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Kovacs, M., and S. Campbell. "LO31: Triage drift: Variation in application of the Canadian Triage Acuity Scale between triage nurses compared to triage paramedics in response to overcrowding pressures in an emergency department." CJEM 22, S1 (May 2020): S18. http://dx.doi.org/10.1017/cem.2020.87.
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Introduction: CTAS is a validated five-level triage score utilized in EDs across Canada and internationally. Moderate interrater reliability between prehospital paramedic and triage nurse application of CTAS during clinical practice has been found. This study is the first assessment of the variation in distribution of CTAS scores with increasing departmental pressure as measured by the NEDOCs scale comparing triage allocations made by triage nurses with those made by triage paramedics. Methods: We conducted a retrospective, observational cohort study of EDIS data of all patients triaged in the Halifax Infirmary Emergency Department from January 1, 2017-May 30, 2017 and January 1, 2018 - May 30, 2018. CTAS score assignment by nursing and paramedic triage staff were compared with increasing levels of ED overcrowding, as determined by the department NEDOCS score. Results: Nurses were more likely to assign higher acuity scores in all situations of department crowding; there was a 3% increased probability that a nurse, as compared to a paramedic, would triage as emergent when the ED was not overcrowded (Pearson chi-square(1) = 4.21, p < 0.05, Cramer's v = 0.028, n = 5314), and a 10% increased probability that a nurse, as compared to a paramedic, would triage a patient as emergent when EDs were overcrowded (Pearson chi-square(1) = 623.83, p < 0.001, Cramer's v = 0.11, n = 56 018). Conclusion: Increasing levels of ED overcrowding influence triage nurse CTAS score assignment towards higher acuity to a greater degree than scores assigned by triage paramedics.
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Cicero, Mark X., Barbara Walsh, Yauheni Solad, Travis Whitfill, Geno Paesano, Kristin Kim, Carl R. Baum, and David C. Cone. "Do You See What I See? Insights from Using Google Glass for Disaster Telemedicine Triage." Prehospital and Disaster Medicine 30, no. 1 (January 9, 2015): 4–8. http://dx.doi.org/10.1017/s1049023x1400140x.
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AbstractIntroductionDisasters are high-stakes, low-frequency events. Telemedicine may offer a useful adjunct for paramedics performing disaster triage. The objective of this study was to determine the feasibility of telemedicine in disaster triage, and to determine whether telemedicine has an effect on the accuracy of triage or the time needed to perform triage.MethodsThis is a feasibility study in which an intervention team of two paramedics used the mobile device Google Glass (Google Inc; Mountain View, California USA) to communicate with an off-site physician disaster expert. The paramedic team triaged simulated disaster victims at the triennial drill of a commercial airport. The simulated victims had preassigned expected triage levels. The physician had an audio-video interface with the paramedic team and was able to observe the victims remotely. A control team of two paramedics performed disaster triage in the usual fashion. Both teams used the SMART Triage System (TSG Associates LLP; Halifax, England), which assigns patients into Red, Yellow, Green, and Black triage categories. The paramedics were video recorded, and their time required to triage was logged. It was determined whether the intervention team and the control team varied regarding accuracy of triage. Finally, the amount of time the intervention team needed to triage patients when telemedicine was used was compared to when that team did not use telemedicine.ResultsThe two teams triaged the same 20 patients. There was no significant difference between the two groups in overall triage accuracy (85.7% for the intervention group vs 75.9% for the control group; P = .39). Two patients were triaged with telemedicine. For the intervention group, there was a significant difference in time to triage patients with telemedicine versus those without telemedicine (35.5 seconds; 95% CI, 72.5-143.5 vs 18.5 seconds; 95% CI, 13.4-23.6; P = .041).ConclusionThere was no increase in triage accuracy when paramedics evaluating disaster victims used telemedicine, and telemedicine required more time than conventional triage. There are a number of obstacles to available technology that, if overcome, might improve the utility of telemedicine in disaster response.CiceroMX, WalshB, SoladY, WhitfillT, PaesanoG, KimK, BaumCR, ConeDC. Do you see what I see? Insights from using Google Glass for disaster telemedicine triage. Prehosp Disaster Med. 2015;30(1):1-5.
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Fraess-Phillips, Alex J. "Can Paramedics Safely Refuse Transport of Non-Urgent Patients?" Prehospital and Disaster Medicine 31, no. 6 (September 19, 2016): 667–74. http://dx.doi.org/10.1017/s1049023x16000935.
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AbstractObjectiveThe goal of this search was to review the current literature regarding paramedic triage of primary care patients and the safety of paramedic-initiated non-transport of non-urgent patients.MethodsA narrative literature review was conducted using the Medline (Medline Industries, Inc.; Mundelein, Illinois USA) database and a manual search of Google Scholar (Google; Mountain View, California USA).ResultsOnly 11 studies were found investigating paramedic triage and safety of non-transport of non-urgent patients. It was found that triage agreement between paramedic and emergency department staff generally is poor and that paramedics are limited in their abilities to predict the ultimate admission location of their patients. However, these triage decisions and admission predictions are much more accurate when the patient’s condition is the result of trauma and when the patient requires critical care services. Furthermore, the literature provides very limited support for the safety of paramedic triage in the refusal of non-urgent patient transport, especially without physician oversight. Though many non-transported patients are satisfied with the quality of non-urgent treatment that they receive from paramedics, the rates of under-triage and subsequent hospitalization reported in the literature are too high to suggest that this practice can be adopted widely.ConclusionThere is insufficient evidence to suggest that non-urgent patients can safely be refused transport based on paramedic triage alone. Further attempts to implement paramedic-initiated non-transport of non-urgent patients should be approached with careful triage protocol development, paramedic training, and pilot studies. Future primary research and systematic reviews also are required to build on the currently limited literature.Fraess-PhillipsAJ. Can paramedics safely refuse transport of non-urgent patients?Prehosp Disaster Med. 2016;31(6):667–674.
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Nakata, Keiji. "Triage Problem Among the Ambulance Crew (Paramedic) in Japan." Prehospital and Disaster Medicine 34, s1 (May 2019): s173. http://dx.doi.org/10.1017/s1049023x19003972.
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Introduction:At various accidents or disaster sites, rescue, first aid, and transport to hospitals has been provided by ambulance crews (paramedics). In the case of mass casualties, they also need to operate triage for injured people.Aim:To consider and reveal challenges in triage by ambulance crews (paramedics) on-site.Methods:Interviews of seven ambulance crews (paramedics) and their instructors were conducted and their answers were analyzed.Results:(1.) Triage black tags: declaring “deceased: not able to survive” might give a heavy mental burden and psychological responsibility. Legal protection and an interstitial rule will be necessary in the future. (2.) Missed triage: the ambulance crew cannot perform a triage that may develop a legal problem. It is always important to prevent ambulance crews from being charged. (3.) Triage education and training: there are few triage trainings at fire departments although the number of emergency medical responses is increasing compared to fire response. It will be necessary to increase time of the triage education and training in near future. (4.) Command system (characteristic rank system in the fire department): There is a problem with the rank system in fire departments since confusion occurs when a commander of the First Aid Station is not a licensed paramedic. The ambulance crew (paramedic) usually consists of the three different ranked people. Individual operations are difficult during operation. Education for the paramedic executive is necessary for the fire organization.Discussion:For the triage by ambulance crew (paramedic), legal protection by medical control operation is required, and it may lead to a reduction of heavy mental burden. Triage training is needed to improve the training of triage. The ambulance crew (paramedic) operates under the fire department command system. However, at the time of disaster, the ambulance crew (paramedic) should also work under the medical command system.
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Cuttance, Glen, Kathryn Dansie, and Tim Rayner. "Paramedic Application of a Triage Sieve: A Paper-Based Exercise." Prehospital and Disaster Medicine 32, no. 1 (December 14, 2016): 3–13. http://dx.doi.org/10.1017/s1049023x16001163.
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AbstractIntroductionTriage is the systematic prioritization of casualties when there is an imbalance between the needs of these casualties and resource availability. The triage sieve is a recognized process for prioritizing casualties for treatment during mass-casualty incidents (MCIs). While the application of a triage sieve generally is well-accepted, the measurement of its accuracy has been somewhat limited. Obtaining reliable measures for triage sieve accuracy rates is viewed as a necessity for future development in this area.ObjectiveThe goal of this study was to investigate how theoretical knowledge acquisition and the practical application of an aide-memoir impacted triage sieve accuracy rates.MethodTwo hundred and ninety-two paramedics were allocated randomly to one of four separate sub-groups, a non-intervention control group, and three intervention groups, which involved them receiving either an educational review session and/or an aide-memoir. Participants were asked to triage sieve 20 casualties using a previously trialed questionnaire.ResultsThe study showed the non-intervention control group had a correct accuracy rate of 47%, a similar proportion of casualties found to be under-triaged (37%), but a significantly lower number of casualties were over-triaged (16%). The provision of either an educational review or aide-memoir significantly increased the correct triage sieve accuracy rate to 77% and 90%, respectively. Participants who received both the educational review and aide-memoir had an overall accuracy rate of 89%. Over-triaged rates were found not to differ significantly across any of the study groups.ConclusionThis study supports the use of an aide-memoir for maximizing MCI triage accuracy rates. A “just-in-time” educational refresher provided comparable benefits, however its practical application to the MCI setting has significant operational limitations. In addition, this study provides some guidance on triage sieve accuracy rate measures that can be applied to define acceptable performance of a triage sieve during a MCI.CuttanceG, DansieK, RaynerT. Paramedic application of a triage sieve: a paper-based exercise. Prehosp Disaster Med. 2017;32(1):3–13.
