Implementation of the Modified Canadian C-Spine Rule by Paramedics.

Study Objective: The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics.

Methods: This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015).

Advanced Life Support for Out-of-Hospital Chest Pain: The OPALS Study.

As many as 14% of patients transported by ambulance with chest pain die prior to hospital discharge. To date, no high-quality controlled trials have revealed that prehospital advanced life support interventions affect survival for these patients. The Ontario Prehospital Advanced Life Support (OPALS) Study assessed the effect of adding an advance life support service to an existing basic life support emergency medical service program, on the rate of mortality and morbidity for patients with out-of-hospital chest pain.

Safety and clinically important events in PCP-initiated STEMI bypass in Ottawa.

Objective: The aim of this study was to determine what clinically important events occur in ST-elevation myocardial infarction (STEMI) patients transported for primary percutaneous coronary intervention (PCI) via a primary care paramedic (PCP) crew, and what proportion of such events could only be treated by advanced care paramedic (ACP) protocols.

Methods: We conducted a health record review of STEMI transports by PCP-only crews and those transferred from PCP to ACP crews (ACP-intercept) from 2011 to 2015. A piloted data collection form was used to extract clinically important events, interventions during transport, and mortality.

The Safety of Bypass to Percutaneous Coronary Intervention Facility by Basic Life Support Providers in Patients with ST-Elevation Myocardial Infarction in Prehospital Setting.

Background: Most patients transferred from a non-percutaneous coronary intervention (PCI) facility for primary PCI do not meet target reperfusion times. Direct transportation of patients with ST-elevation myocardial infarction (STEMI) from the scene by advanced life support (ALS) paramedics has been shown to improve reperfusion times and outcomes.

Objective: The aim of this study was to determine whether it is safe to bypass the closest hospital and transport by basic life support (BLS) provider to a PCI facility.

Characteristics, Prehospital Management, and Outcomes in Patients Assessed for Hypoglycemia: Repeat Access to Prehospital or Emergency Care.

Background: In Ontario, Canada, there currently are no prehospital treat-and-release protocols and the safety of this practice remains unclear. We sought to describe the characteristics, management, and outcomes of patients with hypoglycemia treated by paramedics, and to determine the predictors of repeat access to prehospital or emergency department (ED) care within 72 hours of initial paramedic assessment.

Methods: We performed a health record review of paramedic call reports and ED records over a 12-month period.

Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study.

Background: A minimal amount of research exists examining the extent to which patient safety events occur within paramedicine and even fewer studies investigating patient safety systems for self-reporting by paramedics. The purpose of this study was to identify barriers to paramedic self-reporting of patient safety incidents (PSIs).

Methods: We randomly distributed paper-based surveys among 1,153 paramedics in an Ontario region in Canada.

Effectiveness and safety of a prehospital program of continuous positive airway pressure (CPAP) in an urban setting.

Background: Continuous positive airway pressure (CPAP) is commonly used in the treatment of acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In-hospital evidence is robust: CPAP has been shown to improve respiratory status and to reduce intubation rates. There is less evidence on prehospital CPAP, although the emergency medical services (EMS) adoption of this modality is increasing.

Differential survival for men and women from out-of-hospital cardiac arrest varies by age: results from the OPALS study.

Background: The effect of sex on survival in out-of-hospital cardiac arrest (OHCA) is controversial. Some studies report more favorable outcomes in women, while others suggest the opposite, citing disparities in care. Whether sex predicts differential age-specific survival is still uncertain.

Prehospital use of furosemide for the treatment of heart failure.

Introduction: The diagnosis and management of acute decompensated heart failure (HF) in the prehospital setting can be challenging. The objectives of this study are to evaluate the appropriateness of furosemide use by Emergency Medical Services (EMS) and its association with adverse outcomes.

Methods: This study was a multi-centre health records review of EMS patients who received prehospital furosemide or had an emergency department (ED) diagnosis of HF.

Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention.

Objectives: This study sought to determine whether mortality complicating ST-segment elevation myocardial infarction (STEMI) was impacted by the design of transport systems.

Background: It is recommended that regions develop systems to facilitate rapid transfer of STEMI patients to centers equipped to perform primary percutaneous coronary intervention (PCI), yet the impact on mortality from the design of such systems remains unknown.

Methods: Within the framework of a citywide system where all STEMI patients are referred for primary PCI, we compared patients referred directly from the field to a PCI center to patients transported beforehand from the field to a non-PCI-capable hospital.

Evaluation of the safety of C-spine clearance by paramedics: design and methodology.

Background: Canadian Emergency Medical Services annually transport 1.3 million patients with potential neck injuries to local emergency departments. Less than 1% of those patients have a c-spine fracture and even less (0.

The role of paramedics in a primary PCI program for ST-elevation myocardial infarction.

Time to reperfusion is linked to survival in patients presenting with ST-elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) is now considered the dominant strategy when it can be performed quickly. Because the number of cardiac catherization facilities is limited, health care workers have attempted to develop systems to ensure access to primary PCI for all patients with STEMI.

Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million.

Objectives: The purpose of this study was to assess the effectiveness of contemporary automatic external defibrillator (AED) use.

