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Backup 11/20/2009 COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD AGENDA MEETING TO BE HELD: Neighborhood Health Clinic 120 Goodlette Road North, 2nd floor meeting room Naples, Florida DATE: November 20,2009 TIME: 4:00 P.M. Call to Order Pledge of Allegiance Establish Quorum Agenda AdditionslDeletions Adoption of Agenda Minutes from Previous Meeting AdditionslDeletionslCorrections Adoption of Minutes September 25th Minutes Old Business Adoption of final Bylaws revised @ September meeting CPR save rates New Business a) Elsevier Resuscitation Article-Ambulance Deployment Strategies in regards to Cardiac Arrest survival b) July 2008, Prehospital Emergency Care Article-Paramedic Benchmark Thresholds c) University of North em Colorado Study-Effectiveness of First Response Paramedics Public Comment Board Member Discussion Establish Next Meeting Date Adjournment -,.~- -----. ,. . -,-.---- ._-, .-,--,'-'" --~ - ".-. , ,m, .. .",- . COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISOR Y BOARD BY LAWS ARTICLE I: NAME The name of this organization shall be the Collier County Emergency Medical Services Policy Advisory Board (hereinafter the" Advisory Board"). ARTICLE II: FUNCTIONS, POWERS AND DUTIES The functions, powers and duties of the Advisory Board are set forth in Ordinance 2009-01, as amended from time-to-time, a copy of which is attached hereto. This Advisory Board shall also be governed by Ordinance 01-55, as amended. To the extent these bylaws are in conflict with either of these ordinances, the terms of the ordinance will control. ARTICLE III: MEETINGS The regular meetings of the membership of the Advisory Board shall be held ~ bimonthly at such time and place as designated by the Chairman. The Chairman may call special meetings of the Advisory Board when such meetings are deemed necessary. Notice of special meetings shall be given to each member of the Advisory Board as provided in section 2 below. Pursuant to Florida's Sunshine Law, all meetings shall be open to the public. This also includes committee meetings. Notice of the time, place and purpose of all regular meetings and special meetings of the Advisory Board shall be made to each member not less than five (5) days before such meetings. Attendance by any members at such meetings shall constitute his/her waiver of the requirement of written notice. ARTICLE IV: OFFICERS The membershi[1 of the Advisory Board shall include the current Chairman of the Board of County Commissioners as a non-voting member, who cannot act as either the Chairman or Vice-Chairman. Members shall elect from the membership recommended Society the following officers at their first meeting held after January of each year: A. A Chairman, who shall preside at all meeting of the Advisory Board and be a member ex-officio of all committees. The Chairman shall have further powers and duties as may be assigned by the Advisory Board. - -...---.----".-,., ----__.. n, , '. - _..,-,.~_.~ ~...... ~--~. B. Vice Chairman, who in the absence of the Chairman shall exercise all powers and duties of the Chairman. The Vice-Chair shall have other duties and powers as may be assigned by the Advisory Board. The term of office of all otlieers of the Advisory Board shall be one (1) year or until their successors are elected. The terms will begin on the first meeting after the I st of January, though the end of December of the current year. Any otlieer may be re-eleeted for the same otliee. A vacancy in the otliee of Chairman or Vice-Chairman may be filled by the Advisory Board at any regular meeting or special meeting called for that purpose. The Secretary for the Advisory Board shall be appointed by the Director of the Bureau of Emergency Services. The Secretary shall cause to be kept all minutes of all meetings of the Advisory Board, shall be responsible for giving proper notice of all meetings of the Advisory Board, shall perform all duties incidental to the office of Secretary, shall keep track of and coordinate absences, and shall have such further duties and powers as may be assigned by the Chairman. Excused absences shall be coordinated with Secretary 24 hours prior to each meeting in order to meet attendance requirements. ARTICLE V: COMMITTEES The Chairman is empowered to appoint such permanent or ad hoe sub committee chairs as are deemed necessary for the successful execution of the Advisory Board program. All committee activities must be reported at a regular Advisory Board meeting. All Committees must also comply with the Florida Sunshine law. ARTICLE VI: AMENDMENTS These by-laws may be amended by the Board of County Commissioners on its own initiative or by approving proposed amendments by the Advisory Board. A proposed amendment must be passed by a majority vote of the membership present and voting at any regular, special or annual meeting after notice of such proposals for amendment has been given to all members as provided in these by-laws. Notice of any proposed amendment shall be submitted in writing to all members of the Advisory Board not less than thirty (30) days prior to the meeting at which such amendments are to be considered. ARTICLE VII: RULES OF PROCEDURE All meetings of the Advisory Board and any committees shall be conducted and governed by Parliamentary Procedure and usage as contained and set forth in Robert's Rules of Order, lOth Edition, unless otherwise provided lor in these by-laws or except where modification of such rules is required because of the nature of the work to be accomplished by the Advisory Board. "", ._.~",""_.._.,. Effectiveness of First Response Paramedics University of Colorado ARCTIC Program . Richmond Ambulance Authority and Virginia Commonwealth University Medical Center have improved resuscitation and survival rates within the last two years with the use of cooling measures . Collier County EMS/Fire implemented 0 similar program 10 months ago and wi!! be compiling data over the next year to compare the similarities and differences between the two programs. There is not enough data at this time for comparison . Preliminary conclusions suggest that ALS first responders do not result In higher ROSe, faster scene times, more successful ALS airways, nor shorter times to Intubation. . Better care may be delivered when fewer paramedics run more transports and first response Is limned to a BLS capacity. , Q&A ,'0 ';\f' 2 "_.~."'_"-- -...-------.. -';'-'--"- Contact: Joe Kuttenkuler, Sathya Achia Abraham Office of Communications and Public Relations Phone: (804) 828-6607 Email: jpkutten(llJvcu.edu or sbachia(llJvcu.edu www.news.vcu.edu OR Shannon Jackson Richmond Ambulance Authority Phone: (804) 343-3608 Email: mackson(llJshannonjacksonpr.com Resuscitation and survival rates trom out-ot-hospital cardiac arrest nearly double with comprehensive treatment protocol VCU Medical Center and Richmond Ambulance Authority partner in unique effort RICHMOND, Va. (Nov. 16, 2009) - Virginia Commonwealth University Medical Center and the Richmond Ambulance Authority have improved resuscitation and survival rates dramatically for cardiac arrest patients by training and equipping paramedics to begin lowering a patient's body temperature in the field during resuscitation and following up at the hospital with a host ot high-tech strategies to improve the odds of survival. The VCU and RAA initiative, known as the Advanced Resuscitation Cooling Therapeutics and Intensive Care Center, or ARCTIC, is the most comprehensive program of its kind in the United States, and its strategy resulted in an almost two-fold improvement in the return of spontaneous circulation, from 25 percent in 2001 using conventional treatments to 46 percent in 2008. In turn, the survival rate to hospital discharge improved from 9.7 percent in 2003 to 17.9 percent at the end of 2008. The national average is less than 7 percent. ARCTIC has two goals: to restart the heart as quickly as possible following onset of cardiac arrest, and to protect the brain by starting cooling as early as possible and bringing resuscitated patients to a single specialized post-resuscitation facility. Between 2001 and 2008, the team evaluated 1,598 cases of adult, out-of-hospital cardiac arrest events in Richmond, Va., and concluded that a building block strategy comprised of a unique combination of mechanical chest compressions, airway management, drugs that restart the heart, and cold saline given during resuscitation prior to the return of spontaneous circulation, sequentially improved patient outcomes. "What we now know is that we have to protect the brain and vital organs during resuscitation and after the heart is restarted and this has led to a totally new strategy for how we treat cardiac arrest patients," said Joseph P. Ornato, MD., chair in the ~artment of Emerqency Medicine at the VCU School of Medicine and operational medical director of the Richmond Ambulance Authority. "Richmond Ambulance Authority paramedics are the first in the country to initiate the cooling process during resuscitation. RAA's treatment strategy includes using a combination of drugs given early to support circulation and restart the heart, and performing high quality CPR using a mechanical device _ available in all RAA ambulances - that squeezes the chest to achieve better blood pressure and oxygen delivery than that achieved with just standard CPR," he said. "~--_._-_..,"_.""-" --.-~-~""~-~.~"~-_... 