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Smith, K. E., K. Lobay, and M. Bullard. "P122: The use of decision support tools in the implementation of the Prehospital Canadian Triage Acuity Score (Pre-CTAS)." CJEM 18, S1 (May 2016): S119. http://dx.doi.org/10.1017/cem.2016.297.
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Introduction: The Prehospital Canadian Triage and Acuity Scale (Pre-CTAS) is based upon, and is consistent with, the CTAS (Canadian Triage and Acuity Scale). Paramedic-assigned Pre-CTAS scores using memory compared to Triage Nurse CTAS scores have previously demonstrated moderate inter-rater reliability. This is the first study to measure the effect of two different point-of-care decision support tools on the inter-rater reliability of paramedic assigned Pre-CTAS and Triage nurse CTAS scores. Methods: Paramedics were randomized to Pre-CTAS booklet or CTAS smartphone app during the one-year study period. Pre-CTAS scores assigned on arrival at hospital (AH) were compared with Triage Nurse CTAS scores and analyzed using Cohen’s Kappa. Paramedics were then surveyed to assess the perceived utility and satisfaction with the decision support tools. Results: For 1663 patient transports, the weighted kappa score for Paramedic AH vs. Triage Nurse CTAS was fair at 0.38 (95% CI 0.35-0.41). For patients whose initial on-scene and AH Pre-CTAS scores did not change (n= 1405, 85%), Paramedic-Triage Nurse agreement was moderate at 0.43 (95% CI 0.39-0.46). The survey revealed that tools, when employed, helped assign scores; however accessing the additional resource was cumbersome or time consuming, and scores were occasionally assigned post clinical encounter. Conclusion: Point-of-care external decision support tools did not affect Pre-CTAS and ED CTAS agreement. These tools may add complexity or be perceived to add time to documentation within the delivery of clinical care if not implemented with adequate support. Future research needs to evaluate the impact of clinical decision support embedded within an electronic patient care record consistent with many ED information systems.
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Iezzoni, Lisa I., Dhruva Kothari, Carlos A. Camargo, Amy J. Wint, W. Scott Cluett, Yorghos Tripodis, and Joseph Palmisano. "Making Triage Decisions for the Acute Community Care Program: Paramedics Caring for Urgent Health Problems in Patients’ Homes." American Journal of Medical Quality 34, no. 4 (September 19, 2018): 331–38. http://dx.doi.org/10.1177/1062860618800582.
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The Acute Community Care Program (ACCP) initiative sends specially trained paramedics to evaluate and treat patients with urgent care problems in their residences during evening hours. ACCP safety depends on making appropriate triage decisions from patients’ reports during phone calls about whether paramedics could care for patients’ urgent needs or whether they require emergency department (ED) services. Furthermore, after ACCP paramedics are on scene, patients may nonetheless need ED care if their urgent health problems are not adequately treated by the paramedic’s interventions. To train clinical staff participating in all aspects of ACCP, including these triage decisions, ACCP clinical leaders developed brief vignettes: 27 represented initial ACCP triage decisions and 10 the subsequent decision to send patients to EDs. This report describes findings from an online survey completed by 24 clinical staff involved with ACCP triage. Clinical vignettes could be useful for staff training and quality control in such paramedic initiatives.
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Burns, John. "Paramedic-led acute home visiting services in primary care." Journal of Paramedic Practice 13, no. 6 (June 2, 2021): 238–44. http://dx.doi.org/10.12968/jpar.2021.13.6.238.
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Home visiting is traditionally carried out by GPs but it is becoming increasingly difficult for GPs to do, and many doctors want it removed from their contract. This is opening up a space for the paramedic profession, with paramedics carrying out home visits and designing future primary care services. Paramedics working within primary care can possess the knowledge, leadership and complex skills needed for home visiting, and some are independent prescribers; they can lead acute home visiting services (AHVS). AHVS require effective triage and access to electronic patient records, are underpinned by robust clinical governance and engage in clinical audits. Future primary care paramedic services could include online, video and face-to-face consultations, care home ward rounds, remote triage and home visiting. However, paramedics' contribution to general practice has not been fully evaluated and it may take time for this to become a norm. Regardless, primary care paramedicine has an opportunity to be innovative, shaking off risk-averse protocols for more enlightened practices, and lead the profession.
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Lee, Christopher W. C., Shelley L. McLeod, Kristine Van Aarsen, Michelle Klingel, Jeffrey M. Franc, and Michael B. Peddle. "First Responder Accuracy Using SALT during Mass-casualty Incident Simulation." Prehospital and Disaster Medicine 31, no. 2 (February 9, 2016): 150–54. http://dx.doi.org/10.1017/s1049023x16000091.
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AbstractIntroductionDuring mass-casualty incidents (MCIs), patient volume often overwhelms available Emergency Medical Services (EMS) personnel. First responders are expected to triage, treat, and transport patients in a timely fashion. If other responders could triage accurately, prehospital EMS resources could be focused more directly on patients that require immediate medical attention and transport.HypothesisTriage accuracy, error patterns, and time to triage completion are similar between second-year primary care paramedic (PCP) and fire science (FS) students participating in a simulated MCI using the Sort, Assess, Life-saving interventions, Treatment/Transport (SALT) triage algorithm.MethodsAll students in the second-year PCP program and FS program at two separate community colleges were invited to participate in this study. Immediately following a 30-minute didactic session on SALT, participants were given a standardized briefing and asked to triage an eight-victim, mock MCI using SALT. The scenario consisted of a four-car motor vehicle collision with each victim portrayed by volunteer actors given appropriate moulage and symptom coaching for their pattern of injury. The total number and acuity of victims were unknown to participants prior to arrival to the mock scenario.ResultsThirty-eight PCP and 29 FS students completed the simulation. Overall triage accuracy was 79.9% for PCP and 72.0% for FS (∆ 7.9%; 95% CI, 1.2-14.7) students. No significant difference was found between the groups regarding types of triage errors. Over-triage, under-triage, and critical errors occurred in 10.2%, 7.6%, and 2.3% of PCP triage assignments, respectively. Fire science students had a similar pattern with 15.2% over-triaged, 8.7% under-triaged, and 4.3% critical errors. The median [IQR] time to triage completion for PCPs and FSs were 142.1 [52.6] seconds and 159.0 [40.5] seconds, respectively (P=.19; Mann-Whitney Test).ConclusionsPrimary care paramedics performed MCI triage more accurately than FS students after brief SALT training, but no difference was found regarding types of error or time to triage completion. The clinical importance of this difference in triage accuracy likely is minimal, suggesting that fire services personnel could be considered for MCI triage depending on the availability of prehospital medical resources and appropriate training.LeeCWC, McLeodSL, Van AarsenK, KlingelM, FrancJM, PeddleMB. First responder accuracy using SALT during mass-casualty incident simulation. Prehosp Disaster Med. 2016;31(2):150–154.
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Dippenaar, Enrico. "Triage system performance: consistency and accuracy in the emergency centre." Journal of Paramedic Practice 12, no. 3 (March 2, 2020): 94–99. http://dx.doi.org/10.12968/jpar.2020.12.3.94.
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Triage systems have evolved over recent times with the use of tiered acuity to achieve a balance between patient need and resource availability. Triage is a way to sort patients based on acuity, irrespective of the setting, and whether by telephone, in the prehospital environment or in hospital. The growth of the paramedic profession means that paramedics are now working in emergency centres and having to contend with the concept of triage in this setting. The nature of emergency centres and the variety of patient presentations makes it nearly impossible to have a perfect system that is both consistent and accurate. Paramedics, as decision makers, should understand the underlying concepts of what makes a triage system perform well so best practice can be adopted with specific goals in mind. There is a patient-centred focus to do the most for the most at any given time and to ensure that resources are aligned with the needs of patients. It is vital to monitor a triage system's performance so that improvements or adjustments can be made in response to patient population needs over time. This commentary focuses on the main principles of triage system performance measures and what factors should be taken into consideration during clinical practice. Highlighting the concepts of triage reliability, validity and decision-making should help paramedics to understand the importance of conscious decision-making practice.
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Eastwood, Kathryn, Dhanya Nambiar, Rosamond Dwyer, Judy A. Lowthian, Peter Cameron, and Karen Smith. "Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study." BMJ Open 10, no. 11 (November 2020): e042351. http://dx.doi.org/10.1136/bmjopen-2020-042351.
