Interactive voice response (IVR) technology may facilitate poison centers to handle increased call volumes that may occur during public health emergencies. On 28 April 2009, the Texas Poison Center Network (TPCN) added a H1N1 message in English and Spanish to its IVR system. This study tested whether IVR technology could be used to assist Texas poison centers during the H1N1 outbreak.

The distribution of callers who accessed the H1N1 message during 29 April–31 May 2009 was determined with respect to message language, subsequent caller action, and date of the call.

The H1N1 message was accessed by 1,142 callers, of whom, 92.9% listened to the message in English, and 7.1% listened to the message in Spanish. After listening to the message, 33.3% hung up while 66.7% spoke to a poison center agent. The number of callers who accessed the message was highest on 29 April 2009 and then declined.

Interactive voice response technology can be used to assist poison centers to provide information and handle calls from the public during a public health emergency.

Scant evidence exists to guide policy-making around public health needs during mass gatherings. In 2006, the City and County of San Francisco began requiring standby ambulances at all mass gatherings with attendance of >15,500 people. The objectives were to evaluate needs for ambulances at mass gatherings, and to make evidence-based recommendations for public health policy-makers. The hypothesis was that the needs for ambulances at mass gatherings can be estimated using community baseline data.

Emergency medical services plans were reviewed for all public events with an anticipated attendance of >1,000 people in San Francisco County during the 12-month period 01 August 2006 through 31 July 2007. Ambulance transport data were confirmed by event coordinators and ambulance company records, and the rate was calculated by dividing ambulance transports by event attendance. Baseline ambulance transport rate was calculated by dividing the annual ambulance transports in the county's computer-aided dispatch system by the census population estimate. The risk ratio was calculated using the risk of transport from a mass gathering compared with the baseline risk of ambulance transport for the local community. Significance testing and confidence intervals were calculated.

Descriptive information was available for 100% of events and ambulance transport data available for 97% of events. The majority of the mass gatherings (47 unique events; 59 event days) were outdoor, weekend festivals, parades, or concerts, though a large proportion were athletic events. The ambulance transport rate from mass gatherings was 1 per 59,000 people every six hours. Baseline ambulance transport rate in San Francisco was 1 per 20,000 people every six hours. The transport rate from mass gatherings was significantly lower than the community baseline (risk ratio [RR] = 0.15, 95% CI = 0.10–0.22, p <0.001). At events reserving a standby ambulance, 46% of ambulances were unused.

San Francisco mass gatherings appear to present a lower risk of ambulance transports compared to the community baseline, suggesting that the community baseline sets an appropriate standard for requiring standby ambulances at mass gatherings. The initial ambulance requirement policy in San Francisco may have been overly conservative.

Local baseline data is a recommended starting point when setting policy for public health needs at mass gatherings.

Large, functional, disaster exercises are expensive to plan and execute, and often are difficult to evaluate objectively. Command and control in disaster medicine organizations can benefit from objective results from disaster exercises to identify areas that must be improved.

The objective of this pilot study was to examine if it is possible to use performance indicators for documentation and evaluation of medical command and control in a full-scale major incident exercise at two levels: (1) local level (scene of the incident and hospital); and (2) strategic level of command and control. Staff procedure skills also were evaluated.

Trained observers were placed in each of the three command and control locations. These observers recorded and scored the performance of command and control using templates of performance indicators. The observers scored the level of performance by awarding 2, 1, or 0 points according to the template and evaluated content and timing of decisions. Results from 11 performance indicators were recorded at each template and scores >11 were considered as acceptable.

Prehospital command and control had the lowest score. This also was expressed by problems at the scene of the incident. The scores in management and staff skills were at the strategic level 15 and 17, respectively; and at the hospital level, 17 and 21, respectively.

It is possible to use performance indicators in a full-scale, major incident exercise for evaluation of medical command and control. The results could be used to compare similar exercises and evaluate real incidents in the future.

Kosovo is a post-conflict nation with an extensively damaged infrastructure, a weak primary care base, and poor maternal-child health outcomes. The Kosovo-Dartmouth Alliance for Healthy Newborns (the Alliance) sought to improve maternal and neonatal health in Kosovo by providing family medicine-based antenatal care (ANC).

