RESUMEN
INTRODUCTION: Quality cardiopulmonary resuscitation (CPR) and timely defibrillation are associated with increasing survival to hospital discharge from out-of-hospital cardiac arrest (OHCA). The objective of this study was to demonstrate that performance coaching during an OHCA would improve compression depth and time to defibrillation (TTD). METHODS: This study was conducted in a single emergency medical services (EMS) agency and utilized data collected from 815 patients treated between 1/1/2012 and 12/31/2013. The intervention used multiple Plan-Do-Study-Act (PDSA) cycles to train fire captains to translate performance data into active direction. Testing began in simulation with small-scale expansions prior to system-wide implementation. Performance metrics included average (reported as a percentage) and actual compression depth (reported in millimeters), and TTD (an average in seconds). Analysis was conducted using Xbar and S control charts with standard assessment of special cause for performance data. A statistical shift was seen in means and standard deviations for both depth metrics. RESULTS: Average depth of compressions improved from 69.8% (SD=28.0%) to 80.4 (SD=21.8%). Depth of compressions delivered increased from 43.6mm (SD=8.2mm) to 47.2mm (SD=8.1mm). Analysis of the S charts indicates a statistical shift in process variation for TTD. CONCLUSION: Early results indicate that utilization of a CPR coach during OHCA improves compression depth and TTD. Further data are needed to assess sustainability.
Asunto(s)
Cardioversión Eléctrica/métodos , Servicios Médicos de Urgencia , Masaje Cardíaco/métodos , Paro Cardíaco Extrahospitalario/terapia , Anciano , Reanimación Cardiopulmonar/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Presión , Reproducibilidad de los Resultados , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Our objective was to determine whether there is an association between a patient's impression of his or her overall quality of care and his or her satisfaction with the pain management provided. We hypothesized that satisfaction with pain management would show a significant positive association with a patient's impression of overall quality of care. METHODS: This was a retrospective review of patient satisfaction data initially collected by a third-party company from January 1, 2007, to September 1, 2010. Participants were randomly selected from all transported patients, proportional to their paramedic-defined acuity level, with a goal of 100 interviews per month. The proportions of patients sampled from each acuity level were 25% priority 1 (high), 50% priority 2 (medium), and 25% priority 3 (low). Patients were excluded if there was no telephone number recorded in the prehospital patient record, no transportation was recorded, or the call was labeled as a psychiatric complaint. All satisfaction questions used a five-point Likert scale with ratings from excellent to poor, which were dichotomized for analysis. The outcome variable was the patient's perception of his or her overall quality of care. The main independent variable was the patient's rating of his or her pain management by emergency medical services (EMS) staff at the scene. Demographic variables were assessed for potential confounding. RESULTS: There were 2,741 patients with complete data for the outcome and main independent variables; 41.7% of the respondents were male and the average age was 54.1 years (standard deviation = 22.6). The overall quality of care was rated as excellent by 65.9% of the patients, whereas 59.2% rated their pain management as excellent. Of the patients who rated their pain management as excellent, 79.0% rated the overall quality of care as excellent, whereas only 21.0% of the patients rated the overall quality of care as excellent if pain management was not excellent. When the patients rated EMS staff as excellent for both helping to control or reduce pain and explaining the medications given, they were 2.7 (95% confidence interval 1.4-5.4) times more likely to rate their overall quality of care as excellent. CONCLUSION: Our model indicated that pain management was associated with increased perception of overall quality of care only when EMS providers explained the medications provided and their potential side effects.
Asunto(s)
Servicios Médicos de Urgencia/normas , Manejo del Dolor/normas , Satisfacción del Paciente , Calidad de la Atención de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
OBJECTIVES: Inducing therapeutic hypothermia using chilled saline in resuscitated cardiac arrest patients has been shown to be feasible and effective. Limited research exists assessing the efficiency of this cooling method. The objective of this study was to assess the change in temperature of 4°C saline upon exiting an infusion set in the laboratory setting while varying conditions of fluid delivery. METHODS: Efficiency was studied by assessing change in fluid temperature (°C) during the infusion under four laboratory conditions. Each condition was performed four times using 1-L bags of normal saline. Fluid was infused into a 1000-mL beaker through 10 gtt/mL tubing. Flow rate was controlled using a tubing clamp and in-line transducer with a flow meter, while temperature was continuously monitored in a side port at the terminal end of the intravenous (IV) tubing using a digital thermometer. The four conditions included different insulation methods. Descriptive statistics and analysis of variance were performed to assess changes in fluid temperature. RESULTS: The mean (±SD) fluid temperature at time 0 was 3.2°C (95% confidence interval [CI] = 3.0 to 3.4 °C) with no significant difference in starting temperature between groups (p = 0.45). When flow rate was constant, it was determined that fluid temperatures were significantly cooler when infused using a chilled, gel-filled sleeve around the saline bag (p < 0.006). CONCLUSIONS: In a laboratory setting, the most efficient method of infusing cold fluid appears to be a method that both keeps the bag of fluid insulated and infused at a faster rate.
