The contamination of the environment, ambulance equipment, and staff hands consequently are major factors which create nosocomial infections in emergency patients. The contamination of equipment and devices plays an important role in nosocomial infections.

The aim of this study was to determine the effectiveness of a disinfectant on the rate of microbial contamination of ambulances in Qom Emergency Medical Services (EMS), Qom, Iran.

This is a quasi-experimental study with a before-after design in order to determine microbial contaminations at the rear and front cabin of ambulances, as well as medical equipment being utilized in Qom EMS. Saya sept-HP-2% solution was used for disinfection. Bacteriological standard methods were used to identify the contaminations.

The contamination rates before and after use of disinfection solution were 52% and eight percent, respectively. Coagulase-negative staphylococci were the most commonly isolated bacterial agent from the equipment (53%). In all equipment, the contamination level has shown a significant reduction after applying disinfectant.

In spite of the fact that the rate of infection from ambulance equipment is high, the results showed that the use of the suitable disinfectant had an effective role in the reduction of bacteria.

FarhadlooR, Goodarzi FarJ, AzadehMR, ShamsS, Parvaresh-MasoudM.Evaluation of Bacterial Contamination on Prehospital Ambulances Before and After Disinfection. Prehosp Disaster Med. 2018;33(6):602–606.

Rapid access to defibrillation is a key element in the management of out-of-hospital cardiac arrests (OHCAs). Public automated external defibrillators (PAEDs) are becoming increasingly available, but little information exists regarding the relation between the proximity to the arrest and their usage in urban areas.

This study is a retrospective, observational, cross-sectional analysis of non-traumatic OHCA during a 24-month period in the greater Montreal area (Quebec, Canada). Using logistic regression, bystander shock odds are described with regards to distance from the OHCA scene to the nearest PAED, adjusted for prehospital care arrival delay and time of day, and stratifying for type of location.

Out of a total of 2,443 OHCA victims identified, 77 (3%) received bystander PAED shock, 622 (26%) occurred out-of-home, and 743 (30%) occurred during business hours. When controlling for time (business hours versus other hours) and minimum response delay for prehospital care arrival, a marginal negative association was found between bystander shock and distance to the nearest PAED in logged meters (aOR=0.80; CI, 0.64-0.99) for out-of-home cardiac arrests. No significant association was found between distance and bystander shock for at-home arrests. Out-of-home victims had significantly higher odds of receiving bystander shock up to 175 meters of distance to a PAED inclusively (aOR=2.52; CI, 1.07-5.89).

For out-of-home cardiac arrests, proximity to a PAED was associated with bystander shock in the greater Montreal area. Strategies aiming to increase accessibility and use of these life-saving devices could further expand this advantage by assisting bystanders in rapidly locating nearby PAEDs.

Neves BriardJ, de MontignyL, RossD, de ChamplainF, SegalE. Is Distance to the Nearest Registered Public Automated Defibrillator Associated with the Probability of Bystander Shock for Victims of Out-of-Hospital Cardiac Arrest?Prehosp Disaster Med. 2018;33(2):153–159.

Many Syrians have left their country and migrated to other countries since March 2011, due to the civil war. As of March 2016, a total of 2,747,946 Syrian refugees had immigrated to Turkey. Some Syrian refugees have been living in camps, while 2,475,134 have been living in metropolitan areas, such as Ankara.

This study investigated Emergency Medical Service (EMS) utilization among Syrian refugees residing in Ankara.

This study was a descriptive, cross-sectional database analysis using data obtained from the Department of EMS of the Ankara Provincial Health Directorate.

Five stations in the Altındağ region of Ankara responded to 42% of all calls from Syrian refugees. Prehospital EMS in Ankara have been used mostly by Syrian refugees younger than 18-years-old. Study findings also suggest that medical staff in regions where Syrian refugees are likely to be treated should be supported and provided with the ability to overcome language barriers and cultural differences.

AltınerAO, Tekeli YeşilS. Emergency Medical Service (EMS) Utilization by Syrian Refugees Residing in Ankara, Turkey. Prehosp Disaster Med. 2018;33(2):160–164.