2 "The Richmond Ambulance - VCU Medical Center partnership is so successful because it provides a continuum of care for the cardiac arrest patient from the time the 911 call is received until the patient walks out of the hospital. We are constantly sharing and assessing detailed data to improve the clinical and operational process, and the dramatic increase in our survival rate reflects this," said Chip Decker, chief executive officer of the Richmond Ambulance Authority. Decker continued, "The EMS system in the city of Richmond is a team approach between the Richmond Ambulance Authority and Richmond Fire Department, with Fire as first responder, and it works extremely well. Our rapid response times, combined with leading-edge clinical protocols like the cooling process implemented under Dr. Ornato's guidance, have enabled us to deliver a more viable patient to VCU." VCU Medical Center Is continuously staffed with a team of specially trained physicians and nurses experienced in post-resuscitation care who continue the rapid cooling process by placing a high-tech plastic coil into a large vein soon after arrival at the emergency department. Patients are treated by specially trained coronary care unit nurses and physicians who administer complex "goal-directed" treatment protocols and maintain the patient's body temperature at 93' F for at least 24 hours, following which the patient is gradually rewarmed in a computer-controlled sequence. In previous work, researchers have found that patients who undergo controlled hypothermia using simple techniques such as cooling blankets and ice packs, have a better chance of brain recovery and survival following cardiac arrest than those whose body temperature is not lowered. However, such techniques are crude and often result in large temperature swings. The catheter technique used at VCU allows precise control of the cooling and rewarming process in an attempt to minimize brain injury following the cardiac arrest. The comprehensive ARCTIC approach is showing greater benefit than that which was seen using just conventional resuscitation and simple cooling techniques alone. "One of the novel things about VCU's ARCTIC program is that we have been able to seamlessly incorporate the care of the cardiac arrest patient from the time they arrest in their home to the time they return home with good neurologic survival," said Mary Ann Peberdv. MD.. Professor of Medicine and Emergency Medicine in the Division of Cardiology at the VCU School of Medicine. "We have been able to develop a partnership with our EMS system as well as our referring hospitals and initiate therapies that are unparalleled in the country. The care that this multidisciplinary team provides gives patients better outcomes than we have seen with traditional cooling alone," she said. The team presented their findings on Nov. 14 and 15 during the Resuscitation Science Symposium at the American Heart Association Meeting In Orlando, Fla. In a second study of 181 consecutive, out-of-hospital cardiac arrest patients who were successfully resuscitated in the fieid and brought to VCU from various EMS agencies or other hospitals throughout Central Virginia between 2001 and 2009, the study showed survival to hospital discharge was 19% in 2001-3 when standard post-resuscitation care was provided. It Increased to 38% in 2004-7 when simple cooling techniques were added, but further improved to 49% in 2008-9 using the full ARCTIC strategy. Additionally, patients whose cardiac arrest was caused by the abnormal rhythm, ventricular fibrillation (VF), now have a 72% chance of surviving to hospital discharge if treated in the ARCTIC program. The aggressive ARCTIC treatment also improved the neurological outcomes for VF patients over simple cooling alone. . . 3 Additional Background Cardiac arrest is a condition in which the heart suddenly stops beating, most commonly due to a rhythm disturbance known as ventricular fibrillation (VF). Within 10-20 seconds, the brain and other vital organs are deprived of oxygen, and the victim collapses to the ground unconscious and pulseless. Delivering an electrical shock to the heart promptly with a defibrillator can often start it beating again, but a defibrillator is not often available immediately. Cardiopulmonary resuscitation (CPR) can provide life sustaining blood flow and oxygen delivery to vital organs until trained rescuers can arrive and administer standard resuscitation techniques such as defibrillation, drug therapy, and other treatments. Unfortunately, survival from out-of-hospital cardiac arrest averages only 6-7%, claiming the lives of approximately 350,000 Americans each year using standard techniques. In many communities, paramedics can initially resuscitate cardiac arrest victims, but the majority will never regain consciousness and die due to brain injury. It has long been thought that the brain can only survive without blood and oxygen for 4-6 minutes before irreversible damage occurs. That is now known to be incorrect. Brain cells begin to show signs of abnormal function soon after they are deprived of oxygen, but recent studies show that permanent damage begins after the heart restarts and oxygen returns to the brain. The cells try to consume the oxygen, but their injured machinery converts the oxygen into poisonous chemicals called "free radicals" which kill the cells. Cooling the brain as quickly as possible, ideally before the heart even restarts, slows its metabolism so it can't generate a large quantity of "free radicals". Maintaining precise temperature control for 24 hours and rewarming gradually using the catheter device is designed to prevent large swings in the body temperature which can result in a surge of metabolism and "free radical" production. About VCU and the VCU Medical Center: Virginia Commonwealth University is the largest university in Virginia with national and international rankings in sponsored research. Located on two downtown campuses in Richmond, VCU enrolls 32,000 students in 205 certificate and degree programs in the arts, sciences and humanities. Sixty-five of the programs are unique in Virginia, many of them crossing the disciplines of VCU's 15 schools and one college. MC V Hospitals and the health sciences schools of Virginia Commonwealth University compose the VCU Medical Center, one of the nation's leading academic medical centers. For more, see www. vcu. edu. About the Richmond Ambulance Authority: In 1991, the Richmond City Council and the city manager implemented an Emergency Medical Services (EMS) system that placed the patient first and guaranteed its performance to the City's residents. Today, the Richmond Ambulance Authority responds to approximately 135 calls per day and transports, on average, 110 patients per day. RAA's emergency response times are among the fastest in the nation with ambulances on the scene of life threatening emergencies in less than 8 minutes and 59 seconds in more than 90% of all responses. RAA is one of only 11 EMS agencies in the United States accredited by both the Commission on the Accreditation of Ambulance Services and the National Academies of Emergency Dispatch. 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G 0.2 "'.<e . v 1: - IU &' o -S oS e e. 00',; ~ VJ - C) e:so.!! . ... woO u .,g ~~ ....~ _ t: ca u >.t:=: > ~ ..b U "'.= c;.g~ u...!9: ." e 0 t:: 6 ~ ~ ~ ~ ~E'. l= CllI~ oil .:: 'l) > u o.c 0"'-'' ._::; e e ~8.~B ::T:::lC- ,,_.9. ~ g ~.R . - ~ <.) <E c "" = C It.! ",.-.- - >,"'E..c u ....0:1-0 :.::: Q - :J . " 3 ::I __ ,.J::.<:: ~ - <:,) ~ 'B-~ " - .;:; S ll" ~-o~~ Ece~ !>.Cl:::lQ.g.l c <2.::: t: .,... ... 0 ,.. ~'- u ~ ._ ;l: ~ O~Q!.o o U 0 v - -- 0. - - .c . v ~ o...c:: ::I 'l).- 0 .-~ ':::0_ . RESUSCITATION (i) ELSEVIER Resuscitation 59 (2003) 97-104 www.elsevier.comllocatelresuscitation Cardiac arrest survival as a function of ambulance deployment strategy in a large urban emergency medical services system David E. Perssea,b,c,., Craig B. Keyd, Richard N. Bradleya,b,c, Charles C. Millerc, Atul Dhingra a a The City of Hou.yton Emergency Medical Services, USA b Departments of Surgery and Medicine, The Baylor College of Medit:ine, USA e Department!l of Emergency Medicine and Cardiothoracic Surgery, Hou,yton Medical School, The Univeraity ofTexa,y, USA d Department oj Emergency Medicine, The Ohio State University, USA. Received 13 December 2002; received in revised form 17 April 2003; accepted 17 April 2003 -, ... Abstract Introduction: This study e;K":Amim~s the effect of paramedic deployment strategy on witnessed ventricular fibrillation (VF) cardiac arrest outcomes. Our null hypothesis was that there is no difference in survival between an EMS system using targeted response (TR) and one using a uniform or all advanced life support (ALS) response (UR) model. We define targeted response as a system where paramedics are sent to critical incidents while ambulances staffed with basic EMTs are sent to less critical incidents. A secondary outcome measure was paramedic skill proficiency between the systems. Methods: We conducted a retrospective review of all 1997 VF arrests in a large urban EMS system. The majority of the city is a busy, urban area that uses TR. Outlying areas of the city are suburban and are served by a DR model. All areas have first responders equipped with automated external defibrillators. Outcomes are compared using Utstein criteria. ResulL'i: Patient populations were well matched. There were 181 patients in the TR group and 24 in the DR group. Units in the TR area were able to demonstrate shorter response and time to defibrillation intervals than in the DR area. Rates for return of spontaneous circulation (ROSe), admission to the wardflOtensive care unit (lCU), survival to discharge and survival to 1 year were all better in the cohort of patients cared for in the TR area than those in the UR area. Rates for successful intubation and IV initiation were also better in the TR areas than in the DR areas. Conclusion: This study shows improved outcomes for a subset of patients with cardiac arrest when they are cared for in an area that uses TR compared to an area that uses a UR EMS system. tf) 2003 Elsevier Ireland Ltd. All rights reserved. Keyword3: Advanced life support; Cardiopulmonary resuscitation; Emergency medical services; Paramedic R.esumo Introdufdo: Este estudo tenta estudar 0 resultado da estrategia de accionamento de equipa de paramedicos para sit~Oes de paragem em Fibrilha.;io Ventricular (FV). Colocamos a hip6tese de que MO hi diferencas na sobrevida dependentes do tipo de equipa de paramedicos enviada ao local (equipa accionada por objectivos erR) versus equipa enviada com capacidade de fazer ALS em. todas as sit~ (DR)). De[tnimns TR a equipa accionada por objectivos ou seja, 0 envio de uma equipa mstis diferenciada para as sitU8~ maig criticas e uma equipa mais basica para as situat;:6es mais faceis. Melodo.'i: Estudo retrospectivo de paragens em. FV numa area urbana cobena por um sistema de em.ergencia medica em 1997. A maior parte da cidade usa 0 sistema TR enquanto as areas suburbana utilizam 0 sistema UR. Ambos os sistemas dispOem de desfibri~ao automatics externa. Os resultados foram medidos com base nos criterios Utstein. Resultado...: No grupo TR entraram 181 doentes e 24 no gropo DR. A equipa TR mostrou um tempo ate a desfibrilhacao mais curto que a equipa DR. Em re1a.;io ao retorno da circulacio espontfinP1l (ROSC), admissAo em cuidad08 intensivos, sohrevids a alta hospitalar e sobrevicla ao ano, foram. melhores nos doentes cia area TR. T ambem foram me1hores na area TR as taxas de entubalYio e acesso venoso. ConcluslJe...: Este estudo mostra metharia do resultado . Corresponding author. Present address: 601 Sawyer Street, 5th Floor, Houston, TX 77007. USA. E-mail address:david.persse@cityofhouston.net (D.E. Pense). 