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BackgroundMost calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches.ObjectivesTo examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch.DesignA retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted.SettingThe secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period.ParticipantsThere were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses.Main outcome measuresDescriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients.ResultsThe dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005).ConclusionSecondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.
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Zhao, Henry, Lauren Pesavento, Edrich Rodrigues, Patrick Salvaris, Karen Smith, Stephen Bernard, Michael Stephenson, et al. "009 The ambulance clinical triage-for acute stroke treatment (ACT-FAST) algorithmic pre-hospital triage tool for endovascular thrombectomy: ongoing paramedic validation." Journal of Neurology, Neurosurgery & Psychiatry 89, no. 6 (May 24, 2018): A5.1—A5. http://dx.doi.org/10.1136/jnnp-2018-anzan.9.
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IntroductionThe ambulance clinical triage-for acute stroke treatment (ACT-FAST) algorithm is a severity based 3-step paramedic triage tool for pre-hospital recognition of large vessel occlusion (LVO), designed to improve specificity and paramedic assessment reliability compared to existing triage scales. ACT-FAST sequentially assesses 1. Unilateral arm fall to stretcher <10 s; 2a. Severe language disturbance (right arm weak), or 2b. Severe gaze deviation/hemi-neglect assessed by shoulder tap (left arm weak); 3. Clinical eligibility questions. We present the results of the ongoing Ambulance Victoria paramedic validation study.MethodsAmbulance Victoria paramedics assessed ACT-FAST in all suspected stroke patients pre-hospital in metropolitan Melbourne, Australia, and in the Royal Melbourne Hospital Emergency Department since July 2017. Algorithm results were validated against a comparator of ICA/M1 occlusion on CT-angiography with NIHSS ≥6 (Class 1 indications for endovascular thrombectomy).ResultsData were available from n=119 assessments (ED n=68, pre-hospital n=51). Patient diagnoses were LVO n=20 (15.6%), non-LVO infarcts n=45 (38.5%), ICH n=10 (8.3%) and no stroke on imaging n=44 (37.6%). ACT-FAST showed 85% sensitivity, 88.9% specificity, 60.7% (72% excluding ICH) positive predictive value and 96.7% negative predictive value for LVO. Of 10 false-positives, 4 received thrombectomy for non-Class 1 indications (basilar/M2 occlusions/cervical dissection), 3 were ICH, and 1 was tumour. Three false-negatives were LVO with milder syndromes.DiscussionThe ongoing ACT-FAST algorithm validation study shows high accuracy for clinical recognition of LVO. The streamlined algorithmic approach with just two examination items provides a more practical option for implementation in large emergency service networks. Accurate pre-hospital recognition of LVO will allow bypass to endovascular centres and early activation of neuro-intervention services to expedite endovascular thrombectomy.
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Simmons, Erik, Jerris R. Hedges, Lisa Irwin, Wilhelmine Maassberg, and Howard A. Kirkwood. "Paramedic Injury Severity Perception Can Aid Trauma Triage." Annals of Emergency Medicine 26, no. 4 (October 1995): 461–68. http://dx.doi.org/10.1016/s0196-0644(95)70115-x.
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Mulholland, Stephen A., Belinda J. Gabbe, and Peter Cameron. "Is paramedic judgement useful in prehospital trauma triage?" Injury 36, no. 11 (November 2005): 1298–305. http://dx.doi.org/10.1016/j.injury.2005.07.010.
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Sibley, A. K., T. Jain, B. Nicholson, M. Butler, S. David, D. Smith, and P. Atkinson. "MP01: Use of an unmanned aerial vehicle to provide situational awareness in a simulated mass casualty incident." CJEM 20, S1 (May 2018): S40. http://dx.doi.org/10.1017/cem.2018.155.
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Introduction: Situational awareness (SA) is essential for maintenance of scene safety and effective resource allocation in mass casualty incidents (MCI). Unmanned aerial vehicles (UAV) can potentially enhance SA with real-time visual feedback during chaotic and evolving or inaccessible events. The purpose of this study was to test the ability of paramedics to use UAV video from a simulated MCI to identify scene hazards, initiate patient triage, and designate key operational locations. Methods: A simulated MCI, including fifteen patients of varying acuity (blast type injuries), plus four hazards, was created on a college campus. The scene was surveyed by UAV capturing video of all patients, hazards, surrounding buildings and streets. Attendees of a provincial paramedic meeting were invited to participate. Participants received a lecture on SALT Triage and the principles of MCI scene management. Next, they watched the UAV video footage. Participants were directed to sort patients according to SALT Triage step one, identify injuries, and localize the patients within the campus. Additionally, they were asked to select a start point for SALT Triage step two, identify and locate hazards, and designate locations for an Incident Command Post, Treatment Area, Transport Area and Access/Egress routes. Summary statistics were performed and a linear regression model was used to assess relationships between demographic variables and both patient triage and localization. Results: Ninety-six individuals participated. Mean age was 35 years (SD 11), 46% (44) were female, and 49% (47) were Primary Care Paramedics. Most participants (80 (84%)) correctly sorted at least 12 of 15 patients. Increased age was associated with decreased triage accuracy [-0.04(-0.07,-0.01);p=0.031]. Fifty-two (54%) were able to localize 12 or more of the 15 patients to a 27x 20m grid area. Advanced paramedic certification, and local residency were associated with improved patient localization [2.47(0.23,4.72);p=0.031], [-3.36(-5.61,-1.1);p=0.004]. The majority of participants (78 (81%)) chose an acceptable location to start SALT triage step two and 84% (80) identified at least three of four hazards. Approximately half (53 (55%)) of participants designated four or more of five key operational areas in appropriate locations. Conclusion: This study demonstrates the potential of UAV technology to remotely provide emergency responders with SA in a MCI. Additional research is required to further investigate optimal strategies to deploy UAVs in this context.
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SherridMD, Mark. "Prehospital triage essential for cost-effective paramedic-administered thrombolysis." Journal of Electrocardiology 24 (January 1991): 14. http://dx.doi.org/10.1016/s0022-0736(10)80005-6.
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Austin, M., J. Sinclair, S. Leduc, S. Duncan, J. Rouleau, P. Price, C. Evans, and C. Vaillancourt. "P008: Evaluation of outcomes after implementation of a provincial prehospital bypass standard for trauma patients – an Eastern Ontario experience." CJEM 21, S1 (May 2019): S65—S66. http://dx.doi.org/10.1017/cem.2019.199.
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Introduction: Trauma and injury play a significant role in the population's burden of disease. Limited research exists evaluating the role of trauma bypass protocols. The objective of this study was to assess the impact and effectiveness of a newly introduced prehospital field trauma triage (FTT) standard, allowing paramedics to bypass a closer hospital and directly transport to a trauma centre (TC) provided transport times were within 30 minutes. Methods: We conducted a 12-month multi-centred health record review of paramedic call reports and emergency department health records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness, step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as an urgent transport to hospital, that met one of the 4 steps of the FTT standard and would allow for a bypass consideration. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions. The primary outcome was the rate of appropriate triage to a TC, defined as any of the following: injury severity score ≥12, admitted to an intensive care unit, underwent non-orthopedic operation, or death. We report descriptive and univariate analysis where appropriate. Results: 570 adult patients were included with the following characteristics: mean age 48.8, male 68.9%, attended by Advanced Care Paramedic 71.8%, mechanisms of injury: MVC 20.2%, falls 29.6%, stab wounds 10.5%, median initial GCS 14, mean initial BP 132, prehospital fluid administered 26.8%, prehospital intubation 3.5%, transported to a TC 74.6%. Of those transported to a TC, 308 (72.5%) had bypassed a closer hospital prior to TC arrival. Of those that bypassed a closer hospital, 136 (44.2%) were determined to be “appropriate triage to TC”. Bypassed patients more often met the step 1 or step 2 of the standard (186, 66.9%) compared to the step 3 or step 4 (122, 39.6%). An appropriate triage to TC occurred in 104 (55.9%) patients who had met step 1 or 2 and 32 (26.2%) patients meeting step 3 or 4 of the FTT standard. Conclusion: The FTT standard can identify patients who should be bypassed and transported to a TC. However, this is at a cost of potentially burdening the system with poor sensitivity. More work is needed to develop a FTT standard that will assist paramedics in appropriately identifying patients who require a trauma centre.
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Bhatt, Nirav R., Michael R. Frankel, Raul G. Nogueira, Carol Fleming, Nicolas A. Bianchi, Olivia Morgan, Katleen Chester, et al. "Reliability of Field Assessment Stroke Triage for Emergency Destination Scale Use by Paramedics: Mobile Stroke Unit First-Year Experience." Stroke 52, no. 8 (August 2021): 2530–36. http://dx.doi.org/10.1161/strokeaha.120.033775.