Political parties in Turkey execute political public meetings (PPMs) during their election campaign for members of the parliament (MoP). A great number of people attend these meetings. No guidelines exist regarding preparation and organization of health care services provided during these meetings. Furthermore, there is no study evaluating health care problems encountered in previous PPMs.

Political parties arranged PPMs in 2015 during the election campaign for general election of MoP. The present study aimed to investigate the context of health care services, the distribution of assigned health staff, as well as the number and the symptoms of patients admitted in health care tents in these PPMs.

Two general elections for MoP were done in Turkey on June 7, 2015 and November 1, 2015. Health care services were provided by the City Emergency Medical Services Department (CEMSD) in the cities. Demographic characteristics, symptoms, comorbid conditions, treatment, discharge, and hospital transfer of the patients were obtained from patient medical registration records. Information about the distribution and the number of the assigned staff was received from local CEMSDs. The impact of variables such as the number of attendees, heat index, humidity, and the day of the week on the number of patients and the patient presentation rate (PPR) were analyzed.

A total of 97 PPMs were analyzed. The number of total attendees was 5,265,450 people. The number of patients seeking medical help was 1,991. The PPR was 0.5 (0.23-0.91) patients per 1,000 attendees. Mean age of the patients was 40 (SD=19) years old while 1,174 (58.9%) of the patients were female. A total of 1,579 patients were treated in the tents and returned to the PPM following treatment. Two-hundred and three patients were transferred to a hospital by ambulance. Transfer-to-hospital ratio (TTHR) was 0.05 (0.0-0.13) patients per 1,000 attendees. None of the patients suffered sudden cardiac death (SCD) or cardiac arrest. Medical conditions were the main cause for admission. The most common symptoms were dizziness, low blood pressure, fatigue, and hypertension, respectively. The most commonly used medical agents included pain killers and myorelaxants. The number of attendees, heat index, and weekend days were positively correlated with the number of the patients.

: The majority of medical conditions encountered in PPMs are easily treatable in health care tents settled in the meeting area. The number of attendees, heat index, and weekend days are factors associated with the number of patients.

CeyhanMA, DemirGG, GülerGB. Evaluation of Health Care Services Provided in Political Public Meetings in Turkey: A Forgotten Detail in Politics. Prehosp Disaster Med. 2018;33(6):607–613.

This study evaluated how Tactical Emergency Casualty Care (TECC) training prepared law enforcement officers (LEOs) with the tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma.

This was a retrospective, de-identified study using a seven-item Fairfax County (Virginia USA) TECC After-Action Questionnaire and Arlington County (Virginia USA) police reports.

Forty-six encounters were collected from 2015 through 2016. Eighty-four percent (n=39) of the encounters were from TECC After-Action Questionnaires and 15% (n=7) were from police reports. The main injuries included 13% (n=6) arterial bleeds, 46% (n=21) mild/moderate bleeds, 37% (n=17) large wounds, 20% (n=9) penetrating chest wounds, and 13% (n=6) open abdominal wounds. One-hundred percent of officers reported success in stabilizing victim injuries. Seventy-four percent of officers (n=26) did not encounter problems caring for a patient while 26% (n=9) encountered a problem. Ninety-seven percent (n=37/38) answered Yes, the training was sufficient, and three percent (n=1) indicated it was OK.

This is the most comprehensive study of TECC use among LEOs to date that supports the importance of TECC training for all LEOs in prehospital trauma care. Results of this study showed TECC training prepared LEOs with the operational tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma. Continuing to train increasing numbers of LEOs in TECC is key to saving the lives of victims of trauma in the future.

RothschildHR, MathiesonK.Effects of Tactical Emergency Casualty Care Training for Law Enforcement Officers. Prehosp Disaster Med.2018;33(5):495–500.

Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC.

Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature.

A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment.

The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review.

Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized.

HowardI, CameronP, WallisL, CastrenM, LindstromV. Quality Indicators for Evaluating Prehospital Emergency Care: A Scoping Review. Prehosp Disaster Med. 2018;33(1):43–52.

The central question this study sought to answer was whether the team members of Strategic Crisis Teams (SCTs) participating in mass-casualty incident (MCI) exercises in the Netherlands learn from their participation.