0300-9571J03/$ - !ee front matter @ 2003 Elsevier ireland Ltd. All rights reserved. doi: 10_10 16180300-9572(03)00173-3 ._.~._--,..."~._"-~.~-- . ............-.. --.--. ~ ~._.._.._... 98 D.E. Pt!rs.~e et aL I &suscitation 59 (2()()3) 97 -]04 da paragem em FV nas areas que usam 0 sistema TR quando comparado com as areas que utilizam 0 sistema UR. rQ 2003 Elsevier Ireland Ltd. All rights reserved. Palavras chave: Suporte Avancado Vida; Reanimacio cardio.pulmonar; Servicos de Emergencia Medica; Pa.ra.mirlicos. Resume. lntroducciim: Este eatudio examina el efecto el USa de estrategia de despliegue de paramedicos sobre 108 resultados del paro cardiaco por fibri1aci6n ventricular (VF) presenciada. Nuestra hipOtesis nula es que no hay diferencia en sobrevida entre un sistema de servicio de emergencias medicas (EMS) que usa respuesta dirigida (TR) y uno que usa un modelo de respuesta unifonne (UR) 0 solo de soporte vital avanzado (ALS). Defmimos respuesta dirigida como un sistema dande 108 paramemcos son enviados a incidentes criticos mientras ambulancias tripuladas con recnicos en emergencias medicas (EMT) bAsicos son eoviados a incidentes menos criticos. Una medida secundaria de resultado fue la capacidad de desempefio de destrezas entre los paramedicos de los distintos sistemas. Metodos: Condujimos una revisi6n retrospectiva de tod081os paros cardiacos por VF en un gran sistema de EMS urbano. La mayor parte de la ciudad es un area urbana, muy ocupada, que usa TR. Las partes perifericas de la ciudad son suburbanas y son atendidas por un modele DR. Todas las areas tienen personal de primera respuesta equipados con desfibriladores automaticos externos. Los resultados se comparan usando criterios de Dtstein. Resultados: Las poblaciones de pacientes estaban bien equiparadas. Hubo 181 pacientes en el gropo TR y 24 en el grupo UR. Las unidades en elarea TR pudieron demostrar menor tiempo de respuesta e intervalos de tiempo a la desfibrilaci6n que en el area DR. Las tasa de retorno a la circulaci6n espontlinea (ROSC), admisi6n a sala I unidad de cuidados intensivos OCU), sobrevida al alta hospitalaria y sobrevida a 1 ado fueron todos mctiores en la cohorte de pacientes tratados en el area TR que aquellos en el area UR. Las tasas de intubaci6n exitosa y de iniciacion de via venosa fueron tambien mejores en las areas TR que en las DR. Conc/uflwn: Este estudio muestra resultados mejorados para un subgrupo de pacientes con paro cardiaco cuando eran tratados en un area que usa servicio de emergencias medica.s con respuesta dirigida (TR) comparados con un area que usa un sistema con respuesta Iinics (DR). rQ 2003 Elsevier Ireland Ltd. All rights reserved. Palabras dave: Soporte vital avan7Jlno (SV A); Reanimaci6n cacdiopulmonar (RCP); Servicio de emecgencias medicas; Pacamedicos 1. Introductio. Since the late 19608 emergency medical services (EMS) in the US have experienced dramatic growth and development. The initiatives to create a system to provide emergency medical care for the nations popula- tion began with limited knowledge about what con- stituted the most efficient processes for delivering ideal resources to the spectrum. of situations encountered by EMS [IJ. The National Highway Safety Administra- tion's EMS Agenda for the Future reports out-of- hospital EMS clinic-di care is considered optimat for patients when it improves patient outcomes [2]. Overall success of an EMS system has been described in terms of economic efficiency, clinical performance and response time reliability [31. Survival from out.of-hospital cardiac arrest has been promoted as an indicator of the success of clinical performance [4]. Many experts agree that a number of the deaths due to sudden cardiac arrest are preventable and that systems of critical care, appro- priately applied, could reduce them significantly at a relatively low cost [5J. Ambulance and EMS resource deployment strategies for optimal clinical care vary widely and have been the subject of considerable debate [6.7J. Some EMS systems use police or fire based first responder programs, many of which have been trained to use an automated external defibrillator, while others depend on ambulance re- sources only. Ambulance deployment strategies consist of all basic life support ambulances (BLS) or all advanced life support (ALS) ambulances or a mix of the two, sometimes using priority dispatch procedures and sometimes not. As EMS evolved, two major philosophies of ambu. lance deployment strategies have developed [3,8]. One is commonly referred to as the 'All ALS System', in which the intention is to provide a paramedic response to all emergency requests for help. This deptoyment strategy has been described as being particularly economically efficient [31. Other advantages of the all ALS system include its relative ease of administration and the concept that no critical emergency call will ever go unanswered by a paramedic. The other approach is known as the 'Tiered Response System', in which ALS or BLS ambulances and other EMS resources are selectively dispatched to emergency requests depending upon the reported nature of the medical emergency. Proponents of the tiered strategy have suggested that paramedics are not needed in the majority of EMS cases. Overutilization of paramedics on non.paramedic requiring calls will result in less opportunity for individual paramedics to care for critically ill patients, skill deterioration, lower quality clinical performance and lower cardiac arrest survival rates [8]. Conversely, if paramedics are consistently sent to care for patients in need of higher levels of training and skill, the paramedic will be better prepared to deliver intellectually and technically difficult care more effectively. Tiered propo- D.E Persse et oJ. I Restl.fcitation 59 (2()()3) 97-104 99 nents have further suggested that this system increases the availability of paramedic resources and serves to reduce response times for ALS resources and time for therapies for critically ill or injured patients. Previous attempts to determine success in clinical performance related to deployment strategy have been hampered by difficulty in categorizing accurately the deptoyment strategy used, accounting for confounding variables, such as rates of bystander CPR, presence of first responder defibrillation and consistent measure- ments of response time intervals [7]. As a result, optimal deptoyment strategies for ambulance systems remain controversial. Specific problems encountered trying to evaluate tiered systems have been concerned with defming one versus two versus three tiered strategies. For exampte, some authors refer to EMT -defibrillator first responders with all paramedic ambulances as two- tiered, white others consider two-tiered systems as only those with ALS and BLS ambulances. To avoid the confusion cited in previous reports, the deptoyment strategy in which ALS resources are spared from tow priority calls and are targeted to respond to higher priority incidents is identified in this report as a 'Targeted Response' system. Conversely an 'All-ALS' ambulance deptoyment strategy, where every emergency call is responded to by a paramedic-staffed ambulance is referred to in this report as a 'Uniform Response'. The purpose of this analysis was to compare the survival rates in people with witnessed ventricular fibrillation cardiac arrests and other critical clinical performance indicators within one large urban EMS system that uses both a uniform (all ALS) and a targered (tiered) deployment strategy in different geographic areas of their response territory. 2. Materials and methods This observational study used data collected prospec- tively as part of a continuous quality improvement program. The primary response area for this large metropolitan EMS system covers 620 miles2 of urban and suburban territory. By city ordinance, the 3000- member Fire Department (FD) provides all response to request for emergency medical service that comes through the 9 I I system, including first response and ambulance transportation. During the 12-month report- ing period, the EMS system responded to t66,045 emergency incidents, transporting 103,670 patients. Because of a variety of factors, most notably lower call density; the FD uses a uniform ambulance deptoy- ment strategy in certain areas of this community, while they use a targeted ambulance deployment strategy in others. Regardless of the ambulance deployment strat- egy, EMT-AED staffed first responder fire apparatus serve all parts of the study area. A locally designed priority dispatch system that discriminates between emergency incidents likely to require BLS skills and those requiring ALS skills is emptoyed in the central part of the city. Twenty-two EMT staffed basic life support ambulances respond to '" 40% of all initial dispatches. The FD preferentially dispatched one of 25 paramedic units to high priority incidents in this region. Neighborhood EMT-AED firefighter staffed fire apparatus also respond to all apparent life threatening or otherwise serious EMS calls, as well as many BLS dispatches [9]. This part of the city is a mixed territory with both commercial and residen- tial properties. In contmst to the central area, the peripheral parts of the city served are primarily residential. Seven para- medic units deployed in a uniform response manner serve these areas. Firefighter EMT-AED first respon- ders also support them. The FD changed the deploy- ment strategy for two of the paramedic units during the study period. Therefore, the cases of these units were not included in this anatysis. Cardiac arrest survival data was collected prospec- tively in accordance with the Utstein methodology [IOJ. Quality improvement personnel reviewed patient care records and attempts were made to retrieve any missing data points through direct follow up with the para- medics. The reviewers catcnlated response and treatment intervention (shock, i.v., intubation) intervals from the time of dispatch until arrival at the scene or time of intervention. They also calcutated treatment intervals from the arrival time until the procedure (shock, intubation or i.v. cannulation) was performed. Treat- ment intervention success rates are reported as per patient, not per attempt, basis. A computerized time management system documents times of dispatch and scene arrival. Each emergency vehicle has the ability to transmit its status electronically (en route, on scene, en route to hospital, etc.) to the computer dispatch system. On each cardiac arrest resuscitation, a scribe-genera1ly a non-paramedic fire department olTlCer-is responsible for accumtely recording all interventions. The FD instructs them to use a timepiece synchronized with the dispatch computer. As part of routine operations, the fire departments EMS Command and Community Outreach Command tracked all initial CPR survivors. Patients known to have spontaneous circulation at the hospital were followed through their hospitalization until death or discharge and survival up to t year from the date of the cardiac arrest. We excluded patients from consideration if the etiology of the cardiac arrest was known to be tmu- matico due to drug overdose. temperature extremes. an obvious non-cardiac cause or if the victim was < 18 years of age. We also excluded patients whose medical records were incomplete. Furthermore, only those patients with a witnessed collapse and an initial rhythm ,..