Objectives: "Lean" is a business improvement methodology used widely in manufacturing and industrial engineering. This method maximizes value by achieving the fastest rate of improvement simultaneously with improving customer satisfaction, cost, quality, process speed and invested capital. All existing Lean tools are manufacturing-based and not applicable to clinical service settings. We have developed a tool to allow for time value stream mapping in the clinical setting. In this paper, we apply our new time value stream mapping tool to an important operational process, ED triage. We use this new Lean tool for healthcare: 1) to identify activities that "add value" to the patient encounter versus those that are "wasteful" (non-value-added); 2) to delineate bottlenecks to flow and, 3) to establish a baseline timeframe for improvement by creating a "map" of the existing triage process. Our study objective was to create a "time value stream map" of the course of a patient's encounter as they complete the triage process using the business improvement methodology called "Lean".

Study Objectives: Although peripheral vertigo is a common presenting complaint in the emergency department, few clinical studies concerning the treatment of vertigo exist. Symptoms of vertigo involve the vestibular system, which uses acetylcholine as a neurotransmitter. Evidence suggests that anticholinergic medications decrease vestibular output. This pilot study will document the effectiveness of an anticholinergic elixir of atropine, hyoscyamine, phenobarbital, and scopolamine (Donnatal®) in treating symptomatic vertigo, and assist with the design of a randomized prospective trial. Atropine, hyoscyamine, phenobarbital, and scopolamine elixir (AHPS) is known to be quickly absorbed and non-sedating and it does not require IM/IV injection, as with some other medications used to treat vertigo.

Objectives: Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three-level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states. Methods: In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60-day all-cause mortality. Results: Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n= 3,289) and 0.69 to 0.87 for patient triages (n= 386). Outcomes for the validity cohort (n= 1,042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty-day all-cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%. Conclusions: ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.

OBJECTIVES To implement a new five-level emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population-based cohort using hospitalization and ED length of stay as outcome measures. METHODS The five-level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one-month period immediately following implementation was performed. RESULTS Eight thousand two hundred fifty-one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n = 62 nurses), and 0.73 for patient triages (n = 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 58/63 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a-priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three-level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials. CONCLUSIONS Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes.

OBJECTIVES:Triage is the initial clinical sorting process in hospital emergency departments (EDs). Because of poor reproducibility and validity of three-level triage, the authors developed and validated a new five-level triage instrument, the Emergency Severity Index (ESI). The study objectives were: 1) to validate the triage instrument against ED patients' clinical resource and hospitalization needs, and 2) to measure the interrater reliability (reproducibility) of the instrument.METHODS:This was a prospective, observational cohort study of a population-based convenience sample of adult patients triaged during 100 hours at two urban referral hospitals. Validation by resource use and hospitalization (criterion standards) and reproducibility by blinded paired triage assignments compared with weighted kappa analysis were assessed.RESULTS:Five hundred thirty-eight patients were enrolled; 45 were excluded due to incomplete evaluations. The resulting cohort of 493 patients was 52% female, was 26% nonwhite, and had a median age of 40 years (range 16-95); overall, 159 (32%) patients were hospitalized. Weighted kappa for triage assignment was 0.80 (95% CI = 0.76 to 0.84). Resource use and hospitalization rates were strongly associated with triage level. For patients in category 5, only one-fourth (17/67) required any diagnostic test or procedure, and none were hospitalized (upper confidence limit, 5%). Conversely, in category 1, one of twelve patients was discharged (upper confidence limit, 25%), and none required fewer than two resources.CONCLUSIONS:This five-level triage instrument was shown to be both valid and reliable in the authors' practice settings. It reproducibly triages patients into five distinct strata, from very high hospitalization/resource intensity to very low hospitalization/resource intensity.

OBJECTIVE:To determine the effectiveness of a prototype esophageal detection device (EDD) during use in the prehospital setting.DESIGN/SETTING:Prospective convenience sample in a prehospital setting.POPULATION:Intubated adult patients.INTERVENTIONS:The study device was used to determine esophageal or endotracheal placement of endotracheal tubes in intubated patients. Clinical means were used to confirm tube location. A data sheet was completed for each patient.RESULTS:Of 105 uses of the device, 17 of 17 esophageal tubes were identified correctly (100% sensitivity). Sixty-five of 88 tracheal tubes were correctly identified (78% specificity). There was intermediate reinflation of the device on 13 of the 65 tracheal tubes. Five tests were indeterminate. There were no false negatives (negative predictive value 100%), but 18 false positives (positive predictive value 48%).CONCLUSION:This prototype EDD adequately identifies esophageally placed endotracheal tubes. Correct identification of endotracheally placed tubes was less sensitive. Much work needs to be done regarding the use of negative aspiration devices to identify placement of endotracheal tubes.