Evaluation reports of exercises that took place at two different times were collected and analyzed against a theoretical model with several dimensions, looking at both the quality of the evaluation methodology (three criteria: objectives described, link between objective and items for improvement, and data-collection method) and the learning effect of the exercise (one criterion: the change in number of items for improvement).

Of all 32 evaluation reports, 81% described exercise objectives; 30% of the items for improvement in the reports were linked to these objectives, and 22% of the 32 evaluation reports used a structured template to describe the items for improvement. In six evaluation categories, the number of items for improvement increased between the first (T1) and the last (T2) evaluation report submitted by hospitals. The number of items remained equal for two evaluation categories and decreased in six evaluation categories.

The evaluation reports do not support the ideal-typical disaster exercise process. The authors could not establish that team members participating in MCI exercises in the Netherlands learn from their participation. More time and effort must be spent on the development of a validated evaluation system for these simulations, and more research into the role of the evaluator is needed.

Verheul MLMI, Dückers MLA, Visser BB, Beerens RJJ, Bierens JJLM. Disaster exercises to prepare hospitals for mass-casualty incidents: does it contribute to preparedness or is it ritualism? Prehosp Disaster Med. 2018;33(4):387–393

Mass-casualty incidents (MCIs) easily overwhelm a health care facility’s human and material resources through the extraordinary influx of casualties. Efficient and accurate triage of incoming casualties is a critical step in the hospital disaster response.

Traditionally, triage during MCIs has been manually performed using paper cards. This study investigated the use of electronic Simple Triage and Rapid Treatment (START) triage as compared to the manual method.

This observational, crossover study was performed during a live MCI simulation at an urban, Canadian, Level 1 trauma center on May 26, 2016. Health care providers (two medical doctors [MDs], two paramedics [PMs], and two registered nurses [RNs]) each triaged a total of 30 simulated patients - 15 by manual (paper-based) and 15 by electronic (computer-based) START triage. Accuracy of triage categories and time of triage were analyzed. Post-simulation, patients and participating health care providers also completed a feedback form.

There was no difference in accuracy of triage between the electronic and manual methods overall, 83% and 80% (P=1.0), between providers or between triage categories. On average, triage time using the manual method was estimated to be 8.4 seconds faster (P<.001) for PMs; and while small differences in triage times were observed for MDs and RNs, they were not significant. Data from the participant feedback survey showed that the electronic method was preferred by most health care providers. Patients had no preference for either method. However, patients perceived the computer-based method as “less personal” than the manual triage method, but they also perceived the former as “better organized.”

Hospital-based electronic START triage had the same accuracy as hospital-based manual START triage, regardless of triage provider type or acuity of patient presentations. Time of triage results suggest that speed may be related to provider familiarity with a modality rather than the modality itself. Finally, according to patient and provider perceptions, electronic triage is a feasible modality for hospital triage of mass casualties. Further studies are required to assess the performance of electronic hospital triage, in the context of a rapid surge of patients, and should consider additional efficiencies built in to electronic triage systems. This study presents a framework for assessing the accuracy, triage time, and feasibility of digital technologies in live simulation training or actual MCIs.

BolducC, MaghrabyN, FokP, LuongTM, HomierV. Comparison of Electronic Versus Manual Mass-Casualty Incident Triage. Prehosp Disaster Med. 2018;33(3):273–278.

Analysis of injuries during military operations has focused on those related to combat. Non-combat complaints have received less attention, despite the need for many troops to be evacuated for non-battle illnesses in Iraq. This study aims to further characterize the disease and non-battle injuries (DNBIs) seen at a tertiary combat hospital and to describe the types of procedures and medications used in the management of these cases.

In this observational study, patients were enrolled from a convenience sample with non-combat-related diseases and injuries who were evaluated in the emergency department (ED) of a US military tertiary hospital in Iraq from 2007-2008. The treating emergency physician (EP) used a data collection form to enroll patients that arrived to the ED whose injury or illness was unrelated to combat.