-. , . .-- ,,-"~,,-,._,-~-,..""'-'.~----..'-'" .~~- _._-~_.__._---,~-- ..-.".. 100 D.E. Per.f.ye et al. I Re.rwcitation 59 (2003) 97-104 of ventricular fibrillation are reported here. This study also reports factors commonly known to influence survival from ventricular fibrillation. These factors included presence of bystander CPR, time to defibrilla- tion, response intervals, intervals from dispatch to critical intervention (countershock, intubation and i.v. cannulation) and intervals from paramedic arrival at the scene until a critical intervention. Ambulance activity levels were evaluated using unit hour-utilization (number of transports x average time out -of-service on a transport/time unit is staffed, equipped and being used for emergency operations) [11J. Univariate categorical data were analyzed by con- tingency tabte with computation of common odds ratios and Fisher's exact P values. Continuous data were analyzed by unpaired I-test with appropriate control for inequality of variances as appropriate. Multivariablc analyses were conducted by multipte logistic regression. All computations were performed using SAS version 8.02 running under Microsoft Windows 2000 Profes- sional. This wa.s a retrospective observational study without therapeutic intervention or randomi:rntion. The investi- gational review board (IRB) of the Bay tor College of Medicine reviewed this study and gave its approval (Protocol No. H-123170). 3. Results Of the 1757 cardiac arrest resuscitation attempts during the study period, 410 were due to trauma, drug overdose, temperature extreme, involved a pediatric Table 1 Demographics by deployment type patient ( < t8 years of age) or otherwise were not of cardiac etiology. We considered each of the remaining 1347 (76.7%) resuscitation attempts to have been due to a primary cardiac etiology. A bystander witnessed 46t of these cases (34.2%). Ventricular fibrillation was the presenting rhythm in 221 (47.9%) of these witnessed arrests. We excluded t6 of these cases (7.3%) from analysis: ten because the paramedic units that responded changed deployment strategy during the study period and six due to inadequate documentation. Thus, 205 (92.7%) cases met the criteria for this investigation. It must be noted that one resuscitated patient in the targeted deployment region was allowed to expire in the emergency department after family members arrived with the patients Do-Not-Resuscitate order. We ex- cluded this patient from the denominator of the survival to admission and survival to discharge calculations. A total of 181 patients were victims of witnessed ventricular fibrillation cardiac arrest in the targeted deployment region, while 24-witnessed VF patients were in the uniform deployment region. Baseline character- istics were similar between the two groups (Table I). The average patient age was 61.4 years in the targeted response sample and 63.3 years in the uniform response sample, with 73.5 aud 87.5% male patients, respectively. Bystander CPR was provided in 45.9% of cases in the targeted response area and 62.5% of cases in the uniform response area. The unit hour utilization measurement for the targeted response units was 0.59 (0.52-0.63) and 0.28 (0.12-0.46) for the uniform response units. The average paramedic response interval was shorter for the targeted deployment cases, but the difference was not statistically significant. Targeted response P -value Uniform response 181 133(73.5%) 61.4 7.67 83 (45.9%) 0.59 (0.52-0.63) No. of resuscitation attempts Gender: male Mean age Paramedic response interval (min) Bystander CPR Unit-hour utilization 24 21 (87.5%) 63.3 9.00 15 (62.5%) 0.28 (0.12-0.46) 0.21 0.49 0.12 0.13 0.0001 Table 2 Critical intervention rates by deployment type Uniform response Targeted response P - value Odds ratio (OR) 95% Confidence interval 10 (41.7%) 51 (28.2%") 0.23 0.6 0.2-1.3 14 (58.30/0) t23 (67.9%') 0.36 1.5 0.6-3.6 22 (91.7%) 174 (99.4%....) 0.04 15.8 1.4-181.7 20 (83.3%) 178 (98.3%) 0.004 11.9 2.5-56.9 First shocks delivered by ftnt responder First shocks delivered by paramedic Successful intubation Successful i.v. ... Seven (3.9%) patients were shocked fIrSt by EMS supervisor paramedic or EMS physician. .... Six patients awoke prior to intubation attempt, n = 175. D.E. PeTsse et aL I Resuscitation 59 (2003) 97~104 101 Critical intervention rates differed between the two deployment types, as shown in Table 2. First responders delivered the first shock in 28.2% of the cases, while paramedics delivered the first shock in 67.9% of the targeted response cases. In seven cases (3.9%), either an EMS physician or an EMS paramedic supervisor provided the first shock. In the uniform response cases, first responders delivered the first shock in 41.7% of the cases, while paramedics delivered the first shock 58.3% of the time. Six of the t8t patients (3.32%) in the targeted deployment cases awakened before intubation was attempted. Of the remaining 175 patients, t 74 were successfully intubated (99.4%). Paramedics intubated successfully all but two patients of the 24 (91.7%) of the uniform deployment cases. None of the 24 patients in the uniform deptoyment area awoke prior to intubation. There were no reported cases of unrecognized esopha- geal intubation (reported by emergency department, EMS supervisory or medical examiner personnel) among any of the patients described in this report. The i.v. success rate was 98.3% in the targeted deploy- ment cases and 83.3% in the uniform deployment cases. Table 3 shows critical intervention intervals. Average interval from dispatch until Lv. initiation was 15.2 min for the targeted deployment cases, while uniform deployment cases averaged t8.8 min. The intervat from arrival of paramedics on scene until i. v. initiation averaged 7.8 min in the targeted deployment areas and 10.9 min in the uniform deployment cases. The interval from dispatch to intubation was 14.4 min in the targeted deployment area and t8.2 min in the uniform deploy- Table 3 Critical intervention intervals by deployment type ment area. Time from arrival of paramedics on scene until intubation was 7.3 min in the targeted response cases and 9.8 min in the uniform response cases. Time from dispatch to first shock by paramedic was t 1.1 min for targeted response cases and 13. 3 min for uniform response cases. Time from arrivat until paramedic delivered shock was 4.8 min for the targeted area cases and 5.7 min for the uniform response area cases. The rate of return of spontaneous circulation (ROSC) was 55.8% in the targeted deployment area compared to 33.3% in the uniform deployment area (Table 4). Survival to hospital admission was 51.1% in the targeted deployment area and 29.2% in the uniform deployment area. In the targeted response area, t 6 patients who had ROSe in the field did not survive to hospital admission (one was determined to have DNR papers in the ED) and seven patients who did not achieve ROSe in the field were resuscitated in the emergency department and survived to admission. None of these seven patients resuscitated in the emergency department survived to hospital discharge. Survival to hospital discharge was 23.9% in the targeted deployment area and 4.2% in the uniform deptoyment area. One-year survival was 15.00% for the targeted response area and zero for the uniform response area. Table 5 compares automated external deflbrillator- shocked patients survival data with paramedic-only shocked patients. In the uniform response area, 50% of the patients shocked by first responders using an AED had return of spontaneous circulation compared to 21.4% of those first shocked by paramedics. Survival P .value Targeted response (min) 15.2 7.8 14.4 7.3 1l.t 4.8 Uniform response (min) Dispatch to i.v. interval Arrival to i.v. interval Dispatch to intubation interval Arrival to intubation interval Dispatch to paramedic shock. interval Arrival to paramedic shock. interval 18.8 10.9 18.2 9.8 n.3 5.7 Table 4 Survival by deployment type 0.02 0.02 0.005 O.oJ 0.29 0.47 Uniform response Targeted response P -value Odds ratio 95%CI No. resuscitation attempts Return of spontaneous circulation Survival to hospital admission Survival to hospital discharge Alive at 1 year 24 8(33.3%) 7 (29.2'10) 1 (4.2%) o 181 101 (55.8%) 92(51.1%). 43 (23.9%)' 27 (15.0010). 0.049 0.05 0.03 0.05 2.6 2.5 7.2 8.8 0.16-0.97 0.16-1.01 0.02- 1.06 0.5-148.6** .. n = ISO, one patient was determined to be DNR when papen were presented by family members in the emergency center and was allowed to expire. .. OR and 95% Cl calculated using 0.5 per cell addition and logit computations because oftbe zero cell. Lower CI does not match the Fisher's exact P value. -, _",_-,,~~,-'.-.'.'"~'-- -.. ..".~.~.. ..~.~, ',_.._.