David Ross, DO Medical Director, American Medical Response Emergency Physician, Penrose-St. Francis...
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David Ross, DO Medical Director, American Medical Response Emergency Physician, Penrose-St. Francis Health Se Colorado Springs, Colorado 719-494-7810 [email protected] BACKGROUND • Emergency Medical Services (EMS) emergent transport using lights and siren accounted for 58% of ambulance collisions between 1990 and 2009 • Ambulances driving with lights and siren were responsible for 324 fatalities and nearly 18,000 injuries between 1990 – 2009 • Previous studies have found time saved using emergent transport mode is minimal (43 seconds to 3.5 minutes) • Lights and siren transport has not been demonstrated to offer consistent clinical benefit Airway Procedures Vascular Procedures Eye/Limb Procedures Other Procedures Intensive Procedures Patient expires within 60 mins 1 American Medical Response, Colorado Springs, CO 80915; 2 Penrose Hospital, Colorado Springs, CO 80907; 3 St. Anthony Hospital, Lakewood, CO 80228; 4 Swedish Medical Center, Englewood, CO 80113; 5 Centura Health, Englewood, CO 80113 David Ross 1,2 ; Lisa Caputo 3,4 ; Kristin Salottolo 3,4 ; Bret Gorham 1 ; Charles Mains 3,5; David Bar Or 3,4 Does Emergent Emergency Medical Service Transport Mode Predict Need for Time Critical Hospital Intervention in Trauma Patients? • We retrospectively reviewed EMS patient care reports (PCRs) and trauma registry data for trauma patients consecutively transported from the field by a single Advanced Life Support EMS agency to the Level I trauma center between 7/1/10 - 6/30/12. • Our outcome of interest, receiving a TCHI, was defined as administering at least one preselected life, limb or eye saving procedures within 60 minutes of arrival (list below). • Sensitivity, Specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) demonstrated the predictive ability of emergent transport. RESULTS • 809 patients were transported and admitted during the study period. 66 (8.2%) patients were excluded due to missing data, leaving 743 (91.8%) patients for analysis. • Of 165 patients (20.7% of total transports) transported emergently, 50 (31.8%) received a TCHI. • The PPV was 30.3% (95% CI 23.53, 38.01), demonstrating a low precision rate associated with lights and siren • Emergent transport mode correctly identified 73.5% patients requiring a TCHI (95% CI 61.21, 83.16). • Of 578 (77.8% of total transports) patients transferred non-emergently, 560 (89.9%) did not require a TCHI. • The NPV was 96.9% (95% CI 95.03, 98.09), reflecting a high proportion of patients transferred non-emergently that did not require a TCHI. • Non-emergent transport correctly identified 83.0% (95% CI 79.86, 85.68) of transports that did not require a TCHI. OBJECTIVE To measure the precision of transport modes selected by an urban EMS agency with the likelihood of receiving a time critical hospital intervention (TCHI) within 60 minutes of hospital arrival in adult trauma patients. TIME CRITICAL HOSPITAL INTERVENTIONS (TCHI) Patient expires within 60 minutes of admission Airway or respiratory support • Chest tube • Ventilation • Tracheostomy • Cricothyoroidotomy • Thoracentesis Intensive therapeutic surgery • Craniotomy or Burr holes • Ventricular peritoneal shunt • Ventriculostomy drain • Amputation • Heart Bypass • Other Operative procedures • Caesarean Section • Exploratory Surgery/Procedures • Splenic Repair or Removal • Thoracotomy • Arteriovenous Rewarmer • Cardiac pacemaker Invasive vascular procedures • Vessel Repair • Embolization • Arterial or Central line • Massive Transfusion Eye and limb saving • Ophthalmologic Operative Procedure • Fasciotomy • Irrigation & Debridement Other • Intraosseous needle placement • Cardiac Arrest • Needle Decompression • Open Cardiac Massage • Cross Clamp Aorta • Facial fracture repair • Fresh frozen plasma, Protein Complex Concentration or Factor VII given • Cardiopulmonary resuscitation (CPR) TCHI TRANSPORT MODE Yes No Total Emergent 50 (31.8%) 115 (69.2%) 165 Non- Emergent 18 (3.1%) 560 (98.9%) 578 Total 68 (9.2%) 675 (90.8%) 743 Most Common Time Critical Hospital Interventions METHODS CONCLUSIONS Emergent transport did not appear to be predictive of the need for a TCHI in adult trauma patients, suggesting substantial unnecessary emergent transport. Further research is needed to identify clinical factors closely associated with the need for a TCHI and subsequent protocol development to guide the use of emergent transport in trauma patients. • The mean number of TCHI’s received was 3.7. • 14 (1.9%) patients expired within 60 minutes of hospital arrival. • Most common TCHI’s in the study included intubation (51 incidents) and mechanical ventilation (48 incidents)
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Transcript of David Ross, DO Medical Director, American Medical Response Emergency Physician, Penrose-St. Francis...