Data were gathered on 1,745 patients with a median age of 30 years; 84% of patients were male and 85% were US military personnel. The most common diagnoses evaluated in the ED were abdominal disorders, orthopedic injuries, and headache. Many cases involved intravenous access, laboratory testing, and radiographic testing. Procedures performed included electrocardiogram, lumbar puncture, and intubation.

Disease and non-battle traumatic injuries are common in a tertiary combat hospital. Emergency providers working in austere settings should have the diagnostic and procedural skills to evaluate and treat DNBIs.

BebartaVS, MoraAG, NgPC, MasonPE, MuckA, MaddryJK. Disease and Non-Battle Traumatic Injuries Evaluated by Emergency Physicians in a US Tertiary Combat Hospital. Prehosp Disaster Med. 2018;33(1):53–57.

Acute Coronary Syndrome (ACS) is a life-threatening condition. Immediate and proper treatment will decrease mortality rate. Patient awareness on ACS is still lacking and as the consequence, ACS patients do not seek immediate help.

The patients’ efforts to get rid of ACS symptoms.

The study was a descriptive, qualitative study in which a semi-structured, in-depth interview became the instrument. The respondents were 34 participants (including 17 ACS patients and 17 family caregivers). Data analysis was done by triangulation of data sources.

Three themes were obtained, namely: (1) prefer traditional and self-treatment, for example (a) traditional medicine, (b) taking non-prescription drugs to overcome ACS symptoms, and (c) spontaneous action; (2) using available health resources and facilities that consisted of (a) getting initial treatment at home by nurses, (b) visiting a health center to take care of the symptoms, and (c) using non-ambulance service to visit the health centers; and (3) expectations on health care services to patients composed by sub-themes such as (a) the expectation to get information that supports the healing, and (b) the caring attitude of the heath professional.

The results showed that in the prehospital setting when experiencing ACS symptoms, the patients try to overcome the symptoms independently. However, as the symptoms get worse, they utilize health facilities in different ways. At the time of obtaining health services, patients are satisfied with health professionals who show caring attitudes, explain the results of the examination, and provide health education on health care efforts. Thus, to prevent mortality and morbidity, it is important for a health professional to educate the public about ACS, including topics about ACS healthy lifestyles and potential threats if it is too late to get treatment. Furthermore, it is also important for the government to implement prehospital emergency services nation-wide.KumboyonoK, RefialdinataJ, WihastutiTA, RachmawatiSD, AzizAN. Health-Seeking Behavior of Patients with Acute Coronary Syndrome and Their Family Caregivers. Prehosp Disaster Med. 2018;33(6):614–620.

Ischemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.

This study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED).

A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers.

Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159).

Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ.

LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care. Prehosp Disaster Med.2018;33(5):501–507.

Law enforcement is increasingly viewed as a key component in the out-of-hospital chain of survival, with expanded roles in cardiac arrest, narcotic overdose, and traumatic bleeding. Little is known about the nature of care provided by law enforcement prior to the arrival of Emergency Medical Services (EMS) assets. The purpose of the current study was to perform a descriptive analysis of events reported to a national EMS database.

This study was a descriptive analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set, containing EMS emergency response data from 41 states. Code E09_02 1200 specifically identifies care provided by law enforcement prior to EMS arrival.

A total of 25,835,729 unique events were reported. Of events in which pre-arrival care was documented, 2.0% received prior aid by law enforcement. Patients receiving law enforcement care prior to EMS arrival were more likely to be younger (52.8 [SD=23.3] years versus 58.7 [SD=23.3] years), male (54.8% versus 46.7%), and white (80.3% versus 77.5%). Basic Life Support (BLS) EMS response was twice as likely in patients receiving prior aid by law enforcement. Multiple-casualty incidents were five times more likely with prior aid by law enforcement. Compared with prior aid by other services, law enforcement pre-arrival care was more likely with motor vehicle accidents, firearm assaults, knife assaults, blunt assaults, and drug overdoses, and less likely at falls and childbirths. Cardiac arrest was significantly more common in patients receiving prior aid by law enforcement (16.5% versus 2.6%). Tourniquet application and naloxone administration were more common in the law enforcement prior aid group.