~_~ _ _._. __,. .,_____''_e........' 102 D.E. Per.Y,y€ et aL J Resuscitation 59 (2fKJ3) 97-104 Table 5 Swvival data by deployment type and first shock method Uniform deployment AED (n ~ 10) Paramedic (n = 14) ROSe 5 (50%) 3 (21.4%) SUJVived to Jlnmi!l!lion 3(30%) 4(28.6%) Discharged alive 1 (10%) 0 Targeted deployment AED (n ~ 51) Paramedic (n = 123) ROSe 23 (45.1%) 70 (56.9%) Survived to atlmi'lsioD 23 (45.1%) 61 (49.6%) Discharged alive 11 (21.2%) 28 (23.0%)* P-value Odds ratio 95%Cl 0.20 0.28 0.1-t.6 t.0 0.93 0.2-5.5 0.42 0.21 0.01-5.9 0.13 0.51 0.84 1.74 1.28 t.t 0.9-3.4 0.7-2.5 0.5-2.5 AED, patient was ftrst shocked by a fmt responder using an automated external defibrillator; Paramedic, patient was fust shocked by a paramedic using a manual defibrillator; ROSe, return of spontaneous circulation; Disch. Alive, patient was discharged from the hospital alive. Seven patients were shock.ed nest by EMS paramedic supervisors or EMS physicians in the targeted deployment region. . n = 122, one patient was determined to be DNR when papers were presented by family members in the emergency center and the patient was allowed to expire. to hospital admission was similar at 30 and 28.6%, respectively. A fIrst responder shocked the sole survivor to hospital discharge. In the targeted response area ROSC for those shocked by fIrst responders was 45. t and 56.9% for those shocked by paramedics. Survival to hospitat admission was similar at 45. t and 49.6%, respectively. First responder-shocked patients had a 21.1% survival to discharge rate compared to a 23.0% survival rate for paramedic-shocked patients. Univariate analyses are shown in Tables 1-.5. Dis- patch times, successful intubation and ROSC at the scene were so highly collinear with deployment strategy that reliable multivariable statistics could not be com- puted. 4. Discussion Patients who experienced a bystander witnessed VF cardiac arrest in this major metropolitan area had a greater chance of survival to hospital discharge in the areas where the ambulance response strategy targeted paramedic ambulance dispatch to high priority calls according to a prioritized medical dispatch system. Return of spontaneous circulation and survival to hospital admission, which may be more representative of paramedic and EMS system efficacy, were also greater in the targeted response areas. Paramedics in the targeted response group did have a shorter mean response interval, but this was not statistically significant. While not statistically signifI- cant, the shorter response and time from dispatch to shock intervals may have had signifIcant clinical impact. Proponents of the tiered (targeted deployment) system have suggested that sparing paramedic units from low priority calls allows for greater availability of these units for critical cases. Increased availability is intended to translate in shorter paramedic response times to critical calls by design. In fact, in this EMS system the intent behind using a targeted response interval in the areas of the community with higher U/UH was to concentrate critical care experience among the paramedics, and also to take advantage of the observed shorter paramedic response intervals. Bystanders performed CPR more frequently in the uniform response cases. Early CPR is one of the few interventions recognized to improve chances of survival for victims of cardiac arrest. It would follow that this should have given the uniform response patients a greater chance at survival. First shocks were delivered more often by AED trained fIrst responders in the uniform response cases. Theoretically, this too should have provided the uniform response cases a survival advantage, but only if the first responders arrived more quickly in the uniform region [12]. As mentioned above, the dispatch to shock interval, as well as the arrival to shock interval for paramedic delivered shock was statisticalty similar between the two groups. Dispatch to shock intervals for shocks delivered by an AED were not captured for this study. The intravenous line initiation success rate was less in the uniform cases. The dispatch to i.v. initiation interval as well as paramedic arrival on scene to Lv. initiation interval were both significantly shorter in the targeted response area, suggesting better skill profIciency. The intubation success rate was greater in the targeted response area. The interval to intubation, both from dispatch and from paramedic arrival, were markedly shorter for the targeted response areas, again suggesting better skill profIciency. The American Heart Associations ~Chain of Survival' graphically illustrates those components of resuscitation believed to have the greatest benefIcial effect toward patient survival. Earty access to c-are, early CPR, early defIbrillation and early advanced care are the four links in the Chain of Survival. Proponents of the tiered (targeted response) system have suggested that the selective dispatch of ALS resources (withholding them D.E. Persse et aL I Resuacitation 59 (2003) 97 -104 103 from low priority calls allowing them to be availabte for high priority calls more likety to require ALS interven- tions) will serve to reduce response time by increasing availability to those high priority calls. The data presented here support that claim and reflect a shorter response time to high priority calls in the targeted response area in spite of having higher utilizationlunit- hour vatues. The rates of bystander CPR and fIrst responder defIbril1ation were higher in the uniform response area, yet the targeted response area patients had higher rates of ROSC, admission and survival to discharge. Tiered system proponents have suggested that sparing paramedics from tow priority calls results in higher skill profIciency among paramedics. Successful initiation of an i.v. and successful intubation were both greater in the targeted response cases as well as performed more quickly. The FD does not track the number of Lv. or intubation attempts. Therefore, it is not possible to state conclusivety that the individual paramedics in the targeted response cases were more profIcient at these skills. There are several limitations to this study. First is that although the time of dispatch and scene arrival are recorded electrouiCal1y on a single clock and are there- fore accurate, the time of specific therapeutic interven- tions is recorded on another timepiece which may not be accurately synchronized with the dispatch clock. We assumed that across all patients, the amount of over and under estimates balance allowing for the average time intervals reported to be close to accurate. Difficulty in ensuring accurate critical intervention time information as well as paramedic arrival at patient side is not unique to this system. A second limitation concerns the response interval difference noted between the two deployment strategies. A possible confounding variable is the difference in the size of prima ry response territory. The targeted response area is more densely populated and has more fue stations per unit area. Conversely, the unit hour utilization of the targeted response units far exceeds that of the uniform response units. It is unclear if the shorter response interval for the targeted units is due to an effect of increased availability from selective dispatch. Response time for fIrst responder units and dispatch to shock intervals for fIrst responders were not available. However, the ROSC and survival to discharge rates for patients shocked by fIrst responders in both groups are similar. Other limitations include an inability of the available data to account for any differences that may have resulted from a different number of non- paramedic EMTs on scene. The uniform deployment region would have four EMTs from the fIre apparatus on scene, while in the targeted region there would be six EMTs, four from the fIre apparatus and two from the basic ambulance. It is unclear that the two extra EMTs could have affected survival significantly as all skilts can easily be performed between the pardllledics and the fIrst ".-.-.- -- .^..._.....~..-._. . - '--".'-'''-- four EMTs. The relativety small N for the uniform response territory is also a limitation particularly when one considers the potential for survival variability from year to year. The improved survival data within the targeted response area is similar to that seen in other cities that have similar deployment strategies. Seattle has success- fully used a priority dispatch system to target ALS resources only to those calls most likely to require ALS skills for many years. Seattle has reported witnessed VF cardiac arrest survival rates ranging from 24 to 35% [13,t4J. Similarty, Milwaukee and Boston have also emptoyed tiered ambulance deployment strategies and have reported witnessed VF survival rates of 23% [151 and 25.5% [t6]. Conversely, several major cities with uniform deployment strategies have reported disap- pointingly low witnessed VF survival data. Chicago reported very low overall VF cardiac arrest (3%) survival rates in 199t [17J. Similarty, New York City has reported a 4% survival rate from out-of-hospital witnessed VF cardiac arrest [18]. A more recent article from an academic teaching hospital in Los Angeles County (1998) reported there were no (0%) survivors of out-of-hospital venrricular fIbrillation cardiac arrest [19]. The study demonstrated that witnessed VF cardiac arrest survival rates in areas of this large urban EMS system that used a targeted deployment scheme were similar to those found in other major metropolitan centers, used a targeted deployment scheme. The areas in this system that are served by a uniform response modet have a similar survival mte than those of other major metropolitan are'dS using a similar 'all ALS' deployment scheme. Victims of ventricular fIbril1ation sudden death syn- drome with a bystander witnessed collapse in this major metropolitan area had greater return of spontaneous circulation, survivat to hospital discharge and I-year survival in the area of the city where paramedic ambulances are deployed based on a prioritized medical dispatch system and spared from responding to low priority calls. The data suggest better skill profIciency and faster response by paramedics in this area of the city. These data support the use of 'tiered' EMS deployment strategies, however it is inconclusive whether the survival difference is related to superior critical thinking as well as enhanced clinical and technical skills on the part of the TR paramedic, shorter response interval or a combination of the above. This is the fIrst investigation we are aware of that compares clinical skill profIciency, critical intervals and patient outcomes between the two deployment schemes in a setting that controls for interagency differences such as training requirements, protocols, on-line medical over- sight, wages and equipment. Further investigation into -..- ','~"~'",_,_,",_,"-"-,. "-.-..-~-. . 