David Ross, DOMedical Director, American Medical ResponseEmergency Physician, Penrose-St. Francis Health ServicesColorado Springs, Colorado719-494-7810 [email protected]
BACKGROUND• Emergency Medical Services (EMS) emergent transport using
lights and siren accounted for 58% of ambulance collisions between 1990 and 2009
• Ambulances driving with lights and siren were responsible for 324 fatalities and nearly 18,000 injuries between 1990 – 2009
• Previous studies have found time saved using emergent transport mode is minimal (43 seconds to 3.5 minutes)
• Lights and siren transport has not been demonstrated to offer consistent clinical benefit
Airway Procedures
Vascular Procedures
Eye/Limb Procedures
Other Procedures
Intensive Procedures
Patient expires within 60 mins
1American Medical Response, Colorado Springs, CO 80915; 2Penrose Hospital, Colorado Springs, CO 80907; 3St. Anthony Hospital, Lakewood, CO 80228; 4Swedish Medical Center, Englewood, CO 80113; 5Centura Health, Englewood, CO 80113
David Ross1,2; Lisa Caputo3,4; Kristin Salottolo3,4; Bret Gorham1; Charles Mains3,5; David Bar Or3,4
Does Emergent Emergency Medical Service Transport Mode Predict Need for Time Critical Hospital Intervention in Trauma Patients?
• We retrospectively reviewed EMS patient care reports (PCRs) and trauma registry data for trauma patients consecutively transported from the field by a single Advanced Life Support EMS agency to the Level I trauma center between 7/1/10 - 6/30/12.
• Our outcome of interest, receiving a TCHI, was defined as administering at least one preselected life, limb or eye saving procedures within 60 minutes of arrival (list below).
• Sensitivity, Specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) demonstrated the predictive ability of emergent transport.
RESULTS• 809 patients were transported and admitted during the study
period. 66 (8.2%) patients were excluded due to missing data, leaving 743 (91.8%) patients for analysis.
• Of 165 patients (20.7% of total transports) transported emergently, 50 (31.8%) received a TCHI.
• The PPV was 30.3% (95% CI 23.53, 38.01), demonstrating a low precision rate associated with lights and siren
• Emergent transport mode correctly identified 73.5% patients requiring a TCHI (95% CI 61.21, 83.16).
• Of 578 (77.8% of total transports) patients transferred non-emergently, 560 (89.9%) did not require a TCHI.
• The NPV was 96.9% (95% CI 95.03, 98.09), reflecting a high proportion of patients transferred non-emergently that did not require a TCHI.
• Non-emergent transport correctly identified 83.0% (95% CI 79.86, 85.68) of transports that did not require a TCHI.
OBJECTIVETo measure the precision of transport modes selected by an urban EMS agency with the likelihood of receiving a time critical hospital intervention (TCHI) within 60 minutes of hospital arrival in adult trauma patients.
TIME CRITICAL HOSPITAL INTERVENTIONS (TCHI)Patient expires within 60 minutes of admission
Airway or respiratory support• Chest tube• Ventilation • Tracheostomy • Cricothyoroidotomy • Thoracentesis
Intensive therapeutic surgery• Craniotomy or Burr holes • Ventricular peritoneal shunt • Ventriculostomy drain • Amputation • Heart Bypass • Other Operative procedures• Caesarean Section • Exploratory Surgery/Procedures • Splenic Repair or Removal • Thoracotomy • Arteriovenous Rewarmer • Cardiac pacemaker
Invasive vascular procedures• Vessel Repair • Embolization • Arterial or Central line • Massive Transfusion
Eye and limb saving• Ophthalmologic Operative Procedure • Fasciotomy• Irrigation & Debridement
Other• Intraosseous needle placement• Cardiac Arrest• Needle Decompression • Open Cardiac Massage• Cross Clamp Aorta • Facial fracture repair• Fresh frozen plasma, Protein Complex
Concentration or Factor VII given• Cardiopulmonary resuscitation (CPR)
TCHITRANSPORT
MODE
Yes No Total
Emergent 50 (31.8%) 115 (69.2%) 165
Non-Emergent 18 (3.1%) 560 (98.9%) 578
Total 68 (9.2%) 675 (90.8%) 743
Most Common Time Critical Hospital Interventions
METHODS
CONCLUSIONSEmergent transport did not appear to be predictive of the need for a TCHI in adult trauma patients, suggesting substantial unnecessary emergent transport.
Further research is needed to identify clinical factors closely associated with the need for a TCHI and subsequent protocol development to guide the use of emergent transport in trauma patients.
• The mean number of TCHI’s received was 3.7.
• 14 (1.9%) patients expired within 60 minutes of hospital arrival.
• Most common TCHI’s in the study included intubation (51 incidents) and mechanical ventilation (48 incidents)