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Background and Purpose: Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale is a helpful tool to triage patients with stroke in the field. However, data on its reliability in the prehospital setting are lacking. We aim to test the reliability of FAST-ED scale when used by paramedics in a mobile stroke unit covering a metropolitan area. Methods: As part of standard operating mobile stroke unit procedures, paramedics initially evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic upon patient contact (in-person) and then independently by a vascular neurologist (VN) immediately after paramedic evaluation (remotely/telemedicine). This allowed testing of the interrater agreement of the FAST-ED scoring performance between on-site prehospital providers and remotely located VN. Results: Of a total of 238 patients transported in the first 15 months of the mobile stroke unit’s activity, 173 were included in this study. Median age was 63 (interquartile range, 55.5–75) years and 52.6% were females. A final diagnosis of ischemic stroke was made in 71 (41%), transient ischemic attack in 26 (15%), intracranial hemorrhage in 15 (9%), whereas 61 (35%) patients were stroke mimics. The FAST-ED scores matched perfectly among paramedics and VN in 97 (56%) instances, while there was 0 to 1-point difference in 158 (91.3%), 0 to 2-point difference in 171 (98.8%), and 3 or more point difference in 2 (1.1%) patients. The intraclass correlation between VN and paramedic FAST-ED scores showed excellent reliability, intraclass correlation coefficient 0.94 (95% CI, 0.92–0.96; P <0.001). When VN recorded FAST-ED score ≥3, paramedics also scored FAST-ED≥3 in majority of instances (63/71 patients; 87.5%). A large vessel occlusion was identified in 16 (9.2%) patients; 13 occlusions were identified with a FAST-ED≥3 while 3 were missed. All of the latter patients had National Institutes of Health Stroke Scale score ≤5. Conclusions: We demonstrate excellent reliability of FAST-ED scale performed by paramedics when compared with VN, indicating that it can be accurately performed by paramedics in the prehospital setting.
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Deluhery, Matthew R., E. Brooke Lerner, Ronald G. Pirrallo, and Richard B. Schwartz. "Paramedic Accuracy Using SALT Triage After a Brief Initial Training." Prehospital Emergency Care 15, no. 4 (May 18, 2011): 526–32. http://dx.doi.org/10.3109/10903127.2011.569852.
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Simmons, Erik, Jerris R. Hedges, Lisa Irwin, and Wilhelmine Maassberg. "Information from Paramedic Injury Severity Assessment Can Aid Trauma Triage." Prehospital and Disaster Medicine 9, S2 (September 1994): S57. http://dx.doi.org/10.1017/s1049023x00050184.
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Husty, Todd, Marie Crandall, Alexander R. Logsdon, J. Bracken Burns, David J. Chesire, and David J. Ebler. "Comparative Analysis of State Trauma Triage Criteria vs. Paramedic Discretion." Prehospital Emergency Care 22, no. 5 (February 1, 2018): 551–54. http://dx.doi.org/10.1080/10903127.2018.1426664.
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Sung, Sil, Chan Young Kang, Hee Young Lee, Jung Hun Lee, Oh Hyun Kim, Hyun Youk, and Kang Hyun Lee. "Correlation between the pre-hospital triage scale and emergency department triage scale." Hong Kong Journal of Emergency Medicine 26, no. 5 (January 28, 2019): 281–87. http://dx.doi.org/10.1177/1024907918793780.
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Background:While emergency patient triage system is effective when the pre-hospital triage acuity scale is linked with the in-hospital triage acuity scale. However, the 119 emergency medical triage system and the Korea Triage and Acuity Scale are not linked in Korea.Objective:This study aimed to investigate the correlation between the two triage systems and to utilize the results as basic data for the future development of a pre-hospital triage system.Methods:Among the 1114 patients who visited a regional emergency medical center by a 119 ambulance from April to May 2016, we analyzed the correlation between the pre-hospital and in-hospital triage systems based on the general characteristics of the patients and their reason of hospital visit (non-trauma or trauma).Results:Upon reclassifying the pre-hospital and in-hospital triage systems into three levels, among the 289 patients (28.1%) in level 3 of the pre-hospital triage, 79 (27.3%) were reclassified as the highest level (Resuscitation) in the in-hospital triage. The kappa coefficient as a measure of agreement between the two triage systems was very low at 0.211 (95% confidence interval, 0.164–0.258), and the kappa coefficient of the paramedic category was 0.232 (95% confidence interval, 0.161–0.303).Conclusion:There is a low agreement between the pre-hospital and in-hospital triage systems.
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Waterman, Bradley, Kristine Van Aarsen, Michael Lewell, Homer Tien, Frank Myslik, Michael Peddle, and Sean Doran. "Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model." CJEM 22, S2 (September 2020): S62—S66. http://dx.doi.org/10.1017/cem.2019.495.
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AbstractBackgroundThe Focused Assessment with Sonography in Trauma (FAST) exam is a rapid ultrasound test to identify evidence of hemorrhage within the abdomen. Few studies examine the accuracy of paramedic performed FAST examinations. The duration of an ultrasound training program remains controversial. This study's purpose was to assess the accuracy of paramedic FAST exam interpretation following a one hour didactic training session.MethodsThe interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model containing 300ml of free fluid following a one hour didactic training course. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05.ResultsFourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were mostly ultrasound-naive whereas the emergency physicians all had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups with accuracy of 85.6% and 87.5% (∆1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively.ConclusionsThis study determined that critical care paramedics were able to use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of prehospital ultrasound to aid in the triage and transport decisions of trauma patients while limiting the financial and logistical burden of ultrasound training.
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Leduc, S., G. Wells, V. Thiruganasambandamoorthy, Z. Cantor, P. Kelly, M. Rietschlin, and C. Vaillancourt. "LO20: The characteristics, clinical course and disposition of long-term care patients treated by paramedics during an emergency call: Exploring the potential impact of community paramedicine." CJEM 22, S1 (May 2020): S14. http://dx.doi.org/10.1017/cem.2020.76.
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Introduction: An increasing number of Canadian paramedic services are creating Community Paramedic programs targeting treatment of long-term care (LTC) patients on-site. We explored the characteristics, clinical course and disposition of LTC patients cared for by paramedics during an emergency call, and the possible impact of Community Paramedic programs. Methods: We completed a health records review of paramedic call reports and emergency department (ED) records between April 1, 2016 and March 31, 2017. We utilized paramedic dispatch data to identify emergency calls originating from LTC centers resulting in transport to one of the two EDs of the Ottawa Hospital. We excluded patients with absent vital signs, a Canadian Triage and Acuity Scale (CTAS) score of 1, and whose transfer to hospital were deferrable or scheduled. We stratified remaining cases by month and selected cases using a random number generator to meet our apriori sample size. We collected data using a piloted standardized form. We used descriptive statistics and categorized patients into groups based on the ED care received and if the treatment received fit into current paramedic medical directives. Results: Characteristics of the 381 included patients were mean age 82.5 years, 58.5% female, 59.7% hypertension, 52.6% dementia and 52.1% cardiovascular disease. On arrival at hospital, 57.7% of patients waited in offload delay for a median time of 45 minutes (IQR 33.5-78.0). We could identify 4 groups: 1) Patients requiring no treatment or diagnostics in the ED (7.9%); 2) Patients receiving ED treatment within current paramedic medical directives and no diagnostics (3.2%); 3) Patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and 4) patients requiring admission (34.1%). Most patients were discharged from the ED (65.6%), and 1.1% died. The main ED diagnoses were infection (18.6%) and musculoskeletal injury (17.9%). Of the patients that required ED care but were discharged, 64.1% required x-rays, 42.1% CT, and 3.4% ultrasound. ED care included intravenous fluids (35.7%), medication (67.5%), antibiotics (29.4%), non-opioid analgesics (29.4%) and opioids (20.7%). Overall, 11.1% of patients didn't need management beyond current paramedic capabilities. Conclusion: Many LTC patients could receive care by paramedics on-site within current medical directives and avoid a transfer to the ED. This group could potentially grow using Community Paramedics with an expanded scope of practice.
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Dickinson, Edward T., Jonathan F. Politis, and Francis X. Beaudet. "Triage Accuracy of Priority Dispatching in an All-Paramedic EMS System." Prehospital and Disaster Medicine 9, S2 (September 1994): S70. http://dx.doi.org/10.1017/s1049023x00050445.
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West, Brian, J. Andrew Cusser, Stuart Etengoff, Hank Landsgaard, and Virginia LaBond. "The Use of FAST Scan by Paramedics in Mass-casualty Incidents: A Simulation Study." Prehospital and Disaster Medicine 29, no. 6 (November 13, 2014): 576–79. http://dx.doi.org/10.1017/s1049023x14001204.