104 D.E. Persse et all Resuscitation 59 (2003) 97-104 specific reasons for the observed difference in survival is warranted. Aclmowledgements The authors would like to thank the men and women of the Houston Fire Department for their dedication to duty, sense of selflessness and commitment to commu- nity. Without their help, this manuscript and its findings would never have come to light. The authors would also like to thank Diana Rodriguez for her efforts maintain- ing the cardiac arrest database and arranging multiple meetings and other gatherings pertinent to this project; and to J. Benjamin Baldwin for his many efforts to gather, sort and verify the accuracy of many compo- nents of the data. References [lJ Executive SlImmary, in: EMS Agenda for the Future. Washing- ton, DC: National Highway Traffic Adminilltration. 1996. p. v. [2] Clinical Care, in: EMS Agenda for the Future. Was.tlington, DC: National Highway Traffic ft.c1mi"istratiou, 1996. pp. 51-53. [3] Stout J. System design. In: Kuehl AE, editor. Prehospital systems and merlirAl oversight, 2nd ed. S1. Loui<l: Mosby Lifeline., 1994:8 I -91. [4] Cay ten eG. Evaluation. In: Kuehl AE, editor. Prehospital system!! and medical ovenight, 2nd ed. S1. Louis: Mosby Lifeline, 1994:159-61. [5] Moss AJ. Sudden cardiac death and national health. PACE 1993;16:2190-1. [6] Eisenberg MS, Horwood ST, Cummins RD, et al. Cardiac arcest and resuscitation: A tale of 29 cities. Ann Emerg Moo 1990;19:179-86. [7] Nichol G, Detsky AS, StieU IG, et al. Effectiveness of emergency medical services for victims of out-of-hospital cardiac arrest: a metaanalysis. Ann Emerg Med 1996;27:700~1O. fS] Pepe PE, Warnke WJ, Copass MK. Emergency medical services and sfstems of out-of-hospital resuscitation. In: Paradis NA, Halperin HR. Nowak RM. editors. Cardiac arrest the science and practice of resuscitation medicine. Baltimore: WiHiAms & Wilkins, 1996:581-96 [9] Curb PA, Pepe PE, Ginger VF, et al. Emergency medical services priority dispatch. Ann Emerg Med 1993;22:1688-95. [10] Olmmins RO, Chamberlain DA, Abramson NS, et al. Recom- mended guidelines for uniform reporting of data from out-of- hospital cardiac arrest: The Utstein style. Ann Emerg Med 1991;20:861-14. [11] Comparisons of performance measures of prehospital emergency medical care providers, in: International Association of Fire Fighters: effectiveness of fire-based EMS, Washington, DC: IAFF, 1995. pp. 19-23. [12] Auble TE, Menegazzi JJ, Paris PM. Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a metaanalysis. Ann Emerg Mal 1995;25:642~8. [13] Cobb LA, Fahrenbroch C-E, Walsh TR, et al. Influence of cardiopuhnonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibril1a.tion. JAmMed Assoc 1999;281:1182--8. [14] Kim C, Famenbruch CE, Cobb LA, et at. Out-of-hospital cardiac arrest in men and women. Circulation 2001;104:2699-703. [15] Hargarten KM, Stueven HA, Waite EtvI, et at. Prehospital experience with defibrillation of coarse ventricular fibriBation: a ten-year review. Ann Emerg Med 1990;19:157-62. [16] Moyer P, MD. Personal conununr.ation; August, 1999. [17] .Becker LB, Ostrander MP, Barrett J, et aI. Outcome of CPR in a large metropolitan area-where are the survivors'! Ann Emerg Moo 1991;20:355-61. [18J Lombardi G, Gallagher J, Gennis P. Outcome of out--of-hospital cardiac arrest in New York. City. The Pre-Hospital Arrest Survival Evaluation (PHASE) study. J Am Moo Assoc 1994;211(9):618-83. [19J Stratton S, Niemann JT. Effects of adding link.s to 'The Chain of Survival' for prehospital cardiac arrest: A contrast in outcomes in 1975 and 1995 at a single institution. Ann Emerg Med 1998;31 :411-1 . This article was downloaded by:[UPEC - Prehospital Emergency Care] On: 23 July 2008 Access Details: [subscription number 768277147] Publisher: Informa Healthcare Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Prehospital Emergency Care Publication details, including instructions for authors and subscription information: b1tp:/lwww.informaworld.com/smoD/t.i!le-contmll.::1D 3698:281 Does the Number of System Paramedics Affect Clinical Benchmark Thresholds? Kristin M. Vrotsos 8; Ronald G. Pirrallo be; Clare E. Guse d; Tom P. Aufderheide b a Medical College of Wisconsin, b Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin C Milwaukee County EMS, Milwaukee, Wisconsin d Injury Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin Online Publication Date: 01 Jut 2008 To cite this Article: Vrotsos, Kristin M., Pirrallo, Ronald G., Guse, Clare E. and Aufderheide, Tom P. (2008) 'Does the Number of System Paramedics Affect Clinical Benchmarl< Thresholds?', Prehospital Emergency Care, 12:3, 302 - 306 To link to this article: 001: 10.1080/10903120802101355 URL: ntto:/ldx.doLora/10.1 060/1 090~120802101355 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: htto:lfwww.infQrmaworld.com/terms-and-conditions-of-access.odf This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. -._~..a""~'''_''~'''''"''''"_~ -..,,---. .-. ... .".~'.~..... "_..._----_._-~..,,,._",.- ..---... DOES THE NUMBER OF SYSTEM PARAMEDICS AFFECT CLINICAL BENCHMARK THRESHOLDS? Kristin M. Vrotsos, BS, Ronald G. Pirrallo, MD, MHSA, Clare E. Guse, MS, Tom P. Aufderheide, MD co o o N '" :J -, M N '"' N N N - <( ~ ~ '" o '" u C Ql OJ ~ Ql E ill '" ~ 0- W o .c Ql ~ 0.. ABSTRACT Objective. Competency is affected by skill exposure, skill complexity, and training program quality. The purpose of this study was to reevaluate the biennial (24-month) crit- ical care skill and experience benchmark thresholds es- tablished by the Milwaukee County Emergency Medical Services (MCEMS) system in 1997. Methods. This was a retro- spective review of annual experience profiles for paramedics working during 2001-2005 using the MCEMS patient care record (peR) database. The number of patient contacts, role as team leader I report writer, adult and pediatric endotra- cheal intubations, adult and pediatric intravenous (IV) access initiations, medication administration, and 12-lead electro- cardiogram (ECG) acquisitions were analyzed. t-tests and de- scriptive statistics were performed for comparison with the 1997 study. Results. Over the five-year study period, 1,215 paramedic profiles gleaned from 107,524 PCRs documented a total of 297,900 patient contacts. Annual means ::l: standard deviations [ranges] were as follows: patient contacts 245::l: 133 [12-788]; team leader: 106 r 119 [0-739]; intubations: adult 2.57 r 2.54 [0-201, pediatric 0.1 r 0.3 [0-3]; IV starts: adult 44 r 37 [0-267], pediatric 0.34 r 0.77 [0-5J; Ireated cardiac arrests: adult 8 ::l: 6 [0-34], pediatric 0.26::l: 0.61 [Q-.-4]; treated hypotensive trauma: 5 ::l: 6 [Q-.-42]; and ECGs acquired: 31 ::i: 19 [0-144]. The 1997 analysis (]987-1996 data) included 1,450 paramedic profiles representing 467,559 patient contacts gen- erated from 172,131 filed PCRs. All comparable experiences decreased significantly between the 1997 analysi'i and the current study, except medication administration, which in~ creased 25%. Conclusion. These data show a decreased op- porhmity and a wide variability in the frequency of success- o ill 0.. => - '" m 1:J Ql 1:J '" o c " o Cl Received September 17, 2007, from the Department of Emergency Medicine (RGP, TPA) and the Injury Research Center (CEG), Med- ical College of Wisconsin, Milwaukee, Wisconsin; and Milwaukee County EMS (RGP), Milwaukee, Wisconsin. Ms. Vrotsos was a third- year medical student at the Medical College of Wisconsin at the time of publication. Revision received January 25, 2008; accepted for pub- lication January 28, 2008. Presented at the 15th Annual Emergency Medicine Research Forum, Milwaukee Wisconsin, April 2007; and as a poster at the National Association of EMS Physicians, Phoenix, Arizona, January 2008. Ms. Vrotsos completed this study as a Medical College of Wisconsin Medical Student Summer Research Program Participant, funded through a grant from the National Heart, Lung, and Blood Institute and partially supported by the Centers for Disease Control and Pre- vention grant R49/CCR519614. Address correspondence and reprint requests to: Ronald G. Pir- rallo, MD, MHSA, Froedtert Hospital, Pavilion Building, 9200 West Wisconsin Avenue, Milwaukee, WI 53226. e-mail: pirraUo@mcw.cdu doi: 10.1080/10903120802101355 fully completed paramedic technical skills and experiences in this EMS system. Limited exposure to critically ill adult and pediatric patients reaffirms that high-risk skills are per~ formed infrequently. A multifaceted approach should be con- sidered for maintaining provider competency. Key words: benchmarks; emergency medical services; prehospital care; policy; competency; paramedic. PRE HOSPITAL EMERGENCY CARE 2008;12:302-306 INTRODUCTION Quality emergency medical services (EMS) patient care is dependent on competent providers and can be di- vided into technical and interpersonal components.1 The technical components of quality can be objectively measured and benchmarked. The practice of bench- marking originated in manufacturing and is slowly being introduced into medicine.2 Benchmarks have been implemented to evaluate skills ranging from cul- tural competency in behavioral health care to therapy outcome measures in speech and language therapy.3,4 Common life-saving technical patient care interven- tions that EMS providers perform include endotracheal intubation, 12-lead electrocardiogram (ECG) interpre- tation, medication administration, and intravenous (IV) access initiation. Benchmarking is a tool that can help identify specific provider competency for these inter- ventions. Competency is affected by exposure to the skill, the complexity of the skill, and the quality of the training program. Literature shows that within six to 12 months after initial training, skill deterioration occurs.s The most advanced psychomotor skills de- grade most rapidly.6.7 Even frequently used basic skills deteriorate/i yet the degradation occurs more slowly with increased exposures? Initial training programs may not prepare providers to practice independently'" Assessing the transfer of skills from training into prac- tice reflects the quality of an education program.9 These variables affecting competency should be assessed reg- ularly. Continuing education is one approach for retain- ing competency. Benchmarking is another tool that can provide ongoing evaluation of quality patient care and technical skill proficiency among EMS providers. [n 1997, the Milwaukee County Emergency Med- ical Services (MCEMS) system established biennial (24-month) critical care skill and experience benchmark thresholds to coincide with state regulations for bien- nial recertification.lO The purpose of this study was to 302 co o o ('oj >. :J ...., '" ('oj '" ('oj ('oj ('oj 4: Vrotsos et