LA calls are associated with short-term morbidity and mortality. Patient age was found to be associated with these outcomes. These calls may be early indicators of problems requiring comprehensive medical evaluation and thus further factors associated with poor outcomes should be determined.
Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If treatment is not administered and the patient is not transported to hospital, it is referred to as a “Lift Assist” (LA) call. We have previously shown that LA are associated with morbidity and mortality. What places patients at an increased risk for morbidity and mortality is not yet known. Objective: To determine factors that are associated with increased risk of 14 day morbidity, determined by an ED visit or hospital admission, and mortality in LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year period (Jan - Dec 2013). These calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days. Logistic regression analyses were run to predict ED visit or hospital admission within 14 days of the LA call from patients’ age, gender, co-morbidities and vital signs at the initial LA call. Results: Of 42,055 EMS calls, 808 (1.9%) were LA calls. There were 169 (20.9%) ED visits, 93 (11.5%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA. Patient age > 61 (p < 0.001) and history of cardiac disease (p = 0.006) significantly predicted ED visit, while patient age >61 (p = 0.001) and an Ambulance Call Record (ACR) missing at least 1 vital sign (p = 0.017) significantly predicted hospital admission. There was a 10% increase in risk of ED visit and hospital admission for every 10 year increase of age after the age of 61. Of the 96 patients with at least 1 missing vital sign, 14 (14.5%) were coded as patient refusals. The sample size was too small to determine predictors for mortality. Conclusion: Patients at risk for morbidity are older than 61 years of age and have co-existing cardiac disease. Patients who are greater than 61 years of age and had at least one missing vital sign on the ACR were more at risk for hospital admission.
Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If treatment is not administered and the patient is not transported to hospital, it is referred to as a “Lift Assist” (LA) call. We have previously shown that LA are associated with morbidity and mortality. Subtle pathology may exist in those who require LAs and they may benefit from being transported to the Emergency Department for medical evaluation. Given that the majority of LA calls result in no-transport, there may be a bias towards not upholding the same standards of care as patients who are transported to hospital. Objective: To determine if there is a difference in Ambulance Call Record (ACR) documentation of vitals signs between LA calls and non-LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year period (Jan - Dec 2013). A control group of randomly selected calls of low acuity (Canadian Triage Acuity Scale 3,4,5) from the same time period was collected for comparison. ACRs from these calls were reviewed for missing vital sign documentation. Results: Of 42, 055 EMS calls, 808 (1.9%) were LA calls. A comparison of 784 randomly-selected non-LA control calls were reviewed. There were significantly more missing vitals (12.08% vs 6.64% p < 0.001) and refused vitals (1.87% vs 0.51% p = 0.013). Conclusion: There is a significant discrepancy in the complete documentation of vital signs in LA calls vs non-LA calls. There were also significantly more patient refusals for obtaining vitals compared to transported patients. Abnormal vital signs may be a clue to a subtle disease process that has resulted in a LA call, thus care should be taken to ensure that these patients are treated with the same standards of care and documentation as those patients calling EMS for overt medical reasons.
Introduction: Paramedics are often required to manage violent or combative patients. In order to do so safely, chemical sedation may be required. There are a number of pharmacologic agents which may be used. However, there is a paucity of evidence as to the optimal agent. Objective: To provide a descriptive analysis of a single base hospital’s experience with combative patients and to determine the efficacy and any adverse events (AEs) in the prehospital setting, associated with midazolam use in these patients. Methods: A retrospective chart review of ambulance calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were filtered and manually examined. Patients were excluded if they were 17 or younger. A priori data points were abstracted by trained research personnel from the ambulance call record. Results: Of approximately 350,000 calls over the study period, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam for sedation. Multiple doses were required in 33.3% of patients. Depending on route of administration, the average total dose administered was 6.27 mg (SD 3.98 mg) intramuscular, 10.7 mg (SD 4.00 mg) intranasal and 4.95 mg (SD 3.81 mg) intravenous. Midazolam was documented as effective in treating the combativeness in 133 (71.6%), ineffective in 28 (15.1%), and not documented in 25 (13.4%) calls. AEs post midazolam administration, defined as hypotension, bradypnea, bradycardia, or need for airway intervention, were encountered in 3 (1.61%) calls (respiratory rate of 8, hypotension of 88/59 that responded to intravenous fluid and asymptomatic bradycardia of 59). There was a trend of increasing number of combative patients each year over the study period, with a significant difference in the number of combative calls requiring midazolam administration between 2012 and 2015 (50.0% vs 72.8%, p=0.007). Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with minimal AEs. However, midazolam was ineffective in 15.1% and a third of all patients required multiple doses, prolonging the combative period and compromising paramedic and patient safety. Further research is warranted for this cohort’s emergency department (ED) sedation needs and any associated AEs within 1 hour of ED arrival.
Introduction: Paramedics are required to manage combative patients. In order to do so safely, chemical sedation may be required. Advanced Care Paramedics in our EMS system utilize midazolam for chemical restraint. Our previous research has shown that midazolam appears to have few prehospital adverse events (AEs) associated with its use. However, it required multiple dosages in 33.3% of patients and was deemed ineffective in 15.1% of patients that received it in the prehospital setting. Objective: To determine Emergency Department (ED) AEs associated with the prehospital use of midazolam in combative patients and determine the efficacy of this agent as a chemical restraint during the first hour of the ED stay. Methods: A retrospective chart review of paramedic calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were examined. Patients were excluded if they were 17 or younger. Ambulance call records were linked to the patient’s ED chart. ED charts were reviewed and a priori endpoints were extracted. Results: Of approximately 350,000 calls, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam in the prehospital setting. During the first hour of their ED stay, 68 (36.5%) required further sedation, while 118 (63.4%) patients did not. Of the 186 patients who received midazolam in the prehospital setting there was one death and one AE in the ED (defined as hypotension, bradypnea, or need for airway intervention). After further review of the charts, both AEs were deemed likely resulting from underlying pathology and not related to the use of midazolam. The average ED Length of stay (LOS) was 7.6 hours for all patients. A total of 82 (44.1%) were admitted to hospital with a mean in hospital LOS of 13.1 days. Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with no reported delayed AEs. 36.5% of this cohort required further sedation within 1 hour of their ED arrival. This supports previous findings that midazolam was ineffective in 15.1 % of prehospital combative patients. Further study is required to determine midazolam’s efficacy and AE profile compared to other prehospital agents in order to ensure optimal safety of both patients and paramedics.
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