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AbstractIntroductionThe Focused Abdominal Sonography in Trauma (FAST) scan is used to detect free fluid in the peritoneal cavity, or pericardium, to quickly assess for injuries needing immediate surgical intervention. Mass-casualty incidents (MCIs) are settings where paramedics must make triage decisions in minutes. The Simple Triage and Rapid Transport (START) system is used to prioritize transport. The FAST scan can be added to the triage of critical patients, and may aid in triage.MethodsThis was a single-blinded, randomized control trial. Ten paramedics with field experience were trained with an ultrasound machine in the performance of the FAST scan. Two weeks were allowed to pass before testing to simulate the time between training of standard procedures and their implementation. On test day, five peritoneal dialysis patients with instilled dialysis fluid and five matched control patients were placed in a room in a random order where the paramedics performed FAST scans on each patient. The paramedics were assessed by declaring positive or negative for each evaluation, as well as being timed for the total exercise.ResultsOf the ninety tests (one paramedic dropped out due to family emergency), the paramedics had a mean accuracy of 60% and median of 62% (range 40%-80%). There was a statistically significant higher false-positive rate of 59% than false-negative rate of 41% (P < .01). Sensitivity was 67% with a specificity of 56%. Average time taken was 1,218 seconds (121.8 seconds per patient) with a range of 735-1,701 seconds and a median of 1,108 seconds.ConclusionIn this simulation study, paramedics had difficulty performing FAST scans with a high degree of accuracy. However, they were more apt to call a patient positive, limiting the likelihood for false-negative triage.WestB, CusserJA, EtengoffS, LandsgaardH, LaBondV. The use of FAST scan by paramedics in mass-casualty incidents: a simulation study. Prehosp Disaster Med. 2014;29(6):1-4.
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Austin, M., J. Sinclair, S. Leduc, S. Duncan, J. Rouleau, P. Price, C. Evans, and C. Vaillancourt. "P136: What happens to bypassed trauma patients meeting Field Trauma Triage standards?" CJEM 22, S1 (May 2020): S113. http://dx.doi.org/10.1017/cem.2020.340.
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Introduction: Prehospital field trauma triage (FTT) standards were reviewed and revised in 2014 based on the recommendations of the Centers for Disease Control and Prevention. The FTT standard allows a hospital bypass and direct transport, within 30 min, to a lead trauma hospital (LTH). Our objectives were to assess the impact of the newly introduced prehospital FTT standard and to describe the emergency department (ED) management and outcomes of patients that had bypassed closer hospitals. Methods: We conducted a 12-month multi-centred health record review of paramedic and ED records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness (physiologic), step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as urgent that met FTT standard, regardless of transport time. We developed and piloted a data collection tool and obtained consensus on all definitions. The primary outcome was the rate of appropriate triage to a LTH which was defined as: ISS ≥12, admitted to intensive care unit (ICU), non-orthopedic surgery, or death. We have reported descriptive statistics. Results: 570 patients were included: mean age 48.8, male 68.9%, falls 29.6%, motor vehicle collisions 20.2%, stab wounds 10.5%, transported to a LTH 76.5% (n = 436). 72.2% (n = 315) of patients transported to a LTH had bypassed a closer hospital and 126/306 (41.2%) of those were determined to be an appropriate triage to LTH (9 patients had missing outcomes). ED management included: CT head/cervical spine 69.9%, ultrasound 53.6%, xray 51.6%, intubation 15.0%, sedation 11.1%, tranexamic acid 9.8%, blood transfusion 8.2%, fracture reduction 6.9%, tube thoracostomy 5.9%. Outcomes included: ISS ≥ 12 32.7%, admitted to ICU 15.0%, non-orthopedic surgery 11.1%, death 8.8%. Others included: admission to hospital 57.5%, mean LOS 12.8 days, orthopedic surgery 16.3% and discharged from ED 37.3%. Conclusion: Despite a high number of admissions, the majority of trauma patients bypassed to a LTH were considered over-triaged, with a low number of ED procedures and non-orthopedic surgeries. Continued work is needed to appropriately identify patients requiring transport to a LTH.
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Kaplan, Lewis J., Mark D. Siegel, Alexander L. Eastman, Lisa M. Flynn, Stanley H. Rosenbaum, David C. Cone, David P. Blake, and Jonathan Mulhern. "Ethical Considerations in Embedding a Surgeon in a Military or Civilian Tactical Team." Prehospital and Disaster Medicine 27, no. 6 (August 21, 2012): 583–88. http://dx.doi.org/10.1017/s1049023x12001112.
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AbstractTactical emergency medical services (TEMS) bring immediate medical support to the inner perimeter of special weapons and tactics team activations. While initially envisioned as a role for an individual dually trained as a police officer and paramedic, TEMS is increasingly undertaken by physicians and paramedics who are not police officers. This report explores the ethical underpinnings of embedding a surgeon within a military or civilian tactical team with regard to identity, ethically acceptable actions, triage, responsibility set, training, certification, and potential future refinements of the role of the tactical police surgeon.KaplanLJ, SiegelMD, EastmanAL, FlynnLM, RosenbaumSH, ConeDC, BlakeDP, MulhernJ. Ethical considerations in embedding a surgeon in a military or civilian tactical team. Prehosp Disaster Med. 2012;27(6):1-6.
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Strukel, W. Eric, and James V. Dunford. "55. Analysis of Calls Under-triaged by Priority Medical Dispatch in San Diego." Prehospital and Disaster Medicine 11, S2 (September 1996): S33. http://dx.doi.org/10.1017/s1049023x00045714.
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Purpose: To identify calls “under-triaged” by priority medical dispatch and determine causes and pre-hospital outcomes.Methods: 6 month retrospective analysis identified calls dispatched “low priority” to which medics assigned “high acuity” transports (acute status or requiring ALS meds; not just IV/O2/monitor). CAD data, paramedic run-sheets, and audiotapes were reviewed to determine optimal dispatch levels and transport codes. “Under-triage” was defined as calls warranting “high priority” dispatch based on evidence from the run-sheet. Dispatcher, calling party, and patient data influencing “undertriage” were assessed.Results: In 1995, 11,178/70,887 (16%) medical aid requests were dispatched “low priority”. 201(1.8%) were subsequently assigned “high acuity” transport codes by paramedics. 105/5,737 such consecutive patients were analyzed from July-December 1995. 6 were excluded due to incomplete data. After review, 42/99 actually warranted “high priority” dispatch. 7 had potential life/limb threatening injuries; 35 required ALS intervention. None had adverse prehospital outcome. Undertriage was associated with dispatcher error, information relayed from law enforcement officers (OR =3.4, CI: 1.2-10) calls involving alcohol (OR = 2.8, CI: 0.9-9.2) or patients with ALOC(OR= 3.4, CI: 1.2-10).
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Zhao, Henry, Lauren Pesavento, Skye Coote, Leonid Churilov, Karen Smith, Stephen Bernard, Nawaf Yassi, Stephen M. Davis, and Bruce CV Campbell. "Paramedic validation of an australian large vessel occlusion triage algorithm for stroke." Journal of Neurology, Neurosurgery & Psychiatry 88, no. 5 (May 2017): e1.26-e1. http://dx.doi.org/10.1136/jnnp-2017-316074.3.
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Waterman, B., K. VanAarsen, M. Lewell, H. Tien, F. Myslik, M. Peddle, and S. Doran. "MP12: Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model." CJEM 22, S1 (May 2020): S46—S47. http://dx.doi.org/10.1017/cem.2020.160.
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Introduction: The FAST exam – Focused Assessment with Sonography in Trauma - is a rapid test using ultrasound to identify sonographic evidence of hemorrhage within the abdomen. In the prehospital setting, the information from a FAST examination can help triage patients, direct patients to the most appropriate facilities, assist with management strategies and potentially expedite time to definitive intervention. Few studies examine the accuracy of paramedic-only-performed FAST examinations. However, despite the potential benefits to the Canadian prehospital system, a potential barrier to implementation is the tremendous financial and operational burden if paramedics require prolonged ultrasound training courses. In this study, we conducted a double-blinded observational study comparing the accuracy of paramedic-performed FAST versus physician-performed tests on a sonographic Phantom, after a one-hour didactic training session. Methods: The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model. The mannequin utilized in this study was a realistic model of a human torso where fluid could be injected into the abdomen to create a realistic ultrasound image of abdominal free fluid. Participants were required to scan the mannequin twice, once with 300 mL of fluid instilled and once with the abdomen free of fluid. Participants were blinded to the status of hemoperitoneum. The primary outcome of the study was accuracy rate of FAST examination by paramedics compared to emergency room physicians. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. Total scan time was reported using means, standard deviations and 95% CIs and was compared between groups using standard t-test. Results: Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were ultrasound-naive whereas the emergency physicians had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups 85.6% and 87.5% (Δ1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. Total scan time differed between groups but did not reach statistical significance. Paramedics took longer to complete the FAST examination with a mean (SD) time to complete the two scans of 10.35 (3.43) minutes compared to 7.34 (2.74) minutes for physicians, (Δ3.01 minutes 95%CI -0.97 to 7.00, p = 0.13). Conclusion: This study determined that critical care paramedics were able use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of ultrasound in prehospital programs to determine the most appropriate transport destination and aid in the triage of trauma patients while limiting the financial and logistical burden of ultrasound training.