Where noted, law enforcement pre-arrival care occurs in 2.0% of EMS patient encounters. The majority of cases involve cardiac arrest, motor vehicle accidents, and assaults. Better understanding of the nature of law enforcement care is required in order to identify potential barriers to care and to develop appropriate training and policy recommendations.

KlassenAB, CoreSB, LohseCM, SztajnkrycerMD. A Descriptive Analysis of Care Provided by Law Enforcement Prior to EMS Arrival in the United States. Prehosp Disaster Med. 2018;33(2):165–170.

Personal protective equipment (PPE) recommended for use in West Africa during the Ebola outbreak increased risk for heat illness, and countermeasures addressing this issue would be valuable.

The purpose of this study was to examine the physiological impact and heat perception of four different personal cooling devices (PCDs) under impermeable PPE during low-intensity exercise in a hot and humid environment using thermal manikin modeling and human testing.

Six healthy male subjects walked on a treadmill in a hot/humid environment (32°C/92% relative humidity [RH]) at three metabolic equivalents (METs) for 60 minutes wearing PPE recommended for use in West Africa and one of four different personal cooling devices (PCDs; PCD1, PCD2, PCD3, and PCD4) or no PCD for control (CON). The same ensembles were tested with thermal manikin modeling software in the same conditions to compare the results.

All PCDs seemed to reduce physiological heat stress characteristics when worn under PPE compared to CON. Both the manikin and human testing provided similar results in core temperature (Tc) and heat sensation (HS) in both magnitude and relationship. While the manikin and human data provided similar skin temperature (Tsk) characterization, Tsk estimation by the manikin seemed to be slightly over-estimated. Weight loss, as estimated by the manikin, was under-estimated compared to the human measurement.

Personal cooling device use in conjunction with impermeable PPE may be advantageous in mitigating physiological and perceptual burdens of heat stress. Evaluation of PCDs worn under PPE can be done effectively via human or manikin testing; however, Tsk may be over-estimated and weight loss may be under-estimated. Thermal manikin testing of PCDs may provide fast and accurate information to persons recommending or using PCDs with PPE.

QuinnT, KimJH, SeoY, CocaA. Comparison of Thermal Manikin Modeling and Human Subjects’ Response During Use of Cooling Devices Under Personal Protective Ensembles in the Heat. Prehosp Disaster Med. 2018;33(3):279–287.

Training students has been proven to be the optimal way to deliver cardiopulmonary resuscitation (CPR) skills. However, it is somehow unknown whether or not the current recommendations appropriate for Caucasian students are also suitable for East Asian students. The purpose of this study is to explore the best age for East Asian students to receive CPR training.

Students were recruited from six schools. Students participated in a standard CPR training program provided by tutors. Each student attended a 60-minute training session with a manikin. After being trained, within one hour, the student’s compression quality was assessed.

A total of 360 students who constituted 12 continuous grades were recruited for this study. Adequate compression depth and satisfactory compression rate with correct hand position could be achieved since the age of 12. However, successful compression rate and complete release could be achieved since the younger age of six.

Current recommendations for Caucasian students to cultivate a full-capacity CPR rescuer at the age of 12 are also appropriate for East Asian students. However, the optimal age for students to receive CPR training should be decided based on evidence and importance assessment of CPR.

He D, Huang K, Yang Y, Jiang W, Yang N, Yang H. What is the optimal age for students to receive cardiopulmonary resuscitation training? Prehosp Disaster Med. 2018;33(4):394–398.

Mass crowds outside the routine population create a burden of disease on Emergency Medical Services (EMS). The need for EMS in various mass-crowd events may vary. It is especially important to determine the EMS requirement that emerges during the historic commemoration ceremonies in Çanakkale (Turkey).

This study aims to determine the unique challenges in the planning of EMS responses provided for people from various countries at the commemoration ceremony for a 100-year-old war and to identify the medical provision of those services.

This descriptive study examined the patient applications in the Çanakkale EMS at the commemoration ceremonies for the 100th anniversary of Gallipoli Wars (Çanakkale Amphibious Wars – Turkey) on April 24-25, 2015.

