Evidence Supports Advances in Pre-Hospital Care Home

Purpose:  

Provide clarity for placement of Extended Scope of Practice (ESP) Paramedics to provide advanced back up on complex trauma and medical patients, as well as manage specific high risk patient events and critical care transports.  ESP Paramedics are trained as advanced practice providers, able to function as the “hands, eyes, and ears” of the physician, providing advanced decision making, advanced diagnostics, and advanced care under the direct authority of a specific physician through online and offline medical direction.  The focus of these resources are to improve neurologically and functionally intact survival in the patient population through application of advanced medications and procedures.  This system of advanced providers has shown dramatic results in Washington, Oregon, Victoria, South Africa, and Raleigh.

Application:

In King County Washington, the Portland Metropolitan Area in Oregon, and Clark County Nevada during the past ten years, there has been an ever increasing rate of neurologically intact survival from cardiac arrest, functionally intact recovery from trauma, and functionally intact recovery from myocardial infarction and cerebral vascular accidents.  With all three system being top performing EMS systems in the world, and the King County Medic One system taking firm hold as the top performing EMS system in the world today with cardiac arrest neurologically intact survival exceeding 50% in 2013!

For an EMS system to become a world leader in EMS and match the results of the highest performing EMS systems in the world, there must be a unique, close, and intimate integration of clinical governance, education, and operations management similar to the methodologies utilized in the three systems discussed above, because only through acknowledgement of the equal footing of medical direction and operations can an EMS system be successful in advanced practice.  EMS systems can move to a high fidelity, high performance, and high impact model with the implementation of a tiered response system with a small group of paramedics functioning at an extended scope of practice which mirrors the scope of paramedics in several high-performance systems.  This small cadre of Medical Director approved and mentored ESP providers to provide a supplemental paramedic with a high frequency of critical patient care encounters to augment the care being provided by our outstanding ambulance-based EMS providers and provide those advanced interventions that must be done right now or the patient will perish.

A sample of those impacts follow:

1. As discussed at the International science symposium (1a, 1b, 1c, 1d), full application of the immediate post cardiac arrest algorithm, advanced preparation steps for PCI, and direct PCI admission can improve cardiac arrest survival from 27% to 43%!  With an average of 40 cardiac arrest incidents treated a month by National Ambulance, this level of intervention combined with rapid defibrillation and CPR from first in units and the general public (through increased public response with the use of PulsePoint) would result in a potential 206 neurologically intact cardiac arrest survivors due to National Ambulance!
2. While the use of standard paramedic interventions make a large impact on patient’s suffering ventricular fibrillation arrest, only through application of advanced techniques can the patient in PEA arrest have an equal chance at survival, by the application of a modified approach to the PEA patient, rapid intervention is possible to improve lives saved (2a).
3. In the current lexicon of trauma, Damage Control Resuscitation (DCR) has been the standard of care since 2008 in the military medical systems worldwide for the 3-8% of trauma patients on the edge of physiologic exhaustion and cardiac arrest; but only through application of advanced techniques (3a, 3c, 3d, 3e, 3f), can these patients experience the dramatic recovery rates (approaching 7%3b in traumatic arrest and 80% in multisystem trauma) shown in high performance EMS systems within South Africa and the United States.   The addition of blood products for specific trauma patients allows the ESP paramedic to again increase survival (3g, 3h), when coupled with ultrasound identification of specific traumatic injuries, the ESP paramedic will be able to reduce some injury fatality rates by as much as 50% (5a, 5b, 5c).
4. Through the use of advanced techniques and treatment protocols, the ESP provider will be able to improve outcomes secondary to myocardial infarction in a dramatic fashion, through ESP protocols and direct admission to PCI processes established between the cardiology PCI staff and the small cohort of ESP paramedics, the time of event to PCI intervention can be under 90 minutes (1e)
5. The application of ESP paramedics with advanced airway capability will improve airway management success and improve patient outcomes (4a-g)

Fiscal Impacts:

Fiscal impacts are negligible for implementation of this program, if the model for advanced practice utilized by American Medical Response is utilized in this circumstance:

