Things Your System Should Deliver

What is reasonable to expect from a community’s EMS, and how should we measure it?


Now New Castle County paramedics have a sepsis protocol and are equipped with lactate meters. A venous lactate test is indicated for patients who have a suspected infection, high or low temperature, pulse above 90 or respiratory rate above 20. This covers a large number of patients, and the lactate reading helps identify which of them are likely to decompensate before they start to look sick. Based on this information, paramedics now request a sepsis alert, which triggers a hospital response similar to ones for STEMIs and strokes. For sepsis patients, early recognition, antibiotics and aggressive fluid resuscitation save lives. Preliminary data shows the estimated time saved from prehospital lactate is 98 minutes, and that prehospital sepsis alerts have cut the time to antibiotics in half.

Time to Raise the Bar

This is a case to make the following interventions available to every patient who calls 9-1-1 for EMS. It is based on evidence of how effective they are, their frequency and the difficulty in predicting over the telephone when they are needed.

• 12-lead ECGs incorporated into regional STEMI systems

• CPAP

• Nebulized bronchodilators

• Seizure medication

• Pain medication

• Chemical sedation

References

1. Whitehead S. Sepsis alert: recognition and treatment of a common killer. EMS World, http://www.emsworld.com/article/10319536.

2. Shiuh T, Sweeney T, Reed J. Effect of arrival mode to the emergency department on time to early goal-directed therapy of the septic patient. Prehosp Emerg Care, 2010 Jan; 14(Suppl1):5.

References

1. Myers JB, Slovis CM, Eckstein M, et al. Evidence based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care, 2008; 12: 141–51.
2. Sayre, M, Hallstrom A, Rea, T, et al. Cardiac arrest survival rates depend on paramedic experience. Acad Emerg Med, 2006; 3(5)(Suppl): S55–6.
3. Eisenberg MS. Resuscitate!: How Your Community Can Improve Survival From Sudden Cardiac Arrest. Seattle: University of Washington Press, 2009.
4. Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM. Out-of-hospital endotracheal intubation experience and patient outcomes. Ann Emerg Med, 2010; 55(6): 527–37.
5. Williams DM. 2006 JEMS 200-city survey: EMS from all angles. J Emerg Med Serv, 2007; 2: 38–42.
6. The Medic One Foundation. Seattle’s survival rate for witnessed, shockable cardiac arrest rises to unprecedented levels, www.mediconefoundation.org/wp -content/uploads/Seattles-survival-rate-for-cardiac-arrest.pdf.
7. Hinchey PR, Myers JB, Lewis R, et al. Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: the Wake County experience. Ann Emerg Med, 2010; 56(4): 348–57.
8. Jacobs I, Nadkarni V, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports. Update and simplification of the Utstein Templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation, 2004; 110: 3,385–97.
9. Ragone M. Evolution or revolution: EMS industry faces difficult changes. J Emerg Med Serv, 2011; 37(2): 34–9.
10. Rathore S. Curtis JP, Chen J, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. BMJ, 2009; 338: b1,807.
11. Morrison LJ, Brooks S. Sawadsky B, McDonald A, Verbeek PR. Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment times and mortality: a systematic review. Acad Emerg Med, 2006; 13(1): 84–9.
12. Verbeek PR, Ryan D, Craig AM. Serial prehospital 12-lead electrocardiograms increase identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care, 2012; 16(1): 109–14.
13. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics and mortality among patients with myocardial infarction presenting without chest pain. JAMA, 2000; 283(24): 3,223–9.
14. Jorolemon M, Pikarsky R, Plis L, et al. Does limiting prehospital 12-lead ECGs to patients who complain of chest pain delay diagnosing acute myocardial infarctions? Prehosp Emerg Care, 2012; 16(1)(Suppl): 168.
15. Knapp B, Wood C. The prehospital administration of intravenous methylprednisolone lowers hospital admission rates for moderate to severe asthma. Prehosp Emerg Care, 2003; 7(4): 423–6.
16. Manno E. New management strategies in the treatment of status epilepticus. Mayo Clin Proc, 2003; 78: 508–18.