A total of 221 cases were handled by 112 EMS in the ceremony area. Of those, 87.3% of the cases applied to a mobile operating room (MOR) stationed in the ceremony area while 12.7% of them applied directly to the health care team in a large area in the ceremony area. Overall, 13.1% of the cases were transferred to the hospital for further evaluation and treatment. Patient presentation rate (PPR) of the patients who were treated during the two days was 4.42, and transfer to hospital rate (TTHR) of the cases transferred to the hospital was calculated to be 0.58.

Further studies may create models in regard to the estimations on mass and needs based on the data of previous organizations.

KoçakH, ÇalışkanC, SönmezlerMS, EliuzK, KüçükdurmazF. Analysis of Medical Responses in Mass Gatherings: The Commemoration Ceremonies for the 100th Anniversary of the Battle of Gallipoli. Prehosp Disaster Med. 2018;33(3):288–292.

The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.

A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.

A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.

Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.

Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.

StopyraJP, HarperWS, HigginsTJ, ProkesovaJV, WinslowJE, NelsonRD, AlsonRL, DavisCA, RussellGB, MillerCD, MahlerSA. Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events. Prehosp Disaster Med. 2018;33(1):58–62.

Implementation of high-quality, dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is critical to improving survival from out-of-hospital cardiac arrest (OHCA). However, despite some studies demonstrating the use of a metronome in a stand-alone setting, no research has yet demonstrated the effectiveness of a metronome tool in improving DA-CPR in the context of a realistic 911 call or using instructions that have been tested in real-world emergency calls.

Use of the metronome tool will increase the proportion of callers able to perform CPR within the target rate without affecting depth.

The prospective, randomized, controlled study involved simulated 911 cardiac arrest calls made by layperson-callers and handled by certified emergency medical dispatchers (EMDs) at four locations in Salt Lake City, Utah USA. Participants were randomized into two groups. In the experimental group, layperson-callers received CPR pre-arrival instructions with metronome assistance. In the control group, layperson-callers received only pre-arrival instructions. The primary outcome measures were correct compression rate (counts per minute [cpm]) and depth (mm).

A total of 148 layperson-callers (57.4% assigned to experimental group) participated in the study. There was a statistically significant association between the number of participants who achieved the target compression rate and experimental study group (P=.003), and the experimental group had a significantly higher median compression rate than the control group (100 cpm and 89 cpm, respectively; P=.013). Overall, there was no significant correlation between compression rate and depth.

An automated software metronome tool is effective in getting layperson-callers to achieve the target compression rate and compression depth in a realistic DA-CPR scenario.

Scott G, Barron T, Gardett I, Broadbent M, Downs H, Devey L, Hinterman EJ, Clawson J, Olola C. Can a software-based metronome tool enhance compression rate in a realistic 911 call scenario without adversely impacting compression depth for dispatcher-assisted CPR? Prehosp Disaster Med. 2018;33(4):399–405

In June 2012, the Botswana Ministry of Health and Wellness (MOHW; Gaborone, Botswana) initiated a national Emergency Medical Services (EMS) system in response to significant morbidity and mortality associated with prehospital emergencies. The MOHW requested external expertise to train its developing workforce. Simulation-based training was planned to equip these health care providers with clinical knowledge, procedural skills, and communication techniques.

The objective of this study was to assess the educational needs of the pioneer Botswana MOHW EMS providers based on retrospective EMS logbook review and EMS provider feedback to guide development of a novel educational curriculum.

Data were abstracted from a representative sample of the Gaborone, Botswana MOHW EMS response log from 2013-2014 and were quantified into the five most common call types for both adults and children. Informal focus groups with health professionals and EMS staff, as well as surveys, were used to rank common response call types and self-perceived educational needs.

Based on 1,506 calls, the most common adult response calls were for obstetric emergencies, altered mental status, gastrointestinal/abdominal pain, trauma, gynecological emergencies, and cardiovascular and respiratory distress-related emergencies. The most common pediatric response calls were for respiratory distress, gastrointestinal complaints/dehydration, trauma and musculoskeletal injuries, newborn delivery, seizures, and toxic ingestion/exposure. The EMS providers identified these same chief complaints as priorities for training using the qualitative approach. A locally relevant, simulation-based curriculum for the Botswana MOHW EMS system was developed and implemented based on these data.