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Farrell, C., S. Teed, N. Costain, M. A. Austin, A. Willmore, A. Reed, J. Maloney, and R. Dionne. "P055: EMS boot camp: a real-world, real-time educational experience for emergency medicine residents." CJEM 19, S1 (May 2017): S96—S97. http://dx.doi.org/10.1017/cem.2017.257.
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Introduction/Innovation Concept: In 2014, Eastern Ontario paramedic services, their medical director staff and area community colleges developed an EMS Boot Camp experience to orient Queen’s University and the University of Ottawa emergency medicine residents to the role of paramedics and the challenges they face in the field. Current EMS ride-alongs and didactic classroom sessions were deemed ineffective at adequately preparing residents to provide online medical control. From those early discussions came the creation of a real-world, real-time (RWRT) educational experience. Methods: Specific challenges unique to paramedicine are difficult to communicate to a medical control physician at the other end of a telephone. The goal of this one-day educational experience is for residents to gain insight into the complexity and time sensitive nature of delivering medical care in the field. Residents are immersed as responding paramedics in a day of intense RWRT simulation exercises reflecting the common paramedic logistical challenges to delivering patient care in an uncontrolled and dynamic environment. Curriculum, Tool, or Material: Scenarios, run by paramedic students, are overseen by working paramedics from participating paramedic services. Residents learn proper use of key equipment found on an Ontario ambulance while familiarize themselves with patient care standards and medical directives. Scenarios focus on prehospital-specific clinical care issues; performing dynamic CPR in a moving vehicle, extricating a bariatric patient with limited personnel, large scale multi-casualty triage as well as other time sensitive, high risk procedures requiring online medical control approval (i.e. chest needle thoracostomy). Conclusion: EMS Boot Camp dispels preconceived biases regarding “what it’s really like” to deliver high quality prehospital clinical care. When providing online medical control in the future, the residents will be primed to understand and expect certain challenges that may arise. The educational experience fosters collaboration between prehospital and hospital-based providers. The sessions provide a reproducible, standardized experience for all participants; something that cannot be guaranteed with traditional EMS ride-alongs. Future sessions will evaluate participant satisfaction and self-efficacy with the use of a standard evaluation form including pre/post self-evaluations.
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Jain, Trevor, Aaron Sibley, Henrik Stryhn, and Ives Hubloue. "Comparison of Unmanned Aerial Vehicle Technology-Assisted Triage versus Standard Practice in Triaging Casualties by Paramedic Students in a Mass-Casualty Incident Scenario." Prehospital and Disaster Medicine 33, no. 4 (July 13, 2018): 375–80. http://dx.doi.org/10.1017/s1049023x18000559.
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AbstractIntroductionThe proliferation of unmanned aerial vehicle (UAV) technology has the potential to change the way medical incident commanders (ICs) respond to mass-casualty incidents (MCIs) in triaging victims. The aim of this study was to compare UAV technology to standard practice (SP) in triaging casualties at an MCI.MethodsA randomized comparison study was conducted with 40 paramedic students from the Holland College Paramedicine Program (Charlottetown, Prince Edward Island, Canada). Using a simulated motor vehicle collision (MVC) with moulaged casualties, iterations of 20 students were used for both a day and a night trial. Students were randomized to a UAV or a SP group. After a brief narrative, participants either entered the study environment or used UAV technology where total time to triage completion, GREEN casualty evacuation, time on scene, triage order, and accuracy were recorded.ResultsA statistical difference in the time to completion of 3.63 minutes (95% CI, 2.45 min-4.85 min; P=.002) during the day iteration and a difference of 3.49 minutes (95% CI, 2.08 min-6.06 min; P=.002) for the night trial with UAV groups was noted. There was no difference found in time to GREEN casualty evacuation, time on scene, or triage order. One-hundred-percent accuracy was noted between both groups.Conclusion:This study demonstrated the feasibility of using a UAV at an MCI. A non-clinical significant difference was noted in total time to completion between both groups. There was no increase in time on scene by using the UAV while demonstrating the feasibility of remotely triaging GREEN casualties prior to first responder arrival.Jain T, Sibley A, Stryhn H, Hubloue I.Comparison of unmanned aerial vehicle technologyassisted triage versus standard practice in triaging casualties by paramedic students in a mass-casualty incident scenario. Prehosp Disaster Med. 2018;33(4):375–380
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Jain, Trevor Nirmal, Luca Ragazzoni, Henrik Stryhn, Samuel J. Stratton, and Francesco Della Corte. "Comparison of the Sacco Triage Method Versus START Triage Using a Virtual Reality Scenario in Advance Care Paramedic Students." CJEM 18, no. 4 (November 10, 2015): 288–92. http://dx.doi.org/10.1017/cem.2015.102.
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Durham, Mark. "Paramedic accuracy and confidence with a trauma triage algorithm: a cross-sectional survey." British Paramedic Journal 1, no. 4 (March 1, 2017): 1–7. http://dx.doi.org/10.29045/14784726.2017.1.4.1.
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Cicero, Mark X., Travis Whitfill, Barbara Walsh, Maria Carmen G. Diaz, Grace M. Arteaga, Daniel J. Scherzer, Scott A. Goldberg, et al. "Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations." Prehospital Emergency Care 23, no. 1 (August 21, 2018): 83–89. http://dx.doi.org/10.1080/10903127.2018.1475530.
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Quirion, Andrew, Mahvareh Ahghari, and Brodie Nolan. "Factors associated with non-optimal resource utilization of air ambulance for interfacility transfer of injured patients." CJEM 22, S2 (September 2020): S45—S54. http://dx.doi.org/10.1017/cem.2019.475.
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ABSTRACTObjectiveTimely access to definitive care is associated with improved outcomes in trauma patients. The goal of this study is to identify patient, institutional and paramedic risk factors for non-optimal resource utilization for interfacility transfers of injured adult patients transported by air ambulance to a LTC.MethodsThis is a retrospective cohort study of adult emergent interfacility transports via Ornge with data collected on patient demographics, clinical status, sending facilities, transport details and paramedic qualifications. A logistic regression model was used to analyze data.Results1777 injured patients undergoing transport with Ornge were analyzed with 805 of these undergoing non-optimal transport. Patients who had an optimal resource use were found to be older and mechanically ventilated. Risk factors increasing odds of non-optimal transport included patients transported from a nursing station (OR 1.94), transport with primary or advanced care paramedics (OR 6.57 and 1.44, respectively) and transport between both 0800-1700 and 1700-0000 (OR 1.40 and 1.54, respectively). The median delay to arrival to receiving facility if a patient had a non-optimal resource use was 40 minutes.ConclusionsThree main risk factors were identified in this study. We believe that nursing stations as a sending facility and type of paramedics crew transporting patients resulted in non-optimal resource utilization primarily due to triage of lower acuity patients. However the timing of day is more likely to be a resource availability issue and something that can be further studied and potentially improved moving forward.
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Myers, Lucas A., Christopher S. Russi, and Jeffery L. Schultz. "Paramedic Intercepts with Basic Life Support Ambulance Services in Rural Minnesota." Prehospital and Disaster Medicine 25, no. 2 (April 2010): 159–63. http://dx.doi.org/10.1017/s1049023x00007901.
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AbstractIntroduction:In rural Minnesota, it is common for paramedics providing advanced life support (ALS) to rendezvous with ambulances providing only basic life support (BLS). These “intercepts” presumably allow for a higher level of care when patients have certain problems or need ALS interventions. The aim of this study was to review and understand the frequency of para-medic intercepts with regard to the actual care rendered and transport urgency (lights and sirens vs. none).Methods:All paramedic intercepts occurring between January 2003 and December 2007 for one multi-site emergency medical services (EMS) provider were reviewed for ALS interventions and treatments provided. In addition, the urgency of responses to the dispatch call or “intercept” and transport to a receiving facility were analyzed.Results:During the study period, 1,675 paramedic intercepts occurred and were reviewed. The ALS ambulances responded to the dispatch emergently (lights and sirens) in 97.5% of intercepts (1,633), but emergently transported only 24.2% of the patients (405). Paramedics performed no interventions above BLS levels in 11.6% (194) of the cases. Of the remaining 1,481 patients who received ALS interventions, 955 (64.4%) received no treatment or diagnostic testing other than electrocardiographic monitoring, intravenous access, or both.Conclusions:A significant discrepancy between emergent responses and actual ALS care rendered during intercept calls was demonstrated. Given the significant rate of EMS worker fatalities and transferable patient care costs, further study is needed to determine whether costs and safety are potentially improved by decreasing emergent responses. Future directions include developing or emulating Medical Priority Dispatch System triage protocols for advanced services providing intercepts. In addition, further study of patient outcomes between intercept and non-intercept cases is necessary.
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Bright, Howie, and Jeff Pocock. "Prehospital recognition of acute myocardial infarction." CJEM 4, no. 03 (May 2002): 212–14. http://dx.doi.org/10.1017/s1481803500006424.