al. PARAMEDIC CLINICAL BENCHMARK THRESHOLDS reevaluate these clinical benchmarks in the most recent five years of data available. We hypothesized that the critical care benchmarks achieved would be inversely proportional to the number of paramedics practicing in the system. - ~ '" U >. " c Ql OJ ~ Ql E w '" "" "- oo o "" ~ 0.. METHODS The MCEMS system is a countywide system covering 241 square miles in southeast Wisconsin and serving approximately 1 million people. It consists of 19 munic- ipalities with a central urban community surrounded by suburbs. Milwaukee, the nation's 19th largest city, has a diverse population contained within this county. The MCEMS system is a fire service-based tiered sys- tem, and each of the 19 municipalities provides its own basic life support (BLS) service with shared advanced life support (ALS) services provided by 19 paramedic ambulances. Staffing of the tiered response fire appara- hIs and ambulances varies, resulting typically in one to four paramedics and two to three emergency medical technician (EMT)-Basics on scene. This study is a retrospective review of the MCEMS patient care database. It is a cross-sectional study of the most recent five years of data available, intended to ex- amine any changes in the system compared with the previous cross-sectional study performed in 1997 for the period 1987-1996. MCEMS paramedics who were working during the five-year period (2001-2005) are the study population of interest. Upon receiving prac- tice privileges, each Milwaukee County paramedic is assigned an identifying number to document his or her technical skills performed during each patient contact. The number is written on the patient care record and is then transferred by administrative staff into an elec- tronic database. As part of routine patient care, only successful procedures are documented on the MCEMS record; the number of attempts is not. A profile of skills and experiences is generated three times a year based on the information collected and summarized annu- ally. Each profile reflects a paramedic's unique annual activity. The annual MCEMS paramedic profiles were an- alyzed to compare the current frequencies with the previously established benchmark frequencies and to examine whether the number of practicing paramedics was related to their abllity to achieve these benchmarks. The following technical skills and experiences were benchmarked: patient contacts, team leader/report writer, adult and pediatric endotracheal inrubations, adult and pediatric IV access initiations, medication administration, and 12-1ead ECG acquisitions. These clinical benchmarks were selected by expert panel consensus and include low-frequency, high-patient- harm-potential, and high-difficulty technical skillsll Adult patients were defined as anyone 8 years of age and older and pediatric patients were defined as anyone u W 0.. :J - >. CIl "0 Ql "0 '" o c :;: o Cl -~~,-- - ---~*".<'~.','~'-~--'-"'" 303 TABLE 1. Technical Skills and Experiences to Be Benchmarked Skill Definition Patient contact Each paramedic on scene was credited with one patient contact Acquired the patient's history; documented and directed overall scene care Successful placement, oral or nasal route Team leader/report writer Endotracheal intubation . Pediatric: age <8 years . Adult: age :::8 years Intravenous access . Pediatric: age <8 years . Adult: age >8 years Medication administration Successful placement, peripheral or external jugular location By the following routes: intravenous, intraosseous, subcutaneous, endotracheal, aerosol, rectal Diagnostic quality tracing acquired Any cardiac arrest for which resuscitation efforts were initiated Patients 8 years old or older were included if their systolic blood pressure was less than 90 mmHg 12-Lead ECG acquisition Cardiac arrest treated . Pediatric: age <8 years . Adult: age >8 years Adult hypotensive trauma treated EeG = electrocardiogram. aged less than 8 years, consistent with American Heart Association standards of the time period (Table 1). A range for each skill of interest was calculated in ad- dition to an annual mean and standard deviation. Any paramedic with less than 12 patient care contacts docu- mented within a particular calendar year was excluded from analysis, consistent with the 1997 study methods, and was considered having had too few contacts to evaluate. Note that the total number of patient contacts is the summation of each paramedic's encounters and is a much larger number than the number of unique pa- tient care records written. Each paramedic on the scene is credited with a patient contact. However, only the paramedic who successfully completes the intervention is credited with the skill. A successful intervention was determined by reviewing the documentation on the patient care record; no external verification was used. Skills performed that were not assigned to an individ- ual paramedic were also excluded from analysis. The data formatting rules and exclusions were identical to the 1997 study.IO A two-sample t-test with unequal vari- ances was used to determine significance of the dif- ference in the means of the 1997 study and current benchmarks.12 All data in the MCEMS database meet Health In- surance Portability and Accountability Act (HIPAA) security requirements. This study was reviewed by the Medical College of Wisconsin Institutional Review Board and met the waiver of informed consent re- quirements as specified under 45 CPR 46.116(d) and -.---.- -- . . '-, ....-."" Number 01 system patient contacts and paramedics 30D 35000 250 ~. 30000 - " - en 200 25000 .S! - o .~ .. en ~" 20000 0._ 1l " - u 150 0 .. E E - 15000 ~ " " l!! " 0 z .. toO .c u 0. E 10000 " Z 50 5000 0 0 1990 1995 2001 2002 2003 2004 2005 Year CD o o N >- - ::J -, '" N on N N N 304 ~ <C - OJ ~ ell U >- u c OJ OJ ~ OJ E w ell ~ C. Ul o J:: OJ ~ 0.. PRE HOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2008 VOLUME 12/ NUMBER 3 c---.-.._---- -~__.._.___ _ 1----- Number of paramedics - Number of patient contactsl FIGURE 1. Number of paramedics and patient care records. u W 0.. ~ - the waiver of HIPAA authorization requirements as set forth in 45 CPR 164.512(i)(2)(ii). .. >- m "0 OJ "0 ell o C ~ o RESULTS In the MCEMS system over the five-year study period (2001-2005), 1,215 paramedic profiles documented a to- tal of 297,900 patient contacts, derived from 107,524 pa- tient care records. A mean of 243 practicing paramedics each year resulted in a system mean of 59,580 (range 59,311 to 67,113) patient contacts annually During the five-year study period, the number of paramedics in- creased 12.6% (231 to 260), while the number of unique patient care records written increased 40.6% (21,849 to 30,718) (Fig. 1). The number of patient contacts in- creased comparatively 13.15% (59,311 to 67,113). The annual range for patient contacts and reports written as the team leader is wide. Pediatric intubations and es- tablishing IV access are rare events. Twelve-lead ECGs appear to be performed on a regular basis. These data also show infrequent exposure to critically ill adult and pediatric patients (Table 2). The 1997 study included ten years of data from 1987 through 1996, producing 1,450 paramedic pro- files representing 467,559 patient contacts generated from 172,131 filed patient care records. The num- ber of patient contacts and reports written demon- strated wide ranges, similar to those of the current study All comparable skill and experience frequen- cies decreased significantly between the 1997 analysis and the current study, except medication administra- tion, which increased significantly by 25%. The 1997 analysis did not stratify adult versus pediatric skills (Table 2). TABLE 2. Technical Skill Raw Data and Proposed Benchmarks 2001-2005, n = 1,215 1987-1996, n = 1,450 Technical Skills Annual Mean :I:: Annual Proposed Annual Mean :f:: Annual per Paramedic" Standard Deviation Range 25th Percentile Benchmarks Standard Deviation Range Benchmarks Patient contacts 245 :f:: 133 12-788 161 160 322.5:f:: 177.4 12-888 60 Team leader Ireport writer 106" 119 0-739 37 35 121.2 " 1265 1-726 15 Adult endotracheal intubation t 2.57:f:: 2.54 0-20 I 1 Pediatric endotracheal intubation t 0.1" 0.3 0-3 0 0 8,,7 0-45 1 Adult intravenous access+ 44:1:: 37 0-267 19 18 Pediatric intravenous access+ 0.34 ::!: 0.77 0-5 0 0 67::!: 49.1 1-276 12 Medication administration 74::!: 56 1l-397 37 35 51.1 ::!:: 35.7 1-198 16 12-Lead ECC acquisition 31 ::!:: 19 0-144 17 16 Not measured Adult cardiac arrest treated 8,,6 0-34 4 Pediatric cardiac arrest treated 0.26 ::!:: 0.61 0-4 0 Hypotensive trauma treated 5:f::6 11-42 1 n = total number of paramedic promes: .All comparable comparisons were statistically significant (p < a,aOll. t Adult and pediatric endotracheal intubations were combined for comparison. t Adult and pediatric intravenous access initiations were combined for comparison. co o o N ,., ::J --, '" N on N N N .' ~ <( - i!! '" o ,., u C Ql Ol ~ Ql E w '" ~ Cl. <J) o J:: Ql ~ 0- o W 0- ~ - ,., tIl "0 Ql "0 '" o c '" o o . Vrotsos et al. PARAMEDIC CLINICAL BENCHMARK THRESHOLDS DISCUSSION It is no surprise that as the number of paramedics in the system increases, the number of opportunities to meet critical care benchmark thresholds decreases. Yet, this explains only part of the picture. The clinical practice standards changed concurrently within the MCEMS system to include the introduction of the Combitube for EMT-Basic first responders" and the proliferation of nontransporting first-response paramedic vehicles. In addition, a 48% decrease in the incidence of car- diac arrest patients presenting with an initial rhythm of ventricular fibrillation occurred in the community.14 An unknown factor is whether or not the incidence of critically ill patients has changed during the study pe- riods. Management decisions of if and when to add paramedics to the system were not necessarily guided by these factors and may have further contributed to the situation. Regardless, the 2001-2005 data support the 2004 National EMS Practice Analysis by document- ing the limited opportunity for EMS providers to treat critically ill patientsll Provider experience has been shown to correlate with improved outcomes and fewer complications in several studies performed in the hospital setting8 This relation- ship has not been studied as extensively in the prehos- pital setting. One prehospital study demonstrated that a significant correlation exists between the frequency of inrubations per paramedic and the success