Asunto(s)
Hipotermia Inducida/instrumentación , Infusiones Intravenosas/instrumentación , Cloruro de Sodio/administración & dosificación , Temperatura , Diseño de Equipo , Paro Cardíaco/terapia , Humanos , Hipotermia Inducida/métodos , Soluciones Isotónicas/administración & dosificación , Sensibilidad y EspecificidadRESUMEN
STUDY OBJECTIVE: Intraosseous needle insertion during out-of-hospital cardiac arrest is rapidly replacing peripheral intravenous routes in the out-of-hospital setting. However, there are few data directly comparing the effectiveness of intraosseous needle insertions with peripheral intravenous insertions during out-of-hospital cardiac arrest. The objective of this study is to determine whether there is a difference in the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous insertions during out-of-hospital cardiac arrest. METHODS: This was a randomized trial of adult patients experiencing a nontraumatic out-of-hospital cardiac arrest in which resuscitation efforts were initiated. Patients were randomized to one of 3 routes of vascular access: tibial intraosseous, humeral intraosseous, or peripheral intravenous. Paramedics received intensive training and exposure to all 3 methods before study initiation. The primary outcome was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Needle dislodgement during resuscitation was coded as a failure to maintain vascular access. RESULTS: There were 182 patients enrolled, with 64 (35%) assigned to tibial intraosseous, 51 (28%) humeral intraosseous, and 67 (37%) peripheral intravenous access. Demographic characteristics were similar among patients in the 3 study arms. There were 130 (71%) patients who experienced initial vascular access success, with 17 (9%) needles becoming dislodged, for an overall frequency of first-attempt success of 113 (62%). Individuals randomized to tibial intraosseous access were more likely to experience a successful first attempt at vascular access (91%; 95% confidence interval [CI] 83% to 98%) compared with either humeral intraosseous access (51%; 95% CI 37% to 65%) or peripheral intravenous access (43%; 95% CI 31% to 55%) groups. Time to initial success was significantly shorter for individuals assigned to the tibial intraosseous access group (4.6 minutes; interquartile range 3.6 to 6.2 minutes) compared with those assigned to the humeral intraosseous access group (7.0 minutes; interquartile range 3.9 to 10.0 minutes), and neither time was significantly different from that of the peripheral intravenous access group (5.8 minutes; interquartile range 4.1 to 8.0 minutes). CONCLUSION: Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access.
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Infusiones Intraóseas/métodos , Infusiones Intravenosas/métodos , Paro Cardíaco Extrahospitalario/terapia , Anciano , Servicios Médicos de Urgencia/métodos , Humanos , Húmero , Masculino , Persona de Mediana Edad , Tibia , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to compare the frequency of first attempt success between basic life support (BLS) first responder initiated King LT-D placement and paramedic initiated endotracheal intubation (ETI) among patients experiencing out-of-hospital cardiac arrest (OOHCA). METHODS: In 2009 a large, urban EMS agency modified their out-of-hospital, non-traumatic, cardiac arrest protocol from paramedic initiated ETI to first responder initiated King LT-D placement. This retrospective analysis of all adult, non-traumatic cardiac arrests occurred four months before and four months after protocol implementation. The outcome variable in this analysis was first attempt airway management success defined as placement of the device with end tidal CO(2) wave form or colorimetric color change, auscultation of bilateral breath sounds, and improved or normal pulse oximetry reading. The independent variable of interest was initial device utilized to secure the airway, King LT-D or ETI. RESULTS: There were 351 adult, non-traumatic OOHCAs with 184 patients (52.4%) enrolled during the ETI period and 167 (47.6%) during the King LT-D period. The frequency of first attempt success was 57.6% in the ETI group and 87.8% in the King LT-D group. Patients in the King LT-D group were significantly more likely to experience first attempt success versus standard ETI methods (OR 5.3; 95%CI 2.9-9.5). CONCLUSION: In this analysis of OOHCA airway management, first attempt BLS King LT-D placement success exceeded that of first attempt paramedic ETI success. In addition, patients in the King LT-D group were more likely to have had an advanced airway attempted and to have had a successful advanced airway placed when multiple attempts were required.
