) using a trauma center were overwhelmingly injured management of peri-intubation hypotension in the same survey methods as the first survey. via falls and had variable resource utilization the prehospital setting resulted in statistically In both surveys, data on demographic infor- and clinical outcomes. Additional ways for significant improvements in SBP, DBP, MAP mation, socioeconomic status, and utilization responding EMS providers to identify geriatric and SI. The control group showed statisti- of healthcare, including emergency care in the fall patients who are at high risk for TBI are cally significant worsening of vital signs after past year were collected on every member of warranted. intubation. Overall, fewer patients went into the households via face-to-face interview. Data peri-intubation cardiac arrest after receiving on two surveys were compared and emergency 203. Relationships between Right Atrial PDE. Readily available, easily composed and unit utilization by the distance from CURY was and Aortic Pressures and Jugular and rapidlyeffective,PDEisausefultooltocombat examined. Results: Participants in the both sur- Carotid Flows Respectively in a Swine acute hypotension in the prehospital arena. veys had similar age and gender distribution Model of Asphyxial Pseudo-Pulseless with mean age of 24 and 54% being male. Electrical Activity 206. Accuracy of Stroke Dispatch by a In 2014 survey, healthcare utilization rates for Large Urban EMS Dispatch System Norman Paradis, Karen Moodie, Sarah Crock- outpatient, emergency unit, and hospitalization ett, Jeffrey Gould, Christopher Kaufman, were 37.2%, 4.5%, and 9.6%, respectively. In Thomas Lardaro, Dustin Holland, Tom Dartmouth-Hitchcock Medical Center Category 2017 survey, corresponding rates were 32.4%, Arkins, Dan O’Donnell, Indiana University of Submission: Cardiac 5.7%, and 8.7%, respectively. The increase in School of Medicine Category of Submission: the utilization of emergency unit between two Medical Background: The initial cardiac rhythms found surveys were statistically significantly (p=0.01). during in-hospital respiratory arrests are typi- When the emergency unit utilization rates were Background: Stroke is a time sensitive emer- cally either pulseless electrical activity (PEA) or examined by 3 km radius from CURY, there gency that requires appropriate triage in EMS asystole. Pseudo-PEA (p-PEA) often precedes was decrease in the utilization of emergency transport planning. The existence of hospitals true PEA and is characterized by a low-flow care among residents living near CURY (27.3% with varying stroke-care capabilities and more state in which cardiac contraction produces in 2014 to 22.8% in 2017). Conclusions: After recently mobile stroke units (MSUs) neces- a non-palpable blood pressure. The purpose the establishment of emergency medical center sitates early recognition of stroke symptoms of the study was to characterize the relation- (CURY) in Yaoundé, Cameroon, the utilization and accurate triage of patients to appropriate ships between venous and arterial pressures of emergency care was significantly increased. resources. This study investigates the accuracy and the flows that drive brain perfusion ina This increase was regardless of the distance of the EMS dispatch system in a major U.S. hypoxic asphyxial model of p-PEA. Hypoth- from the patients’ residential places to the emer- metropolitan area in predicting whether or not a esis: We hypothesized that during CPR right gency medical center, suggesting that the estab- patient is having a stroke. Objective: The objec- atrial pressure (RAP) would be related to jugu- lishment of an emergency medical center may tive of this study was to evaluate the accuracy lar venous flow (JVF), and that aortic pressure have impacted the utilization of emergency care of stroke recognition by a large urban EMS dis- (AOP) would be related to carotid flow, and that throughout the entire communities of Yaoundé. patch system in the United States. Methods:We these relationships might change with time dur- performed a retrospective cohort study look- ing at the initial dispatch for stroke within a ing p-PEA. Methods: Pseudo-PEA was induced 205. Prehospital Push Dose Epinephrine in large urban-area EMS system. We then com- via hypoxic asphyxiation in 12 domestic swine Hypotension (∼32 kg) with standard physiological monitor- pared these patients to a stroke registry from ing. AOP and RAP were measured with solid Mark Merlin, Navin Ariyaprakai, a large urban tertiary hospital in the same city state transducers placed in the thoracic aorta Ammundeep Tagore, Matthew Harris, over a two-year period (2015–2016). Results: and right atrium. Blood flow was measured in Andrew Parrish, Josh Schwarzbaum, Alex Over the study period, a total of 33,910 patients the common carotid artery and jugular vein Torres, Michael Carr, Susmith Koneru, Newark were transported to the tertiary care hospital for with ultrasonic flow probes. FiO2 was reduced Beth Israel Medical Center/RWJBarnabas-MONOC any complaint, including 778 patients with an to 6% by increasing the fraction of nitrogen. A Category of Submission: Medical initial dispatch code for stroke. Of the patients target systolic blood pressure (SBP) of 40 mmHg with initial dispatch coded as stroke, 133 were was used to define p-PEA. The relationship Background: Hypotension is commonly then confirmed as truly having a stroke based between pressures and flows was determined encountered in the prehospital arena and on stroke registry data. Dispatch for stroke had with a Pearson correlation coefficient. Results: occurs in the setting of illness, trauma or may a sensitivity of 43.2% (95% CI 37.6–48.9), speci- Overall, RAP was significantly negatively cor- be iatrogenic during rapid sequence intubation ficity of 98.1% (95% CI 97.9–98.2), positive pre- related with JVF (r =−0.51, p < 0.05), however, (RSI). The mainstay of prehospital treatment dictive value of 17.1% (95%CI 15.1–19.3), and the relationship varied over time during p-PEA has been intravenous (IV) fluids; however, this negative predictive value of 99.5% (95% CI 99.4– (Figure). AOP was significantly positively cor- method is not always effective. Push doses 99.5). Conclusions: These findings imply EMS related with carotid flow (r = 0.85, p < 0.05), but of epinephrine or phenylephrine, so called dispatch alone is not sufficient to rule-in stroke. did not show the same time dependence as seen “push-dose pressors,” have long been used by In the case of MSUs, dispatch alone may lead with RAP and JVF. Conclusions:Inanasphyx- anesthesiologists for acute hypotension in the to patients being inappropriately triaged to this ial model of p-PEA, venous blood pressures operating room. Push dose epinephrine (PDE) resource due to the 82.9% false positive rate. The and flows were negatively associated and the offers another tool to advanced life support authors conclude that (1) triage tools beyond relationship varied as a function of time. Arte- (ALS) providers to combat hypotension. Meth- dispatch are required to ensure appropriate rial pressures and flow were positively associ- ods: A retrospective review of data collected for triage of potential stroke patients for intercept ated and the relationship varied less over time. the administration of PDE for the management by a MSU or transport to a stroke center and (2) These findings have implications for how and of acute hypotension in the prehospital setting. EMS systems need triage tools to prevent inap- > when chest compressions or other interventions We included patients 17 years old with propriate triage of non-stroke patients to such < should be applied when treating p-PEA. systolic blood pressures 90 mmHg during the resources such as MSUs to ensure patient safety peri intubation period. Primary outcome was and to prevent delays in definitive care.