: Trauma, respiratory distress, gastrointestinal complaints, and puerperal/perinatal emergencies were common conditions for all age groups. Other age-specific conditions were also identified as educational needs based on epidemiologic data and provider feedback. This needs assessment may be useful when designing locally relevant EMS curricula in other low-income and middle-income countries.GlombNW, KosokoAA, DoughtyCB, RusMC, ShahMI, CoxM, GalapiC, ParkesPS, KumarS, LabaB.Needs Assessment for Simulation Training for Prehospital Providers in Botswana. Prehosp Disaster Med. 2018;33(6):621–626.

The goal of this study was to find out the training received in Urgent and Emergency Medicine (UEM) by the Primary Health Care (PHC) physicians of Asturias (Spain), as well as their perception of their own theoretical knowledge and practical skills in a series of procedures employed in life-threatening emergencies (LTEs), and also to analyze the differences according to the geographical area of their work.

This was a cross-sectional survey of PHC physicians using an ad hoc survey of a sample of 213 physicians in Asturias regarding their self-perception of theoretical knowledge and practical skills in techniques used in LTEs by areas of work (rural, suburban, and urban). The interview was conducted by mail from April through May 2017. The data processing has used absolute and relative frequencies, as well as central tendency parameters and dispersion parameters. The estimates for the entire population have been made using confidence intervals for the mean of 95%. In the comparison of parameters, the differences between parameters with a probability of error less than five percent (P<.05) have been considered significant. For the comparison of means between the different techniques in the different areas of work, ANOVA was used.

With respect to the training of physicians, in general, for managing emergencies, both at the regional level and by areas of work (rural, suburban, and urban), none of the sets analyzed attained five points. By areas of work, it was the suburban region where there was a greater average general level of knowledge. There were significant differences in the average theoretical knowledge and the average practical skills in the procedures studied according to the different areas of work. The greater number of significant differences was between the urban and suburban regions and within the urban area.

It’s necessary to ensure an adequate homogeneity of the levels of theoretical knowledge and practical skills of PHC physicians in order to guarantee the equity of provision of health care in emergencies in different geographical areas.

Cernuda MartínezJA, Castro DelgadoR, Ferrero FernándezE, Arcos GonzálezP. Self-Perception of Theoretical Knowledge and Practical Skills by Primary Health Care Physicians in Life-Threatening Emergencies. Prehosp Disaster Med. 2018;33(5):508–518.

The aim of this study was to assess the risk of cardiopulmonary resuscitation (CPR) performed in out-of-hospital settings for chest injuries in patients with out-of-hospital cardiac arrest (OHCA).

This retrospective, observational study was conducted in an emergency critical care medical center in Japan. Non-traumatic OHCA patients transferred to the hospital from April 2013 through August 2016 were analyzed. The outcome was defined by chest injuries related to CPR, which is composite of rib fractures, sternal fractures, and pneumothoraces. A multivariate logistic regression analysis was performed to assess the independent risk factors for chest injuries related to CPR. The threshold of out-of-hospital CPR duration that increased risk of chest injuries was also assessed.

A total of 472 patients were identified, of whom 233 patients sustained chest injuries. The multivariate logistic regression model showed that the independent risk factors for chest injuries were age and out-of-hospital CPR duration (age: AOR=1.06 [95% CI, 1.04 to 1.07]; out-of-hospital CPR duration: AOR=1.03 [95% CI, 1.01 to 1.05]). In-hospital CPR duration was not an independent risk factor for chest injuries. When the duration of out-of-hospital CPR extended over 15 minutes, the likelihood of chest injuries increased; however, this association was not statistically significant.

Long duration of out-of-hospital CPR was an independent risk factor for chest injuries, possibly due to the difficulty of maintaining adequate quality of CPR. Further investigations to assess the efficacy of alternative CPR devices are expected in cases requiring long transportation times.

TakayamaW, KoguchiH, EndoA, OtomoY. The Association between Cardiopulmonary Resuscitation in Out-of-Hospital Settings and Chest Injuries: A Retrospective Observational Study. Prehosp Disaster Med. 2018;33(2):171–175.