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Advanced Life Support (ALS) may not be effective in the treatment of respiratory distress patients, according to a recent Canadian study published in The New England Journal of Medicine. The controversial findings come with some weight: 4000 patients, across 15 cities, took part in the study. The Ontario Prehospital Advanced Life Support study compared Basic Life Support (BLS) and Advanced Life Support (ALS) in fifteen cities over a one year period. The first six-month period involved treatment by a "primary care paramedic," which roughly equates to a US EMT-B. They did not provide medications (other than supplemental oxygen) to patients without additional training. During the second six-month block, the "advanced care paramedics" who responded were similar to US paramedics, with training in IV medication, endotracheal intubation, and other skills we regard as ALS in the United States. These ALS providers had trained for twenty-four weeks in the additional skill set.

During the intervention period, 56% of patients received ALS services. Fewer ALS phase patients were intubated in the ED, and ALS phase patients were far more likely to improve in condition while en route to hospital. The authors took a conservative stand with their data, acknowledging the slim majority of patients that actually received ALS. Technically, a 1.7% reduction in mortality was proven through use of ALS, but that number came in below the 2% endpoint that researchers marked as a threshold of significance.

The study only counted data on patients with a complaint of respiratory distress, and excluded cardiac arrests, chest pain, trauma, or other processes that made dyspnea a secondary symptom. Therefore, only a small number of patients who were just dyspneic received a benefit from ALS. Since EMS is a system, assessing the benefit for all types of patients is very difficult. In a system such as Ontario’s, with designated 24-hour PCI facilities, I would wonder what the benefit to chest pain patients who are pre-diagnosed with ST-elevation MI would be. Likewise, does the extra training provide a mechanism for paramedics to provide better assessment and intervention in trauma cases? This study does prove that EMS makes a critical difference in a very small proportion of dyspnea cases. The overall effects of EMS have to be measured more deeply, however.

Study is just the beginning

EMS is expensive. The true cost of EMS varies widely from system to system, with local prevailing wages, transport times, response times and benchmarks for response time being extremely variable. In our time of growing municipal budget cuts and shrinking reimbursements, everyone is looking for places to cut costs. Many have suggested in recent years that ALS services fail to save lives in a cost effective manner, from literature suggesting the lack of benefit in endotracheal intubation, mortality increases with increased prehospital times, and a failure of fluid resuscitation to benefit the trauma patient. These studies are hard to ignore, especially if your municipal managers get hold of them.

Much more research like this is needed in the future, as we set the agenda for EMS. Many national and international organizations, including the Institute of Medicine and The World Bank’s Disease Control Priorities Project have issued guidelines on EMS’s future and the direction we should direct resources in the future. This study is a great step in measuring the value of EMS. We as emergency physicians must build on this foundation and continue to question interventions and their efficacy and cost-effectiveness as we move through the 21st century. Since we do not have a good cost benefit ratio for EMS, further research is needed to provide focus for our efforts, because the need for unscheduled treatment and transportation is not going away. Our agenda as emergency physicians must be to advocate: first for our patients, even before they arrive; and second for our prehospital colleagues, to position and equip them to do the most good with the resources that will certainly continue to be questioned by policy makers at all levels. EMS is expensive, but EMTs and paramedics are our front line personnel and colleagues. We must be wary of government and other bureaucrats cutting back on service levels until we have certain definitions and reasonable probabilities of benefit.

~Bledsoe

Next page:
MRSA rears its ugly head inside yet another bastion of emergency care
by Ellen Lamel, MD
{mospagebreak title=MRSA in ambulances}
 

Study shows: Ambulances house MRSA

Methicilin-resistant Staphlococcus aureus (MRSA) is becoming bacterial public enemy #1 in emergency departments. But are patients contracting the superbug even before they come through the ambulance bay doors? In an eye-opening study, researchers swabbed 21 ambulances at two urban stations and discovered a veritable breeding ground for MRSA.

The study, published in the April–June 2007 issue of Prehospital Emergency Care, looked at swabs collected from five locations within each of the 21 ambulances. After 96 hours of plating, researchers found 10 out of the 21 ambulances tested positive for MRSA in at least one location.

We probably shouldn’t be surprised at these results. The Association for Professions in Infection Control and Epidemiology published their MRSA National Prevalence Study in June 2007. Looking at both community and hospital acquired MRSA, acute and long-term care facilities, they found prevalence rates 8 to 11 times higher than previously thought. This was the largest, most comprehensive study to date, and 46.3 of every 1000 patients were infected or colonized with MRSA.

Across the pond, the British have been studying and talking about MRSA contamination in ambulances at least since 2003, and have found similar results. How do we use this information? It’s tempting to write it off as just one more voice crying out about infection control in the wilderness of the overburdened American emergency medical system. For the sake of ourselves, our colleagues and our patients, we can’t.

Impractical Mandates

To be fair, we ask paramedics to do a lot of work in a small space. We ask them to do it quickly, as call after call comes in. They wipe down the gurney with an antimicrobial and change linens after each patient. When they see body fluids, they follow OSHA guidelines. And they may be doing a good job for the "obviously contaminated" areas, but there’s more than meets the eye. In the Prehospital Emergency Care study, by far the largest single group of positive swabs (33.3%) was found not on equipment in contact with the patient, but on the work area to the right of the patient.

Existing guidelines aren’t as helpful as they could be—OSHA rules apply mainly to known body fluid contamination. CDC guidelines assume health care workers know in advance that the patient is MRSA positive; many will be difficult or impossible for ambulance personnel to follow. EMTs and paramedics rarely know they have a MRSA-infected patient, and they are unlikely to be wearing gowns over their uniforms, as the CDC suggests. For the same reason, ambulance personnel will not have dedicated equipment for each MRSA positive patient.

Most individual department standards are equally unhelpful, ranging from mandating thorough cleaning once a month to addressing only body fluid contamination. Some departments only specify the cleanser to be used.

An EP’s Role

There are many creative solutions being pioneered by other countries (see sidebar). However, we cannot force American ambulance companies and fire departments to adopt a particular solution.We can add our voice, though, and insist that a solution must be found and appropriately funded. Adding our voices might mean discussion between your ED director and the local EMS director. It might mean political support for additional funding so departments can find better solutions and monitor the effects of changed cleaning protocols.

We can also help with making sure paramedics and EMTs have the supplies and education they need. Just as importantly, remind paramedics to care for themselves as they care for patients; they should protect themselves by cleaning their work areas as they clean the patient contact areas.
One paramedic listed his department’s procedures, and then said, "We probably clean the outside of the ambulance more often." It’s time to give paramedics the information and tools to reverse the ratio.

Creative Solutions for MRSA

More Ambulances, Dedicated Cleaners
Perhaps we need to go beyond our existing rules. A 2005 Britain’s Ambulance Service Association study showed MRSA persisted in ambulances despite standard cleaning procedures. Their disinfection process was similar to that currently in the U.S., using similar microbicides. The British now take ambulances out of service to use a "deep cleaning" procedure with vaporized hydrogen peroxide; extra ambulances ensure service isn’t interrupted while the ambulances are cleaned by dedicated personnel.
 
~Lamel

 

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