The ANC Program used a modification of the World Health Organization's four-visit, prenatal care model. The program is based in family medicine and requires minimal medical equipment, such as a blood pressure cuff, fetal doppler, measuring tape, urine dipstick, and charting materials. Patient education and counseling are stressed. Women are taught about danger signs in pregnancy and establishing an emergency plan, so that they can respond promptly if complications occur. Antenatal care doctors and nurses are trained to refer women to obstetricians for deviations from normal pregnancy. The providers are taught using a “Training of Trainers” approach, building on an existing system of family medicine trainers. In order to address challenges in implementation and sustainability, microsystems methodology is used to focus on implementing change and assuring quality improvement through shared decision-making and the study of outcomes.

Based on chart reviews and direct observation, ANC providers showed mastery of the components of ANC, including physical examination, recognition and referral of high-risk pregnancies, and patient education. After an initial pilot project, Kosovo's Ministry of Health recommended this program for dissemination throughout the country. During the next year, ANC was implemented at 27 Family Medicine Centers in nine municipalities; 1,671 women were seen for a total of 3,399 visits. Currently, the Alliance's model of ANC is offered in 30% of Kosovo's municipalities.

International aid projects often lack attention to long-term sustainability. Microsystems training gives participants the tools and framework to implement and sustain change, even after international support is withdrawn.

The Alliance's model of family medicine-based ANC is simple to teach and emphasizes sustainability. It may be modified for use in different cultures and healthcare systems and offers the opportunity to improve maternal and infant health by providing low cost antenatal care, available in a woman's own community.

Attendance at UK emergency departments is rising steadily despite the proliferation of alternative unscheduled care providers. Evidence is mixed on the willingness of emergency medical services (EMS) providers to decline to transport patients and the safety of incorporating such an option into EMS provision. Physiologically based Early Warning Scores are in use in many hospitals and emergency departments, but not yet have been proven to be of benefit in the prehospital arena.

The use of a physiological-social scoring system could safely identify patients calling EMS who might be diverted from the emergency department to an alternative, unscheduled, care provider.

This was a retrospective, cohort study of patients with a presenting complaint of “shortness of breath” or “difficulty breathing” transported to the emergency department by EMS. Retrospective calculation of a physiologicalsocial score (PMEWS) based on first recorded data from EMS records was performed. Outcome measures of hospital admission and need for physiologically stabilizing treatment in the emergency department also were performed.

A total of 215 records were analyzed. One hundred thirty-nine (65%) patients were admitted from the emergency department or received physiologically stabilizing treatment in the emergency department. Area Under the Receiver Operating Characteristic Curve (AUROC) for hospital admission was 0.697 and for admission or physiologically stabilizing treatment was 0.710. No patient scoring <2 was admitted or received stabilizing treatment.

Despite significant over-triage, this system could have diverted 79 patients safely from the emergency department to alternative, unscheduled, care providers.

Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting.

A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting.

This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations.

There were 454 incidents identified from 230 cases (mean = 2.0; 95% CI 1.8−2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI = 1.4−1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean = 2.0; 95% CI = 1.8−2.2 per case), and there were 74 incidents from 26 combined cases (mean = 2.9; 95% CI = 2.2−3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%).

The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of “near miss” type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.

Survival from pulseless cardiac arrest typically is dismal. Some suggest that adding vasopressin to epinephrine as a cardiovascular stimulant can improve outcomes.

This study compares survival outcomes using epinephrine verses vasopressin and epinephrine in persons with pulseless cardiac arrest.

This is a retrospective, cohort evaluation of two resuscitative protocols (P1-epinephrine or P2-vasopressin with epinephrine) in a tiered response, community emergency medical service (EMS) with an approximately 100,000 catchment area. Cases are defined as 18 years or older determined to be in pulseless cardiac arrest. Outcomes were survival to emergency department arrival, to 24 hours, and to hospital discharge. Data were entered into Microsoft Office Excel® and processed using Analyze-it® for continuous and categorical data and Epi-Info® for odds ratios with confidence intervals.

There were 204 cases (60.3% males and 39.7% females) who met the inclusion criteria. Thirteen cases received electrical therapy only, and were dropped from analysis, leaving 191 (93.6%) who were included in the study; P1 to 85 (44.5%) and P2 to 106 (55.5%). Younger age was associated with improved survival to discharge home in both protocols, p = 0.003 (95% CI = 0.004–0.010). No difference in survival was noted at the levels of emergency department arrival OR 1.42 (95% CI = 0.73, 2.76) p = 0.26; 24 hour survival OR 0.54 (95% CI = 0.22–1.30) p = 0.133, or discharge home OR = 1.81 (95% CI = 0.49–6.88) p = 0.319.

This study in a community EMS did not demonstrate improved survival with the addition of vasopressin to epinephrine for pulseless cardiac arrest.