The Top 5 of Relevant. Counterintuitive. Practice-Changing. Research that matters to our patients.
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1 The Top 5 of 2016 Relevant. Counterintuitive. Practice-Changing. Research that matters to Mike says, You kids, get off my lawn! #NAEMSP17
2 EMS Physician Influence on Cardiac Arrest
3 Does our presence improve outcomes? Bottiger; Bernhard; Knapp; Nagele Critical Care :4 Systematic Review PRISMA, MOOSE, English or German MEDLINE, EMBASE, Cochrane Up to June 2014 Yield = 14/3153 Low risk of publication bias based on funnel plot No RCTs High risk of selection bias
4 Does our presence improve outcomes? Bottiger; Bernhard; Knapp; Nagele Critical Care :4 Systematic Review Comparison between EMS physician guided and paramedic guided CPR OOHCA Adult Population Survival Data Available
5 Does our presence improve outcomes? Bottiger; Bernhard; Knapp; Nagele Critical Care :4 Systematic Review Total poled sample size = 126,829 pts Survival to hospital discharge: EMS Physician 15.1% (95% CI ) Paramedic 8.4% (95% CI ) OR 2.03 (95% CI ; p < 0.001)
6 Does our presence improve outcomes?
7 Does our presence improve outcomes? Bias/Confounders Selection Bias Anesthesiologist Hawthorn Effect Heterogenous Systems
8 How do we put this into practice?
9
10 Stay and Play? Load and Go? Or Leave and Let Die The case of the nontransport.
11 2011 NAEMSP Position Paper A prerequisite to EMS provider decision to not transport requires, at a minimum, additional education for the providers, a quality improvement process, and stringent physician oversight.
12 Leave and let die? Tohira, Finn, et al PEC 2016(20) Retrospective Cohort Study Linked ambulance, ER and death registry data Outcomes: 911, admission, death Comparison: left at home vs transported
13 Leave and let die? Tohira, Finn, et al PEC 2016(20) 47,000 patients 40% left at scene 60% transported
14 What s your sign-off rate?
15 Leave and let die? Tohira, Finn, et al PEC 2016(20) Within 24 hours: Request ambulance: 6.1 vs 1.8 (OR 3.4) Get admitted: 3.3 vs 0.8 (OR 4.2) Die: 0.2 vs 0.1 (OR 1.8, CI )
16 Leave and let die? Tohira, Finn, et al PEC 2016(20) Within 7 days: Request ambulance: 11.8 vs 6.7 (OR 1.7) Get admitted: 5.7 vs 3.0 (OR 1.8) Die: 0.5 vs 0.3 (OR 1.8)
17 Leave and let die? WELLS SCORE <2% CT HEAD RULE <1% Tohira, Finn, et al PEC 2016(20) Within 7 days: Request ambulance: 11.8 vs 6.7 (OR 1.7) Get admitted: 5.7 vs 3.0 (OR 1.8) Die: 0.5 vs 0.3 (OR 1.8) CURB65 SCORE <5% HEART SCORE <2%
18
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20 Mortality and Prehospital Blood Pressure with Major TBI
21 Guidelines for Prehospital Management of TBI Patients with suspected severe traumatic brain injury (TBI) should be monitored in the prehospital setting for hypotension (<90 mmhg systolic blood pressure [SBP]). Hypotensive patients should be treated with isotonic fluids Badjatia, et al. PEC (1)
22 What is the effect of hypotension? Spaite; Hu; Bobrow; Chikani; Sherrill; Barnhart; Gaither; Denninghoff; Viscusi JAMA Surg Secondary Analysis of EMS TBI Database Parent Study: Excellence in Prehospital Injury Care TBI (EPIC TBI) Evaluating the Effect of Implementation of the Prehospital TBI Guidelines Arizona State Trauma Registry; 8 level I trauma centers Patients in EPIC database linked to EMS epcr
23 What is the effect of hypotension? Spaite; Hu; Bobrow; Chikani; Sherrill; Barnhart; Gaither; Denninghoff; Viscusi Secondary Analysis of EMS TBI Database January 2007 to March 2014 Pre-intervention group from the EPIC-TBI database Moderate or Severe TBI: Barell Matrix Type 1; ICD head >2; AIS head > 2 Prehospital SBP mmhg Study the risk-adjusted associations between mortality and SBP
24 What is the effect of hypotension? Spaite; Hu; Bobrow; Chikani; Sherrill; Barnhart; Gaither; Denninghoff; Viscusi Secondary Analysis of EMS TBI Database Unadjusted morality examined using moving average plots Risk-adjusted: age, sex; race; trauma type; trauma center; hypoxia; intubation
25
26 What is the effect of hypotension? Spaite; Hu; Bobrow; Chikani; Sherrill; Barnhart; Gaither; Denninghoff; Viscusi Secondary Analysis of EMS TBI Database N = 3316 pts studied out of 17,105 pts in the pre-intervention group Adjusted OR (95% CI ; p < 0.001) associated with a 10 mmhg increase of SBP 18.8% lower odds of death for every 10 point increase of SBP
27 What is the effect of hypotension?
28
29 What is the effect of hypotension? Limitations Cause -> Effect Counter to current recommendations MAP vs. SBP
30 What do we do tomorrow?
31
32 Detection difficult Care bundle can be done
33 * No difference in survival to discharge * Better than placebo in bystander witnessed cases * May result in less hospital CPR
34 Is it right for your system?
35 Need a protocol May lose a chance to provide care
36 Hypotension is common Dose of hypotension is important
37 We would love your feedback. How is the #NAEMSP17
Daniel W. Spaite, MD Uwe Stolz, PhD, MPH Bentley J. Bobrow, MD Vatsal Chikani, MPH Duane Sherrill, PhD Michael Sotelo, BS Bruce Barnhart, RN, CEP
Daniel W. Spaite, MD Uwe Stolz, PhD, MPH Bentley J. Bobrow, MD Vatsal Chikani, MPH Duane Sherrill, PhD Michael Sotelo, BS Bruce Barnhart, RN, CEP Joshua B. Gaither, MD Terry Mullins, MBA Will Humble, MPH
Daniel W. Spaite, MD Vatsal Chikani, MPH Bentley J. Bobrow, MD Michael Sotelo, BS Bruce Barnhart, RN, CEP Kurt R. Denninghoff, MD Joshua B.
Daniel W. Spaite, MD Vatsal Chikani, MPH Bentley J. Bobrow, MD Michael Sotelo, BS Bruce Barnhart, RN, CEP Kurt R. Denninghoff, MD Joshua B. Gaither, MD Chad Viscusi, MD David P. Adelson, MD Duane Sherrill,
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