rate.15 This suggests that actual experiences, instead of the dura- tion of service, should be used to assess the frequency of skill use. Recertification is currently a biennial practice in most states, but basing recertification on a time interval is problematic because it does not ensure competence in skill performance8 It is well established that high- difficulty technical skills are performed infrequently, so even over the course of two years it is not guar- anteed that each provider will have performed these tasks.ll In fact, some providers may not perform a par- ticular skill in their entire careers. The number of op- portunities will vary greatly in each EMS system. For example, the median number of endotracheal intuba- tions performed by Pennsylvania paramedics was one per year, but more than 39% of these providers did not have a singte intubation opportunity.16.17In Seattle, the number of paramedics in the system is restricted, so each provider averages 12 intubations per year.17 When questioned, paramedics themselves found the skills performed in the field to be more important than the initial training or simulation experiences in main- taining skill compentency8 Other studies have shown that using mannequins alone to teach endotracheal intubations is successful,18 but maintaining clinical competency with this approach is yet to be determined. Unanswered questions include 1) Would it be beneficial to shorten the recertification period and require each 305 provider to refresh his or her skills in a simulated set- ting more frequently? and 2) Would it be beneficial to extend the recertification period to increase the hands- on opportunities to perform skills in the field? EMS benchmarks can also be used to compare the per- formances among different EMS services. Traditionally, attempts to incorporate assessment of quality into EMS systems have been limited to implementation of qual- ity assurance processes.19 Now benchmarking plays a primary role in quality improvement20 Benchmarks can identify the "leaders" of a system so their prac- tices can be understood and replicated.20 Much vari- ation exists between EMS services, ranging from the number of practicing providers and the types of pa- tients served to the geographical service area covered. Comparing system benchmarks may help identify the optimal standard of performance expected across EMS systems. The number of successful performances of a given skill by an individual EMS provider to maintain his or her competence is currently unknown. The best ap- proach to maintain competence among EMS providers may be to establish benchmarks for the high-difficulty technical skills performed. And unless EMS systems are willing to report their benchmarks, external unin- formed decision makers may impose arbitrary stan- dards. The Institute of Medicine's recent Future of Emergency Care report recommended adopting na- tional certification, which may further facilitate skill benchmarking.21 Based on these data and reevaluating current clin- ical benchmarks, we propose the following annual benchmark thresholds: 160 patient contacts, 35 as team leader/report writer, I adult endotracheal intubation, 18 adult IV starts, 35 medication administrations, and 16 acquisitions of 12-lead ECGs (Tabte 2, column 5, Pro- posed Benchmarks). Because of the rare opportunity to treat critically ill pediatric patients, establishing pe- diatric skill benchmarks would not be meaningful in our system. Pediatric skills will remain the focus of the system's continuing education program. In addi- tion, the implementation of these thresholds will re- quire redesign of the remediation program, as nearly 25 % of the active paramedics will not achieve the benchmarks. The proposed benchmarks arbitrarily approximate a 25% threshold. This threshold was established by the EMS medical director based on the observation that the current care provided by the EMS system's paramedics generated few receiving hospital com- plaints, patient care protocol deviations, and contrary medical examiner reports. At this time, limited patient outcome data are available to further guide this impor- tant yet subjective decision making. Notwithstanding, it is the ultimate responsibility of the EMS medical di- rector to make this decision with much thought and deliberation. ,._... ~"'~__'."-"'''_''''''V_'_' _, ..___,.._....~... "._~..."...".._~_~~__~ ~-", co o o N ;>, =' -, '" N '" N N N :::;: 306 LIMITATIONS As with any retrospective chart review, selection bias and missing data may influence the analysis. Although all interventions are assigned to a specific paramedic, missing or errant documentation coding does exist. However, missing data composed only 2% of the over 100,000 cases and are not believed to be biased. The study period covered five years, and patient acuity or working assessments were not captured and likely changed over time. This reflected the natural incidence of disease in Milwaukee County and is a factor for any adaptable EMS system. Only successful self-reported completion of a skill is recorded on the MCEMS pa- tient care record. We are unable to comment on attempts made to achieve success or verification of success and clearly need to capture these data moving forward. Re- grettably, patient outcomes were not linked to specific paramedic skills or interventions. The reported data provide no information on the quality of patient care or competency of the individual paramedic. Understand- ably, benchmarks are not intended to answer the defini- tive question-Is a provider who has had one attempt with success as competent as a provider who has had two attempts with one success? However, it is without question that for a provider who has had no opportuni- ties to perform a skill, no comment can be made about his or her competency. Benchmarking does well to doc- ument the opportunity for providers to demonstrate their competency. ~ " ~ C\l U ;>, " c: " OJ ~ " E w C\l - 0. <1l o ..c: " ~ Do- u W D0- =:) - ;>, a:l "0 " "0 C\l o c: ;: o o CONCLUSION These data support the hypothesis thatthe achievement of critkal care benchmarks is inversely proportional to the number of practicing paramedics in the Milwau- kee County EMS system. The annual mean for each technical skill has decreased for the 2001-2005 data set compared with the means established in 1987-1996, except for medication administration. Additionally, a wide variability in the frequency of successfully com- pleted technical skills exists. These data reaffirm that high-risk skills are per- formed infrequently. Milwaukee County paramedics have limited exposure to critically ill adult and pe- diatric patients. This suggests that a multifaceted ap- proach should be considered for maintaining provider competency, especially when it comes to low-frequency, high-patient-harm-potential, and high-difficulty tech- nical skills. The authors thank Seema Sernovitz for coordinating the Summer Research Program, Lauryl Pukansky for facilitating database access, Terry Modrak for her patience, and, most importantly, the paramedics of the Milwaukee County EMS system for their passion toward im- proving the health and safety of the community. PREHOSPITAI. EMERGENCY CARE JULY / SEPTEMBER 2008 VOLUME 12/ NUMBER 3 References 1. Donabedian A. The Definition of Quality and Approaches to Its Assessment. Volume L Ann Arbor, Michigan: Health Adminis- tration Press, 1980. 2. Dunwoody WH. Traditional benchmarking in EMS. In: Swor RA, Pirrallo RG (eds). Quality in EMS. Dubuque, IA: Kendall/Hunt, 2005. 3. Siegel C, Haugland G, Chambers ED. Performance measures and their benchmarks for assessing organizational cultural compe- tency in behavioral health care service delivery. Admin Policy Ment Health. 2003;31(2):141-70. 4. John A, Hughes A, Enderby P. Establishing clinician reliability using the therapy outcome mcasure for the purpose of bench- marking services. Adv Speech Language Pathol. 2002;4(2):79-87. 5. :Miller DR, Kalinowski EJ, Wood D. Pediatric continuing educa- tion for E!vITs: recommendations for content, method, and fre- quency. Pediatr Emerg Care. 2004;2:269-72. 6. Zautcke JL, Lee RW, Ethington NA. Paramedic skill decay. J Emerg Mee!. 1987;5:505-12. 7. Latman NS, Wooley K. Knowledge and skill retention of emer- gency care attendants, EMT-As, and EMT-Ps. Ann Emerg Med. 1980;9:183-9. 8. Pointer JE. Experience and mentoring requirements for compe- tence in new / inexperienced paramedics. Prehosp Emerg Care. 2001;5379-83. 9. Walters G, Glucksman E. Retention of skills by advanced trained ambulance staff: implications for monitoring and retraining. BMJ. 1989;298;649-50. 10. Pirrallo RC, Larsen JE, Bragg DA. Establishing biennial paramedic experience benchmarks [editorial letter}. Prehosp Emerg Care. 1998;2:335--6, 11. National Registry of Emergency Medical Technicians. National EMS Practice Analysis. Columbus, OH: NREMT, 2005. 12. Delaney HD, Vargha A. The effect of nonnonnality on Shldent's two-sample t test. April 2000. Available at: http:// eric.ed.gov /ERICWebPortal/custom/portlets/record Details/ detailmini.jsp? Jlipb=true&_&ERICExtSearch...5earch Value_O= ED443850&ERICExtSearch...5earchType_O=eric...accno&accno= ED443850. Accessed September 10, 2007. 13. Cady CE, Pirrallo RG. The effect of Combitube use on paramedic experience in endotracheal intubation. Am J Emerg Med. 2005;23(7);868-71. 14. I'olentini MS, Pirrallo Re, McGill W. The changing incidence of ventricular fibrillation in Milwaukec, Wisconsin 0992-2002). Pre- hasp Emerg Care. 2006;10:52-60. 15. Garza AC, Gratton MC, Coontz 0, Noble E, Ma OJ. Effect of paramedic experience on orotracheal intubation success rates. J Emerg Med. 2003;25:251-6. 16. Wang HE, Kupas OF, Hostler 0, Cooney R, Yealy EM, Lave JR. Procedural experience with out-of-hospital endotracheal intuba- tion. Crit Care Med. 2005;33:1718-21. 17. Davis OP, Fakhry SM, Wang HE, et a1. Paramedic rapid sequence intubation for severe traumatic brain injury: perspectives from an expert panel. Prehosp Emerg Care. 2007;11:1-8. 18. Rumball C, Macdonald 0, Barber P, Wong H, Smecher C. Endo- tracheal intubation and esophageal tracheal Combitube insertion by regular ambulance attendants: a comparative trial. Prehosp Emerg Care. 2004;8:15-22. 19. Moore L. Measuring quality and effectiveness of prehospital EMS. Prehosp Emerg Care. 1999;3:325-31. 20. Weissman NW, Allison IT, Kiefc CI, et al. Achievable benchmarks of care: the ABCs of benchmarking. J Eva] Clin Pract. 1999;5:269- 81. 21. 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