1. Personnel must apply for the available positions and attend a training/selection academy on their own time.
2. The Medical Director appoints a single supervising educator for the program, this individual works directly with the advanced personnel as the medical director’s designee and intimately with operations to develop an effective team of personnel while guiding and assessing their education and clinical competencies in the classroom and field.
3. The supervising training officer selects field training officers at a ratio of 10:1 for the advanced practice personnel, these FTO personnel work as shift personnel, but report to the Medical Director and Supervising Educator.
4. No additional monetary compensation is offered to these personnel, the only return for their time and investment in their clinical practice is dramatically increased training opportunities, field mentoring, the addition of three “education days” to their leave time per year, and a small increase in work schedule privileges.

Fiscal impacts to the healthcare system can exceed $2,000,000 per patient who is converted from a disabled state to a fully functional state by the application of these techniques.  In the United States, the CDC estimates that in 2000 the medical costs and indirect costs (lost productivity) of TBI in United States totaled $60 billion, with extended care for comatose patients exceeded $1,000 usd/day.  The Markov model estimated rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per long term maintenance patient care; and the American Heart Association estimated significant savings in their “Cost and Outcome of Mechanical Ventilation for Life-Threatening Stroke” consensus statement for patients whose functionality could be improved rather than long term care being required.  This process also applies to the post cardiac arrest and trauma patient populations.

Evidence References:

Improving Post Cardiac Arrest Survival and ACS

1. Implementation of complete field post cardiac arrest care and direct admission to PCI resulted in an adjusted unpaired analysis of 27.4% neurologically survival without immediate PCI verses 43.7% neurologically intact survival with PCI (Immediate PCI after Cardiac Arrest is associated with short and long term outcome; Guillaume Geri, Florence Dumas, etAl; Original Research Presented November 16, 2014 at AHA/ILCOR Science Meeting, Chicago, Illinois, USA)
2. Few systems worldwide have achieved the benchmark time of less than 90 minutes from emergency medical services (EMS) contact to balloon inflation (E2B) for patients sustaining ST-segment elevation myocardial infarction (STEMI) (Paramedic contact to balloon in less than 90 minutes: a successful strategy for st-segment elevation myocardial infarction bypass to primary percutaneous coronary intervention in a Canadian emergency medical system. Cheskes S, Turner L, Foggett R, Huiskamp M, Popov D, Thomson S, Sage G, Watson R, Verbeek R.; Prehosp Emerg Care. 2011 Oct-Dec;15(4):490-8)
3. Overall, optimizing advanced and systemic implementation is the action most likely to result in widespread improvement in survival after OHCA (Implementation Strategies for Improving Survival After Out-of-Hospital Cardiac Arrest in the United States; Robert W. Neumar, et Al; Circulation; 2011; 123: 2898-2910)
4. If Out Of Hospital Cardiac Arrest (OOHCA) associated with STEMI, field providers should bypass nearest hospitals and go directly to a cardiac receiving hospital so patients can receive angiography within 90 minutes (Regional Systems of Care for OOHCA: A Policy Statement from the AHA, Circulation Feb 9, 2010)
5. Hospital door-to-balloon time for those patients averaged 47 minutes and only 87 minutes from when the 9-1-1 call was answered until the patient received a PCI. (Paramedics Activate Cath Lab for STEMI Patients in Some Areas; JEMS, June 25, 2007)
6. A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality (Reduction in Mortality as a Result of Direct Transport From the Field to a Receiving Center for Primary Percutaneous Coronary Intervention; Michel R. Le May, MD, et Al; Journal of the American College of Cardiology Vol. 60, No. 14, 2012)
7. Improving Cardiac Arrest Survival
8. A modified approach to PEA focuses on “cause-specific” interventions utilizing two simple tools: ECG and Bedside Ultrasound (US) (Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity. Littmann L, Bustin D, Haley M.  A; Med Princ Pract 2014; 23:1-6)
9. In CARES, survival was higher among OHCA receiving ETI than those receiving SGA (McMullan J, Gerecht R, Bonomo J, et al. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation. 2014;85(5):617–622. doi:10.1016/j.resuscitation.2014.02.007)
10. “In out-of-hospital urban and rural settings, patients intubated during resuscitation had a better survival rate than patients who were not intubated, whereas in an in-hospital setting, patients who required intubation during CPR had a worse survival rate. A recent study found that delayed endotracheal intubation combined with passive oxygen delivery and minimally interrupted chest compressions was associated with improved neurologically intact survival after out-of-hospital cardiac arrest in patients with adult witnessed VF/pulseless VT “ (2010 CPR/ECC Science Guidelines, Part 8.1, Advanced Airways)
11. The presence of an intensive care paramedic had a significant effect on survival (OR = 1.43, 95% CI = 1.02 to 1.99). (Impact of advanced cardiac life support‐skilled paramedics on survival from out‐of‐hospital cardiac arrest in a statewide emergency medical service; John Woodall, Molly McCarthy and Vivienne Tippett, Emerg Med J. Feb 2007; 24(2): 134–138)