Background: In the PAD (Public Access Defibrillation) trial, survival was doubled by focused training of lay volunteers to use an AED in high-risk public settings.

Methods: We performed a population-based cohort study of persons with nontraumatic out-of-hospital cardiac arrest before emergency medical system (EMS) arrival at Resuscitation Outcomes Consortium (ROC) sites between December 2005 and May 2007.

Review of endotracheal intubations by Ottawa advanced care paramedics in Canada.

Objectives: In the last several years, the National Association of EMS Physicians (NAEMSP) has called for better reporting on prehospital endotracheal intubation (ETI) and has provided guidelines and tools for better systematic review. We sought to evaluate the success of prehospital, non-drug-assisted ETI performed by Ottawa advanced care paramedics (ACPs) based on those guidelines.

Methods: A retrospective review was conducted on ETI performed by Ottawa ACPs over a 25-month period to determine the overall success rate of ETI.

The out-of-hospital validation of the Canadian C-Spine Rule by paramedics.

Study Objective: We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.

Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers.

Study Objective: To identify any association between out-of-hospital transport interval and survival to hospital discharge in victims of out-of-hospital cardiac arrest.

Methods: Data from the Ontario Prehospital Advanced Life Support Study (January 1, 1991, to December 31, 2002), an Utstein-compliant registry of out-of-hospital cardiac arrest patients from 21 communities, were analyzed. Logistic regression identified factors that were independently associated with survival in consecutive adult, nontraumatic, out-of-hospital cardiac arrest patients and in the subgroup with return of spontaneous circulation.

Comparison of the Cerebral Performance Category score and the Health Utilities Index for survivors of cardiac arrest.

Study Objective: The Cerebral Performance Category score is an easy to use but unvalidated measure of functional outcome after cardiac arrest. We evaluate the comparability of results from the Cerebral Performance Category scale versus those of the validated but more complex Health Utilities Index scale for health-related quality of life.

Methods: This prospective substudy of the Ontario Prehospital Advanced Life Support (OPALS) Study included adult out-of-hospital cardiac arrest patients treated in 20 cities.

The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity.

Background: To date, the benefit of prehospital advanced life-support programs on trauma-related mortality and morbidity has not been established

Methods: The Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study was a before-after systemwide controlled clinical trial conducted in 17 cities. We enrolled adult patients who had experienced major trauma in a basic life-support phase and a subsequent advanced life-support phase (during which paramedics were able to perform endotracheal intubation and administer fluids and drugs intravenously). The primary outcome was survival to hospital discharge.

A citywide protocol for primary PCI in ST-segment elevation myocardial infarction.

Background: If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain.

Advanced life support for out-of-hospital respiratory distress.

Background: Respiratory distress is a common symptom of patients transported to hospitals by emergency medical services (EMS) personnel. The benefit of advanced life support for such patients has not been established.

Methods: The Ontario Prehospital Advanced Life Support (OPALS) Study was a controlled clinical trial that was conducted in 15 cities before and after the implementation of a program to provide advanced life support for patients with out-of-hospital respiratory distress.

Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field.

Objectives: Most studies of pre-hospital management of ST-elevation myocardial infarction (STEMI) have involved physicians accompanying the ambulance crew, or electrocardiogram (ECG) transmission to a physician at the base hospital. We sought to determine if Advanced Care Paramedics (ACPs) could accurately identify STEMI on the pre-hospital ECG and contribute to strategies that shorten time to reperfusion.

Methods: A STEMI tool was developed to: 1) measure the accuracy of the ACPs at diagnosing STEMI; and 2) determine the potential time saved if ACPs were to independently administer thrombolytic therapy.

Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital.

Speed of reperfusion is critical in ST-segment elevation myocardial infarction (STEMI). We assessed the safety and feasibility of an integrated metropolitan approach in which advanced-care paramedics interpret the prehospital electrocardiogram and independently refer patients with STEMI to a designated center for primary percutaneous coronary intervention (PCI). We developed and implemented a protocol in which paramedics trained in electrocardiographic interpretation bypassed the nearest emergency room and referred patients with suspected STEMI directly to a designated primary PCI center (paramedic-referred primary PCI).

Comparison of mortality patterns in patients with ST-elevation myocardial infarction arriving by emergency medical services versus self-transport (from the prospective Ottawa Hospital STEMI Registry).

Emergency medical services (EMSs) play a key role in the recognition and treatment of ST-elevation of myocardial infarction (STEMI). We sought to determine contemporary use of EMS in patients with STEMI and its relation to treatment, morbidity, and mortality patterns. Patients who arrived by EMS were compared with those who arrived by self-transport.

Combined angioplasty and pharmacological intervention versus thrombolysis alone in acute myocardial infarction (CAPITAL AMI study).

Objectives: We compared a strategy of tenecteplase (TNK)-facilitated angioplasty with one of TNK alone in patients presenting with high-risk ST-segment elevation myocardial infarction (STEMI).

Background: Previous trials show that thrombolysis followed by immediate angioplasty for the treatment of STEMI does not improve ischemic outcomes compared with thrombolysis alone and is associated with excessive bleeding complications. Since the publication of these trials, however, significant pharmacological and technological advances have occurred.