Asunto(s)
Servicios Médicos de Urgencia/métodos , Auxiliares de Urgencia/normas , Intubación Intratraqueal/instrumentación , Maniquíes , Paro Cardíaco Extrahospitalario/terapia , Resucitación/instrumentación , Población Urbana , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND: Intraosseous (IO) needle insertion is often utilized in the adult population for critical resuscitation purposes. Standard insertion sites include the proximal humerus and proximal tibia, for which limited comparison data are available. OBJECTIVE: This study compared the frequencies of IO first-attempt success between humeral and tibial sites in out-of-hospital cardiac arrest. METHODS: This observational study was conducted in an urban setting between August 28, 2009, and October 31, 2009, and included all medical cardiac arrest patients for whom resuscitative efforts were performed. Cardiac arrest protocols stipulate that paramedics insert an IO line for initial vascular access. During the first month of the study, the proximal humerus was the preferred primary insertion site, whereas the tibia was preferred throughout the second month. The primary outcome was first-attempt success, defined as secure IO needle position in the marrow cavity and normal fluid flow. Any needle dislodgment during resuscitation was also recorded. The association between first-attempt IO success and initial IO insertion location was analyzed using a test of independent proportions and 95% confidence intervals (CIs) for the difference in proportions. RESULTS: There were 88 cardiac arrest patients receiving IO placement, with 58 (65.9%) patients receiving their initial IO attempt in the tibia. The rate of first-time IO success at the tibia was significantly higher than that observed at the humerus (89.7% vs. 60.0%; p < 0.01). There were 18 initial successes at the humerus; for six (33.3%) of these, the needle became dislodged during resuscitation, compared with 52 initial successes at the tibia, with three (5.8%) dislodgments. The rate of total success for initial IO placements was significantly lower for the humerus (40.0%) compared with that for the tibia (84.5%; p < 0.01) during resuscitation efforts. CONCLUSIONS: In this subset of patients, tibial IO needle placement appeared to be a more effective insertion site than the proximal humerus. Success rates were higher with a lower incidence of needle dislodgments. Further randomized studies are required in order to validate these results.
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Muerte Súbita Cardíaca/prevención & control , Húmero , Infusiones Intraóseas/métodos , Paro Cardíaco Extrahospitalario/terapia , Tibia , Protocolos Clínicos , Intervalos de Confianza , Servicios Médicos de Urgencia , Humanos , Infusiones Intraóseas/instrumentación , Sistema de Registros , Resultado del TratamientoRESUMEN
INTRODUCTION: Therapeutic hypothermia has been shown to improve both mortality and neurologic outcomes following pulseless ventricular tachycardia and fibrillation. Animal data suggest intra-arrest induction of therapeutic hypothermia (IATH) improves frequency of return of spontaneous circulation (ROSC). Our objective was to evaluate the association between IATH and ROSC. METHODS: This was a retrospective analysis of individuals experiencing non-traumatic cardiac arrest in a large metropolitan area during a 12-month period. Six months into the study a prehospital IATH protocol was instituted whereby patients received 2000ml of 4°C normal saline directly after obtaining IV/IO access. The main outcome variables were prehospital ROSC, survival to admission, and to discharge. A secondary analysis was conducted to assess the relationship between the quantity of cold saline infused and the likelihood of prehospital ROSC. RESULTS: 551 patients met inclusion criteria with all the elements available for data analysis. Rates of prehospital ROSC were 36.5% versus 26.9% (OR 1.83; 95% CI 1.19-2.81) in patients who received IATH versus normothermic resuscitation respectively. While the frequency of survival to hospital admission and discharge were increased among those receiving IATH, the differences did not reach statistical significance. The secondary analysis found a linear association between the amount of cold saline infused and the likelihood of prehospital ROSC. CONCLUSION: The infusion of 4°C normal saline during the intra-arrest period may improve rate of ROSC even at low fluid volumes. Further study is required to determine if intra-arrest cooling has a beneficial effect on rates of ROSC, mortality, and neurologic function.
Asunto(s)
Reanimación Cardiopulmonar/métodos , Hemodinámica/fisiología , Hipotermia Inducida/métodos , Paro Cardíaco Extrahospitalario/terapia , Recuperación de la Función , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/fisiopatología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Among individuals experiencing an ST segment-elevation myocardial infarction, current guidelines recommend that the interval from first medical contact to percutaneous coronary intervention be ≤90 minutes. The objective of this study was to determine whether prehospital time intervals were associated with ST-elevation myocardial infarction system performance, defined as first medical contact to percutaneous coronary intervention. METHODS AND RESULTS: Study patients presented with an acute ST-elevation myocardial infarction diagnosed by prehospital ECG between May 2007 and March 2009. Prehospital time intervals were as follows: 9-1-1 call receipt to ambulance on scene ≤10 minutes, ambulance on scene to 12-lead ECG acquisition ≤8 minutes, on-scene time ≤15 minutes, prehospital ECG acquisition to ST-elevation myocardial infarction team notification ≤10 minutes, and scene departure to patient on cardiac catheterization laboratory table ≤30 minutes. Time intervals were derived and analyzed with descriptive statistics and logistic regression. There were 181 prehospital patients who received percutaneous coronary intervention, with 165 (91.1) having complete data. Logistic regression indicated that table time, response time, and on-scene time were the benchmark time intervals with the greatest influence on the probability of achieving percutaneous coronary intervention in ≤90 minutes. Individuals with a time from scene departure to arrival on cardiac catheterization laboratory table of ≤30 minutes were 11.1 times (3.4 to 36.0) more likely to achieve percutaneous coronary intervention in ≤90 minutes than those with extended table times. CONCLUSIONS: In this patient population, prehospital timing benchmarks were associated with system performance. Although meeting all 5 benchmarks may be an ideal goal, this model may be more useful for identifying areas for system improvement that will have the greatest clinical impact.