Patients initially refusing care (PIRC) place their health in jeopardy and consume paramedic and base-station physician time. This study quantifies the time spent on-scene related to PIRC cases.

A retrospective analysis of 128 PIRC cases was performed in the Multomah County EMS system.

The PIRC cases had a significantly longer mean on-scene time than did non-refusal cases (30.3 vs 14.6 min; p<.001). Medication administration by paramedics (14% of patients) significantly increased the on-scene time. Overall, the mean time on-scene was not affected by age, gender, vital signs (pulse, blood pressure, respiratory rate), police involvement, and whether the patient was transported. The type of call had limited influence on on-scene time, although mean on-scene time was significantly longer for altered mental status cases than for trauma related cases (35.6 vs 22.4 min; p<.03).

PIRC cases create a burden on the EMS system by consuming paramedic and base-station physician time and by preventing these personnel from responding to other calls.

The risk of exposure to the Hepatitis B Virus (HBV) is a known occupational health risk in medical personnel. The specific risk in emergency medical services (EMS) personnel in the United States (U.S.) is not known. Estimates have ranged from 0.6 to 30.0% The purpose of this investigation was to provide an estimate of the prevalence of this exposure, to determine if this risk is homogeneous throughout the U.S., and to provide an estimate of relative risk. The study hypothesis was that the risk of exposure to HBV is not homogeneous throughout the U.S.

All articles containing HBV studies of non-immunized EMS personnel (physicians, nurses, and emergency medical service technicians [EMTs]) were considered, provided they reported at least two of the following seromarkers: hepatitis B (HB) surface antigen; HB surface antibody; and/or HB core antibody. A computerized literature search of a database (MEDLARS) from 1980–1989 was performed. Reference sections of relevant articles and texts also were searched. The chi-square test of homogeneity of proportion was used, assuming binomial distribution. The alpha error rate was set at 0.05.

Seven articles from 1982 to 1989 qualified for inclusion. The average rate of prevalence for all studies was 14.04% (160/1,140), with a 95% confidence interval of 11.40 to 16.68%. The chi-square test was statistically significant (chi-square=12.59, 6 df, p<.01), suggesting that the risk of exposure is not homogeneous throughout the U.S., and may not be homogeneous within a city, nor between prehospital and hospital personnel. When compared to CDC estimates for the general population in the U.S., this analysis suggests that the EMS personnel tested run three times (2.8) greater risk of HBV exposure than does the general population.

EMS personnel run a great risk of exposure to HBV with a nationwide prevalence of 14.04%, but this risk is not spread homogeneously throughout the country.

A prior report demonstrated a five-minute decrement in scene and total prehospital times in the standing order and limited standing order intervals as compared to control.

The Alameda County Emergency Medical Service (EMS) District studied the impact of standing orders on field times, comparison of paramedic assessments with emergency department diagnoses, field drug use and procedures, and hospital outcome. These variables were studied over three discrete, six-week, time-study intervals, which represented three different levels of base-hospital medical control (control, standing order, and limited standing order).

There were no statistically significant differences between the three time-study intervals for the following variables: 1) incidence of prehospital administration of three cardiac arrest drugs; 2) incidence of prehospital administration of no drugs; 3) incidence of performance of endotracheal intubation; 4) incidence of performance of defibrillation; 5) assessment comparison; and 6) hospital outcome. There were statistically significant differences between intervals for incidence of: 1) administration of naloxone; 2) administration of 50% dextrose; 3) intravenous (IV) starts; and 4) paramedic performance of no procedures.

Although there are several potential flaws in method, the data suggest that standing orders result in decreased incidence of drug administration and IV starts in non-critical situations without a negative impact on paramedic assessments or hospital outcome.

A retrospective study of patients transported by paramedics to a community teaching hospital was conducted to: 1) determine the response of hypoglycemic patients to prehospital treatments, 2) develop criteria to identify patients who safely could be released without transport to a hospital, and 3) evaluate the prehospital release criteria.

Patients presenting to EMT-paramedics with an altered level of consciousness were identified retrospectively. Pre- and post-treatment blood glucose levels were measured and response to treatment noted (Phase 1). Criteria were established using these data and a second sample was evaluated using these criteria (Phase 2).

During a 12-month period, 60 patients with an altered level of consciousness (ALOC) were encountered. Of the 60 patients, 27 (45%) were documented to be hypoglycemic (blood glucose [BG] <80 mg/dl, mean 27±13 mg/dl). Of the 27 hypoglycemic patients, 24 (89%) were discharged from the emergency department (ED) and three patients (11%) were admitted. Criteria were developed to identify patients who could be treated and released safely without transport to a hospital: 1) history of insulin (IDDM) or non-insulin (NIDDM) dependent diabetes mellitus; 2) pre-treatment BG <80 mg/dl; 3) post-treatment BG >80 mg/dl; 4) return to normal mental status within 10 minutes of treatment; and 5) absence of complicating factors (renal dialysis, chest pain, arrhythmia, dyspnea, seizures, alcohol intoxication, focal neurological signs/symptoms). The criteria were applied retrospectively to 27 hypoglycemic (mean BG=28±14 mg/dl) patients during a different 10-month period. Of the 27 hypoglycemic patients, 23 (85%) were discharged from the ED, and prehospital release criteria correctly identified 19 of 23 (83%). The prehospital release criteria did not select for release any patient who required an additional, major intervention or who was admitted.

This study demonstrates that there is a group of hypoglycemic patients who respond favorably to paramedic interventions. Retrospectively, the prehospital release criteria were successful in selecting patients who did not require additional interventions. A larger prospective study must be conducted before prehospital treatment and release can be recommended for general practice.

A daily EMS audit was performed to assess whether a paramedic peer review audit would improve the quality of documentation and radio communications in cases transported to a single receiving facility.

Prehospital EMS run sheets and run tapes were reviewed for adherence to standards developed for the county EMS system. Items evaluated were run sheet documentation of care and paramedic radio presentation. Checklists were used and multiple parameters evaluated for each case. Two periods, 1987–88 and 1989 were compared to evaluate the effectiveness of this system. Care rendered by a total of 106 paramedics was evaluated. Confidence intervals of 0.95 were calculated on the differences between groups. Practicing paramedics audited 63% of the days in 1987–88 and 80% in 1989. Data from each case were tabulated and a profile, average deficiencies per run calculated for each paramedic.

A total of 4175 run sheets and tapes were audited for the period 1987–88 with an average of deficiencies/run of 0.27, and for 1989 a total of 1872 run sheets and tapes were reviewed with a deficiency/run rate of 0.21, indicating a statistically significant improvement (0.95 CI= 0.02, 0.08). Twelve paramedics were not auditors in 1987–88, but audited in 1989. Their deficiencies/run decreased from 0.13 to 0.08

A peer review audit in this system appears to be effective in improving documentation and radio performance. Performance also improved when paramedics served as auditors.