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ABSTRACT Introduction: Paramedics often provide advance notice of patients with suspected acute myocardial infarction (AMI) so that emergency department (ED) staff can prepare for early aggressive management and expeditious thrombolysis, but the validity of this practice is unclear. Our objective was to determine the accuracy of prehospital AMI diagnosis by Paramedic Level III (ALS) attendants. Methods: ALS paramedics serving a busy community hospital were instructed regarding the clinical diagnosis of chest pain and the value of early thrombolysis. For all patients transported with a chief complaint of chest pain, they were asked to record an explicit diagnosis of “probable AMI” or “chest pain, other.” Prehospital diagnoses were subsequently compared to ED diagnoses. Sensitivity, specificity and predictive values of the prehospital diagnosis for AMI were determined. Results: During the 5-year study period, 1305 patients were studied. Based on clinical features alone, ALS paramedics were 77.8% sensitive and 82.2% specific for the diagnosis of AMI. Conclusion: ALS paramedics can accurately identify patients likely to benefit from early aggressive AMI management. These data have implications with respect to prehospital triage of chest pain patients, “early notification” protocols and future prehospital thrombolytic strategies.
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de Koning, Enrico, Tom E. Biersteker, Saskia Beeres, Jan Bosch, Barbra E. Backus, Charles JHJ Kirchhof, Reza Alizadeh Dehnavi, Helen AM Silvius, Martin Schalij, and Mark J. Boogers. "Prehospital triage of patients with acute cardiac complaints: study protocol of HART-c, a multicentre prospective study." BMJ Open 11, no. 2 (February 2021): e041553. http://dx.doi.org/10.1136/bmjopen-2020-041553.
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IntroductionEmergency department (ED) overcrowding is a major healthcare problem associated with worse patient outcomes and increased costs. Attempts to reduce ED overcrowding of patients with cardiac complaints have so far focused on in-hospital triage and rapid risk stratification of patients with chest pain at the ED. The Hollands-Midden Acute Regional Triage—Cardiology (HART-c) study aimed to assess the amount of patients left at home in usual ambulance care as compared with the new prehospital triage method. This method combines paramedic assessment and expert cardiologist consultation using live monitoring, hospital data and real-time admission capacity.Methods and analysisPatients visited by the emergency medical services (EMS) for cardiac complaints are included. EMS consultation consists of medical history, physical examination and vital signs, and ECG measurements. All data are transferred to a newly developed platform for the triage cardiologist. Prehospital data, in-hospital medical records and real-time admission capacity are evaluated. Then a shared decision is made whether admission is necessary and, if so, which hospital is most appropriate. To evaluate safety, all patients left at home and their general practitioners (GPs) are contacted for 30-day adverse events.Ethics and disseminationThe study is approved by the LUMC’s Medical Ethics Committee. Patients are asked for consent for contacting their GPs. The main results of this trial will be disseminated in one paper.DiscussionThe HART-c study evaluates the efficacy and feasibility of a prehospital triage method that combines prehospital patient assessment and direct consultation of a cardiologist who has access to live-monitored data, hospital data and real-time hospital admission capacity. We expect this triage method to substantially reduce unnecessary ED visits.
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Zhao, Henry, Karen Smith, Stephen Bernard, Michael Stephenson, Henry Ma, Ronil V. Chandra, Thanh Phan, et al. "Utility of Severity-Based Prehospital Triage for Endovascular Thrombectomy." Stroke 52, no. 1 (January 2021): 70–79. http://dx.doi.org/10.1161/strokeaha.120.031467.
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Background and Purpose: Severity-based assessment tools may assist in prehospital triage of patients to comprehensive stroke centers (CSCs) for endovascular thrombectomy (EVT), but criticisms regarding diagnostic inaccuracy have not been adequately addressed. This study aimed to quantify the benefits and disadvantages of severity-based triage in a large real-world paramedic validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) algorithm. Methods: Ambulance Victoria paramedics assessed the prehospital ACT-FAST algorithm in patients with suspected stroke from November 2017 to July 2019 following an 8-minute training video. All patients were transported to the nearest stroke center as per current guidelines. ACT-FAST diagnostic accuracy was compared with hospital imaging for the presence of large vessel occlusion (LVO) and need for CSC-level care (LVO, intracranial hemorrhage, and tumor). Patient-level time saving to EVT was modeled using a validated Google Maps algorithm. Disadvantages of CSC bypass examined potential thrombolysis delays in non-LVO infarcts, proportion of patients with false-negative EVT, and CSC overburdening. Results: Of 517 prehospital assessments, 168/517 (32.5%) were ACT-FAST positive and 132/517 (25.5%) had LVO. ACT-FAST sensitivity and specificity for LVO was 75.8% and 81.8%, respectively. Positive predictive value was 58.8% for LVO and 80.0% when intracranial hemorrhage and tumor (CSC-level care) were included. Within the metropolitan region, 29/55 (52.7%) of ACT-FAST-positive patients requiring EVT underwent a secondary interhospital transfer. Prehospital bypass with avoidance of secondary transfers was modeled to save 52 minutes (95% CI, 40.0–61.5) to EVT commencement. ACT-FAST was false-positive in 8 patients receiving thrombolysis (8.1% of 99 non-LVO infarcts) and false-negative in 4 patients with EVT requiring secondary transfer (5.4% of 74 EVT cases). CSC bypass was estimated to over-triage 1.1 patients-per-CSC-per-week in our region. Conclusions: The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.
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Lee, Christopher W. C., Shelley L. McLeod, and Michael B. Peddle. "First Responder Accuracy Using SALT after Brief Initial Training." Prehospital and Disaster Medicine 30, no. 5 (September 1, 2015): 447–51. http://dx.doi.org/10.1017/s1049023x15004975.
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AbstractBackgroundMass-casualty incidents (MCIs) present a unique challenge with regards to triage as patient volume often outweighs the number of available Emergency Medical Services (EMS) providers. A possible strategy to optimize existing triage systems includes the use of other first responder groups, namely fire and police, to decrease the triage time during MCIs, allowing for more rapid initiation of life-saving treatment and prioritization of patient transport.HypothesisFirst-year primary care paramedic (PCP), fire, and police trainees can apply with similar accuracy an internationally recognized MCI triage tool, Sort, Assess, Life-saving interventions, Treatment/transport (SALT), immediately following a brief training session, and again three months later.MethodsAll students enrolled in the PCP, fire, and police foundation programs at two community colleges were invited to participate in a 30-minute didactic session on SALT. Immediately following this session, a 17-item, paper-based test was administered to assess the students’ ability to understand and apply SALT. Three months later, the same test was given to assess knowledge retention.ResultsOf the 464 trainees who completed the initial test, 364 (78.4%) completed the three month follow-up test. Initial test scores were higher (P<.05) for PCPs (87.0%) compared to fire (80.2%) and police (68.0%) trainees. The mean test score for all respondents was higher following the initial didactic session compared to the three month follow-up test (75% vs 64.7%; Δ 10.3%; 95% CI, 8.0%-12.6%). Three month test scores for PCPs (75.4%) were similar to fire (71.4%) students (Δ 4.0%; 95% CI, −2.1% to 10.1%). Both PCP and fire trainees significantly outperformed police (57.8%) trainees. Over-triage errors were the most common, followed by under-triage and then critical errors, for both the initial and follow-up tests.ConclusionsAmongst first responder trainees, PCPs were able to apply the SALT triage tool with the most accuracy, followed by fire, then police. Over-triage was the most frequent error, while critical errors were rare.LeeCWC, McLeodSL, PeddleMB. First responder accuracy using SALT after brief initial training. Prehosp Disaster Med. 2015;30(5):447–451.
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Fries, Gerald R., Gary McCalla, M. Andrew Levitt, and Ron Cordova. "A prospective comparison of paramedic judgment and the trauma triage rule in the prehospital setting." Annals of Emergency Medicine 24, no. 5 (November 1994): 885–89. http://dx.doi.org/10.1016/s0196-0644(94)70207-1.
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Jain, T., A. Sibley, H. Stryhn, and I. Hubloue. "P074: Comparison of unmanned aerial vehicle technology versus standard practice in triaging casualties by paramedic students in a mass casualty incident scenario." CJEM 20, S1 (May 2018): S83. http://dx.doi.org/10.1017/cem.2018.272.
