Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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Review
A systematic review of the evidence supporting the use of priority dispatch of emergency ambulances.
Systematic reviews of the literature assist in the location, appraisal, and synthesis of available evidence. This systematic review aimed to 1) assess the existing literature evaluating the effect of the priority dispatch of emergency ambulances on clinical outcome and ambulance utilization and 2) assess the relative effectiveness of sources of literature relevant to prehospital care. ⋯ There is very little evidence to support the effect of the prioritization of emergency ambulances on patient outcome. Electronic databases identify only approximately half of all relevant prehospital literature. Future systematic reviews in this area should use electronic databases, supplemented by contact with appropriate experts.
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The proposed Medicare fee schedule for medically necessary ambulance transportation will have a profound impact on emergency medical services (EMS) systems throughout the country. When the new Medicare rules are implemented, reimbursement for Medicare patients will be largely based on national relative value units that vary depending on the level of service provided, from basic life support to advanced life support emergency. Under the new fee schedule, nearly all EMS systems will lose money when compared with the actual cost of providing the service, particularly advanced life support services, rural services, efficient systems, and those that bill for services. To adapt to these impending changes, EMS administrators and medical directors must work together to diversify and solidify their revenue sources and to seek out ways to make their systems even more efficient while maintaining a high quality of clinical care.
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A paramedic may be unprepared to practice alone or with an inexperienced partner immediately following completion of training. Emergency medical services systems have not generally set standards to ensure that a newly-licensed paramedic is competent to practice alone. ⋯ This paper summarizes mentoring requirements for other clinical professions and reviews studies from the out-of-hospital and hospital literature that demonstrate a positive correlation between experience and outcome and/or competence. The author recommends specific benchmarking and supervision by a training officer or an experienced paramedic to ensure competence in new and inexperienced paramedics.
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Approximately 1,000 people in the United States suffer cardiac arrest each day, most often as a complication of acute myocardial infarction (AMI) with accompanying ventricular fibrillation or unstable ventricular tachycardia. Increasing the number of patients who survive cardiac arrest and minimizing the clinical sequelae associated with cardiac arrest in those who do survive are the objectives of emergency medical personnel. In 1990, the American Heart Association (AHA) suggested the chain of survival concept, with four links--early access, cardiopulmonary resuscitation (CPR), defibrillation, and advanced care--as the way to approach cardiac arrest. ⋯ This paper addresses a number of the issues associated with each of the links of the chain of survival, the evidence that exists, and what should be done to achieve the clinical evidence needed for true clinical significance. Also included in this paper are the consensus statements developed from small discussion groups held after the main presentation. These comments provide another perspective to the problems and to possible approaches to deal with them.
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End-tidal carbon dioxide (ETCO2) monitoring is an exciting technology and has the potential to become a very useful tool in the prehospital setting. It can be useful in verifying endotracheal tube position and during cardiopulmonary resuscitation in the field. ⋯ The new American Heart Association guidelines require secondary confirmation of proper tube placement in all patients by exhaled CO2 immediately after intubation and during transport. This article covers the terminology, the basic physiology, the technology (both colorimetric detectors and infrared capnometers), and the clinical applications of ETCO2 monitoring with special reference to the pediatric patient.