Improving Trauma Survival

1. The natural extension and development of DCS has been damage control resuscitation.  DCR is a structured, mobile intervention that can be delivered to a critically ill patient in any location. Basic principles include arresting hemorrhage; restoring blood volume; and correcting coagulopathy, acidosis and hypothermia (Damage control resuscitation: history, theory and technique; Chad G. Ball, MD, MSc; Can J Surg. Feb 2014; 57(1): 55–60)
2. 6.6% of the patients survived with a CNR. Our data allow us to state beyond any doubt that advanced life support should be initiated in TCA patients regardless of the initial rhythm, especially in children and those with VF or PEA as the initial rhythm.  (Traumatic cardiac arrest: should advanced life support be initiated?; Leis CC1, Hernández CC, Blanco MJ, Paterna PC, Hernández Rde E, Torres EC; J Trauma Acute Care Surg. 2013 Feb;74(2):634-8)
3. Contrasted patients kept at a MAP of 65 verses those kept at a MAP of 50; Patients in the low MAP group: Had lower transfusion requirements, Developed coagulopathy less frequently, Had a lower 24-hour mortality (Hypotensive Resuscitation Strategy Reduces Transfusion Requirements And Coagulopathy In Trauma Patients With Hemorrhagic Shock; Morrison CA. J Trauma 2011; 70:652-663)
4. Targeted pre-hospital ventilation is associated with lower mortality after severe TBI (The impact of prehospital ventilation on outcome after severe traumatic brain injury; Warner KJ, Cuschieri J, Copass MK, Jurkovich GJ, Bulger EM; J Trauma. 2007 Jun;62(6):1330-6)
5. Aeromedical crews appear to appropriately select major trauma victims to undergo field needle thoracostomy and tube thoracostomy. A low incidence of complications and a small but significant group of unexpected survivors support continued use of this procedure by aeromedical personnel.(The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel; Davis DP, Pettit K, Rom CD, Poste JC, Sise MJ, Hoyt DB, Vilke GM; Prehosp Emerg Care. 2005 Apr-Jun;9(2):191-7)
6. Found that advanced scope paramedics could safely provide ALS care in a backcountry environment. This care improved patient comfort during long extrication and allowed for life-saving interventions such as advanced airway management, at the patient’s side preventing loss of life. (Advanced life support in the wilderness: 5-year experience of the Reach and Treat team; Terri A. Schmidt; Carol S. Federiuk; Andrew Zechnich; Markus Forsythe; Michael Christie; Christopher Andrews; Wilderness and Environmental Medicine. 1996;7(3):208-215.)
7. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital, allowing earlier infusion of life-saving products to critically injured patients. (Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients; John B. Holcomb, Daryn P. Donathan, et Al; Prehospital Emergency Care, June 16, 2014)
8. It is feasible and practical to provide prehospital trauma teams with pRBCs for use in the field. Use of pRBCs in the prehospital setting is associated with similar rates of pRBC wastage to that reported in emergency departments. (The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells; Daniel Bodnar, et Al; Emerg Med J 2014;31:93-95)
9. Airway Management at the ESP Level:
10. In this population-based cohort of out-of-hospital cardiac arrest, RSI was used in 15% of patients and associated with a better prognosis than intubation attempted without paralytics. Because this subset with a favorable prognosis may not be readily intubated in systems without paralytics, these findings could help to explain the adverse relationship between intubation and survival observed in prior studies. (Use of rapid sequence intubation predicts improved survival among patients intubated after out-of-hospital cardiac arrest; Kwok, et Al; Resuscitation. 2013 Oct;84(10):1353-8)