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Introduction: The proliferation of unmanned aerial vehicle (UAV) technology has the potential to change the way medical incident commanders respond to mass casualty incidents (MCI) in triaging victims. The aim of this study was to compare UAV technology to standard practice (SP) in triaging casualties at a MCI Methods: A randomized comparison study was conducted with forty paramedic students from the Holland College Paramedicine Program. Using a simulated motor vehicle collision with moulaged casualties, iterations of twenty students were used for both a day and a night trial. Students were randomized to an UAV or a SP group. After a brief narrative participants either entered the study environment or used UAV technology where total time to triage completion, green casualty evacuation, time on scene, triage order and accuracy was recorded Results: A statistical difference in the time to completing of 3.63 minutes (95% CI: 2.45, 4.85, p=0.002) during the day iteration and a difference of 3.49 minutes (95% CI: 2.08,6.06, p=0.002) for the night trial with UAV groups was noted. There was no difference found in time to green casualty evacuation, time on scene or triage order. One hundred percent accuracy was noted between both groups. Conclusion: This study demonstrated the feasibility of using an UAV at a MCI. A non clinical significant difference was noted in total time to completion between both groups. There was no increase in time on scene by using the UAV while demonstrating the feasibility of remotely triaging green casualties prior to first responder arrival.
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Vaillancourt, Christian, Manya Charette, Monica Taljaard, Kednapa Thavorn, Elizabeth Hall, Brent McLeod, Dean Fergusson, et al. "Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial." JMIR Research Protocols 9, no. 6 (June 1, 2020): e16966. http://dx.doi.org/10.2196/16966.
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Background Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. Objective This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. Methods We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. Results Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. Conclusions We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). Trial Registration ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. International Registered Report Identifier (IRRID) DERR1-10.2196/16966
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Quirion, A., and B. Nolan. "P103: Factors associated with non-optimal resource utilization of air ambulance for interfacility transfer of injured patients." CJEM 21, S1 (May 2019): S101. http://dx.doi.org/10.1017/cem.2019.294.
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Introduction: Timely access to definitive care has been associated with improved outcomes for injured patients. Air ambulance services have become an integral part of Canadian trauma systems to help provide earlier access to a lead trauma centre (LTC). Multiple factors can lead to non-optimal resource utilization resulting in potential transport delays. The goal of this study is to identify patient, institutional and paramedic risk factors for non-optimal resource utilization for interfacility transfers of injured adult patients transported by air ambulance to a LTC. Methods: Ornge is a paramedic-staffed organization that is the sole provider of air ambulance services from a non-trauma centre to a LTC for the province of Ontario, Canada. This is a retrospective cohort study of all Ornge adult emergent interfacility transports over a 5-year period. Data was collected on patient demographics and clinical status, sending facilities, transport details and paramedic qualifications. Optimal resource utilization was determined based on distance and historical times. A logistic regression model was used to explore patient, provider and institutional risk factors for non-optimal resource use. Results: Between January 1, 2013 and December 31, 2017 a total of 1777 injured patients underwent interfacility transport with Ornge. Of these 805 were identified as having non-optimal resource utilization. Patients who had an optimal resource use were found to be older and mechanically ventilated. Risk factors increasing odds of non-optimal transport included patients transported from a nursing station (OR 1.94), transport with primary or advanced care paramedics (OR 6.57 and 1.44, respectively) and transport between both 0800-1700 and 1700-0000 (OR 1.40 and 1.54, respectively). The median delay to arrival to receiving facility if a patient had a non-optimal resource use was 40 minutes Conclusion: We were able to identify several factors resulting in non-optimal resource utilization. We believe that nursing stations as a sending facility and type of paramedics crew transporting patients resulted in non-optimal resource utilization mainly due to these patients being of lower acuity and this affecting their triage. However the timing of day is more likely to be a resource availability issue and something that can be further studied and potentially improved.
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Heaney, Katy, Kerry Whiting, Lynda Petley, Ian Fry, and Andy Newton. "Point-of-care testing by paramedics using a portable laboratory: an evaluation." Journal of Paramedic Practice 12, no. 3 (March 2, 2020): 100–108. http://dx.doi.org/10.12968/jpar.2020.12.3.100.
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Use of point-of-care testing (POCT) equipment by paramedics for triage may reduce unnecessary attendance in emergency departments and inconvenience to patients. A hospital pathology service and an ambulance trust wanted a system for safe and effective use of diagnostic devices by paramedics at the patient bedside. A suite of POCT devices to perform an expanded repertoire of pathology tests was provided, along with technology for electronic data capture, temperature control and monitoring, in a specially designed kit bag—the Labkit. Following a proof-of-concept phase, three Labkit bags were deployed as a pilot in rapid response vehicles and used by specialist paramedics in urgent and emergency care who had been trained in their use. The paramedics used the bag in 25% of patient interactions, typically three times every 24 hours. Having POCT results available at the time of paramedic assessment reduced conveyance to the emergency department by 21%. There was also a 10% rise in admission of patients where pathology results indicated problems that required urgent treatment which would otherwise have gone unnoticed. Overall, 31% of conveyance decisions were changed as a direct consequence of the Labkit results. Patients reported high levels of satisfaction, and paramedics said it added value in 97% of cases where it was used to support decision-making. Reliable, quality-assured POCT by paramedics has the potential to improve efficiency in the healthcare system and benefit patients.
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Cone, David C., John Serra, and Lisa Kurland. "Comparison of the SALT and Smart triage systems using a virtual reality simulator with paramedic students." European Journal of Emergency Medicine 18, no. 6 (December 2011): 314–21. http://dx.doi.org/10.1097/mej.0b013e328345d6fd.
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Reilly, Michael J. "Accuracy of a Priority Medical Dispatch System in Dispatching Cardiac Emergencies in a Suburban Community." Prehospital and Disaster Medicine 21, no. 2 (April 2006): 77–81. http://dx.doi.org/10.1017/s1049023x00003393.
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AbstractIntroduction:Over-triage of patients by emergency medical services (EMS) dispatch is thought to be an acceptable alternative to under-triage, which may delay how quickly life-saving care reaches a patient. Previous studies have looked at advanced life support (ALS) misutilization in urban- and county-based EMS systems and have attempted to analyze how dispatch methods either contribute to or alleviate this problem.1–5Objective:The purpose of this study is to assess the relationship between dispatches of a cardiac nature in a Medical Priority Dispatch (MPD) system, and the actual clinical diagnosis as determined by an emergency department physician.Methods:Calls for emergency medical assistance in a suburban community outside of a major metropolitan area were surveyed over a three-month period. Medical Priority Dispatch protocols determined that 104 of these calls were cardiac-related. Of these emergency calls, 56 (53.8%) patients were transported to the local community hospital and treated by the emergency physician. A retrospective review of the medical records was conducted to determine whether the patient had a cardiac-related discharge diagnosis from the emergency department.Results:Sixteen (28.6%) of the patients in this cohort were diagnosed with a cardiac-related condition upon discharge from the emergency department. Forty (71.4%) were diagnosed with a non-cardiac-related condition. The positive, predictive value of the dispatch protocol for the detection of an actual cardiac emergency in this EMS system was 28.6%.Conclusion:In this suburban community, the MPD system may over-triage emergency medical responses to cardiac emergencies. This can result in the only ALS (paramedic) unit in the community being unavailable in certain situations. Future studies should be conducted to determine what level (in any) of over-triage is appropriate in EMS systems using a MPD system.
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Bismah, V., J. Prpic, S. Michaud, N. Sykes, J. Amyotte, P. Myre, and R. Ohle. "MP04: rEDirect: safety and compliance of an emergency department diversion protocol for mental health and addictions patients." CJEM 21, S1 (May 2019): S43. http://dx.doi.org/10.1017/cem.2019.139.
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Introduction: Transportation of patients better served at an alternative destinations (diversion) is part of a proposed solution to emergency department (ED) overcrowding. We evaluated the pilot implementation of the “Mental Health and Addiction Triage and Transport Protocol”. This is the first Canadian diversion protocol that allows paramedics to transport intoxicated or mental health patients to an alternative facility, bypassing the ED. Our aim was to implement a safe diversion protocol to allow patients to access more appropriate service without transportation to the emergency department. Methods: A retrospective analysis was conducted on patients presenting to EMS with intoxication or psychiatric issues. Study outcomes were protocol compliance, determined through missed protocol opportunities, noncompliance, and protocol failure (presentation to ED within 48 hours of appropriate diversion); and protocol safety, determined through patient morbidity (hospital admission within 48 hours of diversion) and mortality. Data was abstracted from EMS reports, hospital records, and discharge forms from alternative facilities. Data was analyzed qualitatively and quantitatively. Results: From June 1st, 2015 to May 31st, 2016 Greater Sudbury Paramedic Services responded to 1376 calls for mental health or intoxicated patients. 241 (17.5%) met diversion criteria, 158 (12.9%) patients were diverted and 83 (4.6%) met diversion criteria but were transported to the ED. Of the diverted patients 9 (5.6%) represented to the ED <48rs later and were admitted. Of the 158 diversions, 113 (72%) were transported to Withdrawal Management Services (WMS) and 45 (28%) were taken to Crisis Intervention (CI). There was protocol noncompliance in 77 cases, 69 (89.6%) were due to incomplete recording of vital signs; 6 (10.3%) were direct protocol violations of being transferred with vital sings outside the acceptable range. Conclusion: The Mental Health and Addiction Triage and Transport Protocol has the potential to safely divert 1 in 6 mental health or addiction patients to an alternative facility.