Updated February 2015
EMS use of positive pressure ventilation reduces mortality
Use of noninvasive positive-pressure ventilation (NIPPV) by EMS reduces the risk of in-hospital mortality and the need for invasive ventilation such as intubation or other advanced airway interventions for patients in respiratory distress, according to researchers at the University of Western Ontario in Canada.
Researchers pooled the results from seven randomized controlled trials involving a total of 632 patients experiencing severe shortness of breath (dyspnea) due to pulmonary edema, COPD, pneumonia or severe asthma. About one-half were treated with NIPPV; the others received standard therapy. The patients treated with NIPPV were 42% less likely to die in the hospital and 63% less likely to require invasive ventilation. Researchers found no differences between the groups in length of hospital or ICU stay.
NIPPV is delivered through a mask, facemask or nasal plugs. NIPPV can also be referred to as bi-level, bi-phasic, Bipap or Vpap ventilation. The National Association of EMS Physicians endorsed the use of NIPPV by EMS in December 2010.
The study was published online Dec. 16, 2013, in the Annals of Emergency Medicine.
Lots of helping hands improve bystander CPR
Cardiac arrest victims who receive CPR from multiple bystanders tend to receive better quality resuscitation, a Japanese study shows. The study, published online Jan. 2 in Resuscitation, asked EMTs to prospectively evaluate the performance of bystander CPR in 553 out-of-hospital cardiac arrests. When they arrived on scene, EMTs asked bystanders to continue administering CPR and then evaluated the quality of the CPR, including appropriate hand position (fingers for infants), a compression rate of at least 100 per minute and a depth of at least 2 inches.
Multiple bystanders performed better than single rescuers. Having a cardiac arrest in an urban or central location was also associated with higher-quality resuscitation. Family members, older bystanders and CPR done in the home tended to be of poorer quality, according to the study.
ED visits by Medicaid patients rise in California, Oregon
From 2005 to 2010, emergency department visits by adults in California rose 13.2%, from 5.5 to 6.1 million patients. About 35% of the increase was due to a rise in visits from Medicaid (Medi-Cal in California) patients, according to a letter by researchers at the University of California, San Francisco published Sept. 18, 2013, in JAMA.
As the Affordable Care Act takes effect, this trend could continue, researchers note, because many of the newly insured will be Medicaid recipients. ED visits by the uninsured also rose 25% during the period, while visits by patients with private insurance went up just 1%.
Meanwhile, a study in Oregon looked at the Medicaid-ED connection from a different angle. Researchers from the National Bureau of Economic Research in Cambridge, Mass., and colleagues analyzed the impact of a 2008 expansion of Medicaid that enrolled about 25,000 low-income, uninsured patients through state lottery. Researchers found those patients used the ED 40% more in the 18 months after they enrolled than the uninsured, contradicting hopes that expanding Medicaid coverage would lower ED use by giving adults access to primary care. The study was published online Jan. 2 in Science.
Do interventions to reduce unnecessary ED visits work?
About two-thirds of published studies on interventions to reduce unnecessary emergency department visits show evidence of effectiveness. That’s according to a review of 62 studies on several types of strategies, including those led by EMS, by researchers from George Washington University and colleagues. The study, published in the October 2013 issue of Academic Emergency Medicine, found:
- Two of five patient education interventions reduced ED usage by 21%, to 81%. Three studies showed no significant decrease in ED use.
- Of 10 studies on interventions that increased capacity at ED alternatives such as community clinics or expanding hours at doctor’s offices, four found decreases in ED use, ranging from 9% to 54%. Five studies found no decrease and one actually showed an increase.
- Two studies (one in the U.S. and one in the U.K.) involved EMS providing either home care or alternative transport of low-acuity patients to clinics. Reduction in ED use ranged from 3% to 7%.
- Of 12 studies looking at the impact of managed care on ED use, nine found reductions in ED use, two found no difference and one found mixed results depending on the type of managed care strategy used.
- Ten studies examined using financial incentives to reduce ED use, either requiring a co-payment of coinsurance or implementation of a high deductible. Nine found reductions in ED use ranging from 3% to 50%; one found an increase in ED visits.
Few studies, the researchers noted, looked at the impact on such interventions on patient outcomes. Some, such as adding non-ED capacity, reduced ED use but led to an increase in overall healthcare spending by those patients.
