ED overcrowding, ambulance diversions may cost lives

Overcrowding at EDs led to an estimated 300 extra deaths in California hospitals over a one-year period, according to a study published in 2012

Updated June 2015

Patients seen at emergency departments on days when ambulances were on diversion had a 5 percent increased chance of dying in the hospital than those admitted on other days, say researchers from Oregon Health and Science University in Portland and colleagues.

Researchers analyzed discharge data on nearly 1 million patients seen at 187 California EDs in 2007 and electronic ambulance diversion logs provided by EMS agencies. Children, children’s hospitals, centers without EDs, federal hospitals, transfers and centers prohibited from diverting ambulances were excluded. Ambulances were on diversion due to overcrowding about one-quarter of days; diversion lasted for a median of seven hours.

Overcrowding at EDs led to an estimated 300 extra deaths in California hospitals over the one-year period, according to the study, which was published online Dec. 12, 2012, in Annals of Emergency Medicine.

Advanced airway management: More harm than good?

Patients in cardiac arrest treated by EMS with advanced airway management—ET intubation or supraglottic airway devices—were less likely to survive with good neurological outcome than those who received conventional bag-valve-mask ventilation, found a large observational study involving 650,000 Japanese adults. Advanced airway management was also associated with lower odds of a return of spontaneous circulation.

The study, in the Jan. 15 issue of the Journal of the American Medical Association, analyzed data on patients who experienced an out-of-hospital cardiac arrest from 2005 through 2010 and were included in the All-Japan Utstein Registry of the Fire and Disaster Management Agency. About 57 percent were treated with BVM ventilation, while 43 percent received advanced airway management (6 percent with intubation and 37 percent via supraglottic airway device).

About 1.1 percent of those receiving advanced airway management survived with a favorable neurological outcome one month after the arrest, compared to 2.9 percent of those who received BVM ventilation. The poorer outcomes among patients who received advanced airway management remained after adjustment for factors such as age, gender, cause of arrest, type of rhythm, whether the arrest was witnessed, type of bystander CPR performed and use of a public-access AED.

Because this was not a randomized controlled trial, researchers caution that they could not determine causality, nor should it necessarily change practice immediately. However, one explanation for the findings is that intubation may interfere with good-quality chest compressions. In addition, “it has been well documented that pre-hospital intubation is a complex psychomotor task and that EMS personnel have difficulty gaining and maintaining competency in this skill,” they wrote, noting that improperly performed intubation can lead to unrecognized esophageal intubation, tube dislodgement, iatrogenic hypoxemia, bradycardia and the need for multiple insertion attempts.

In an accompanying editorial, Henry Wang, M.D., of the University of Alabama at Birmingham, and Donald Yealy, M.D., of the University of Pittsburgh, noted that complicating factors for advanced airway management in the field include that paramedics deliver care in uncontrolled settings; paramedic training offers little exposure to actual ET intubations; and paramedics have few opportunities to practice on the job. The authors cite a study that found Pennsylvania paramedics perform only one intubation yearly on average.

The editorialists urge a randomized trial to confirm the findings. “The emergency medical services community risks turning a blind eye and embracing ineffective or harmful airway interventions,” they wrote. “Patients with cardiac arrest and the out-of-hospital rescuers who care for them deserve to know what is best.”

Watch a video interview about the study findings with Joseph Ornato, M.D., chairman of the department of emergency medicine at Virginia Commonwealth University Medical Center in Richmond. Ornato was not involved with the research.

CPR kit helps parents know how to handle emergencies

Parents of children at high risk of cardiac arrest given a CPR-training video and baby mannequin feel better prepared to deal with an emergency at home, researchers have found.

CPR educators at Lucile Packard Children’s Hospital in Stanford, Calif., gave 117 parents a CPR Anytime Kit at discharge. A telephone survey six months later found that 82 percent had watched the video; 79 percent had shared the kit with at least two other family members; 67 percent reported being “somewhat” or “very confident” with basic CPR techniques; 80 percent knew to call 911 as a first step for an unresponsive child; and 98 percent knew to watch for chest rise to assess ventilation during rescue breathing. The study is in the January–February issue of Journal for Healthcare Quality.

Possible increase in certain types of cancer among 9/11 responders

World Trade Center rescue and recovery workers may be at higher risk of certain types of cancer, including prostate, thyroid and myeloma (a blood cancer), compared to the general population of the state of New York. However, researchers said the findings should be viewed cautiously because their data did not detect an overall higher risk of cancer; nor did they find a relationship between the level of exposure and likelihood of cancer, an association that would have been expected if the exposure to toxic dust containing known and suspected carcinogens had been the cause of the excess cancer cases.

Researchers classified exposure to the WTC environment as high, intermediate and low. Highly exposed participants included rescue/recovery workers who were at the site when the towers collapsed and worked there in the days afterward; people who had two or more injuries on Sept. 11, 2001; or people who resided in lower Manhattan and did not evacuate. Researchers found no association between high exposure and cancer.

The only association was found among rescue and recovery workers and the specific cancer types, according to researchers from the New York City Department of Health and Mental Hygiene and colleagues in the Dec. 19, 2012, issue of the Journal of the American Medical Association. The data were from the WTC Health Registry, which includes health-related information on nearly 56,000 people, including 22,000 rescue/recovery workers. Registry participants were followed through 2008.

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