11. In adults with severe TBI, pre-hospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital. (Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury; Stephen A. Bernard MD, Vina Nguyen BSc, Peter Cameron MD, et Al; Annals of Surgery  Volume 252, Number 6, December 2010)
12. Seattle Medic One’s first-pass success rate for oral endotracheal intubation is 75%; its overall success rate is 98.4%. (Prehospital Management of the Difficult Airway: A Prospective Cohort Study; Keir J. Warner, BS, Sam R. Sharar, MD, Michael K. Copass, MD, Eileen M. Bulger, MD; Journal of Emergency Medicine, Volume 36, Issue 3, Pages 257–265, April 2009)
13. Although rarely performed, cricothyroidomy can be a life-saving procedure. Evidence from model lung studies shows that the surgical method provides effective ventilation independent of the degree of upper airway restriction, whereas the efficacy of initial ventilation via a cannula reduces as an inverse function of increasing upper airway restriction, and becomes totally inadequate within 60 s if a low pressure (15 l.min−1) self-assembled ventilation system is used (Needle vs surgical cricothyroidomy: a short cut to effective ventilation; I. Scrase and M. Woollard; Anaesthesia; Volume 61, Issue 10, pages 962–974, October 2006)
14. Surgical cricothyrotomy appeared to be a preferable method for establishing a definitive airway over the percutaneous method (A laboratory comparison of emergency percutaneous and surgical cricothyrotomy by prehospital personnel; Keane MF, Brinsfield KH, Dyer KS, Roy S, White D; Prehosp Emerg Care. 2004 Oct-Dec;8(4):424-6.)
15. In this study, only 1.1% of patients required a surgical airway. We attribute this low rate to the use of paralytic agents. The availability of paralytic agents also allows expansion of the indications for prehospital airway control. (An analysis of advanced prehospital airway management; Bulger EM1, Copass MK, et Al; J Emerg Med. 2002 Aug;23(2):183-9.)
16. Paramedics successfully intubated 95.5% (1,582) of all patients receiving Succinylcholine; 94% (1,045) of trauma patients and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative advanced methods, such as SGA or surgical cricothyroidomy. (Prehospital use of Succinylcholine: a 20-year review; Wayne MA, Friedland E.; Emergency Medical Services, Bellingham/Whatcom County, Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.)
17. Ultrasound Application for Patient Improvement:
18. Pre-hospital ultrasound when applied by an proficient examiner using a goal-directed, time sensitive protocol is feasible, does not delay patient management and provides diagnostic and therapeutic benefit. Further studies are warranted to identify the exact indications and role of pre-hospital sonography. (Portable ultrasound in pre-hospital emergencies: a feasibility study; M. Busch, et Al; Acta Anaesthesiologica Scandinavica, Volume 50, Issue 6, pages 754–758, July 2006)
19. Prehospital emergency ultrasound has many clinical applications that would reduce morbidity and improve outcomes of patients with life-threatening emergency conditions. This imaging modality improves diagnostic accuracy and provides crucial information to prehospital providers to guide management and help triage patients to appropriate destinations (Prehospital Emergency Ultrasound: A Review of Current Clinical Applications, Challenges, and Future Implications; Mazen J. El Sayed and Elie Zaghrini; Department of Emergency Medicine, Beirut Medical Center, Beirut, Lebanon; Emergency Medicine International, 2013
20. Logistic regression revealed that ABD CT was independently associated with more than a 70% higher risk of mortality. (OR, 1.71; 95% CI 1.2-2.2, p <0.001) (Over reliance of CT imaging in patients with severe abdominal injury: Is the delay worth the risk?; Neal MD. J Trauma 2011; 70:278-284)