Objective: To determine the ability of a prototype esophageal detection device (EDD) to identify esophageal misplacement of an endotracheal (ET) tube.Methods: A prospective, randomized, blinded study of detection of esophageal intubation was conducted using 51 elective surgical patients who met inclusion criteria. A squeeze-bulb aspirator that creates a negative pressure of -80 to -90 torr was used for detection of esophageal intubation. The bulb should reinflate rapidly if the tube is in the noncollapsible trachea, but should not reinflate if the tube is in the collapsible esophagus. Each patient was prepared for surgery in the usual manner. The anesthesiologist placed an ET tube into the trachea. An identical tube was advanced the same distance into the esophagus. The tubes were labeled ''A'' or ''B'' according to a computer-generated random number list. An evaluator, who was blinded to the placement of the tubes, assessed one tube with the EDD. For most patients, a second evaluator, who was blinded to both tube placement and the results of the first evaluator, assessed the other tube. During evaluation, the tube cuffs were deflated. After data collection, the esophageal tube was removed and surgery was completed.Results: All 45 esophageal tube placements were correctly identified. Thirty-five of the 40 ET tubes were correctly identified. Of the five ET tubes mislabeled, three were found in a mainstem bronchus. All had delayed bulb re-expansion.Conclusion: This prototype EDD is a useful method of identifying esophageal misplacement of an ET tube in anesthetized adult surgical patients

Study objective: To evaluate a standardize training program in intraosseous (IO) infusion for prehospital providers.Design: Prospective multicenter 24-month study.Setting: 10 infusions were performed by prehospital providers from eight advanced life support units serving 14 hospitals within nine counties.Participants: Field advanced life support providers (paramedics and registered nurses).Interventions: All providers participated in a one-hour standardized training session and supervised hands-on simulation. Providers completed a data sheet on all 10 infusions performed. Data sheets were collected and summarized.Results: One hundred thirty-four prehospital providers completed the training session and were approved to perform the procedure. Fifteen patients requiring 10 infusion were encountered during the study period. Thirteen (87%) had 10 infusion completed successfully. Clinical indications included 11 patients in cardiac arrest, two trauma resuscitations, one seizure, and one toxic ingestion. Patient ages ranged from 1 to 24 months. Seven patients were initially resuscitated. Four survived to hospital discharge. Procedural complications included one incidence of local fluid extravasation and one 10 line that became dislodged en route. There were no complications at time of discharge in the four survivors. All procedures were performed in less than two minutes.Conclusion: A one-hour standardized training session was successfully used to train prehospital providers in the procedure of 10 infusion. 10 infusion then was implemented into their clinical practice with a satisfactory success rate and few complications.

To evaluate the recently published Utstein algorithm (Ann Emerg Med 1991;20:861), the authors conducted a retrospective review of all advanced life support (ALS) trip sheets and hospital records of patients with prehospital cardiac arrests between January 1988 and December 1989. Telephone follow-up was used to determine 1-year survival rates. Of 713 arrests in the 24-month study period, 601 were of presumed cardiac etiology. Approximately 599 of these charts were available for analysis. One hundred ninety-three (32.2%) of these had return of spontaneous circulation (ROSC), 36 (6.0%) survived to hospital discharge, and 24 were alive at 1-year follow-up (4.0% of total or 67% of survivors to discharge). The Utstein style was found to be a useful algorithmic format for reporting prehospital cardiac arrest data in a manner that should allow direct comparison between emergency medical service (EMS) systems. Existing prehospital record-keeping practices (trip sheets) are easily adapted to this style of data collection, although certain data for the template (eg, resuscitations not attempted and alive at 1-year) are more difficult to ascertain. Additionally, the authors report their own experience during a 2-year period, including data that suggest that the majority of patients with cardiac arrest who survive to hospital discharge are still alive at 1 year.

We show that automated external defibrillation training of emergency medical technicians (EMTs) is less time consuming than manual defibrillation training, and hypothesize that both improve survival from sudden cardiac death. Data on 91 cardiac arrests over 27 months among five basic life support services was collected before EMT-defibrillation (EMT-D) training. Subsequently, seven BLS services were trained in EMT-D using either manual defibrillation or automated external defibrillation technology, and 55 sudden cardiac death patients were entered after training. Manual defibrillation required 11 more hours per student in initial training. Survival to hospital discharge improved from two of 91 patients (2.2%) in the series before EMT-D training to nine of 55 patients (16.4%) after EMT-D training (P = .001). Improved survival was correlated with shorter prehospital defibrillation times, 8.84 minutes, when EMTs performed defibrillation versus 16.3 minutes before training when EMTs awalted advanced life support defibrillation (P < .001). To enhance equipment famillarity we allowed EMTs to apply three-lead electrode monitors to all medical/cardiac patients during transport (surveillance). There were six emergency medical service-witnessed “surveillance” arrests and three arrests survived to hospital discharge (50% survival). This group represented 33% of all survivors in the series. We recommend automated external defibrillation training for EMTs. Improved survival in sudden cardiac death cases in well-run emergency medical service systems should result from EMT-D training. Finally, we recommend that routine “surveillance” of high-risk patients during transport by defibrillation-capable EMTs be considered in EMT-D programs, rather than limiting EMT-D only to units capable of rapid “man-down” response.

INTRODUCTION:Airway management is the most critical and potentially life-saving intervention performed by emergency medical service (EMS) providers. Invasive airway management often is required in non-cardiac-arrest patients who are combative or otherwise uncooperative. The success of prehospital invasive airway management in this patient population was evaluated.METHODS:A retrospective review was undertaken of the records of all such patients requiring endotracheal intubation over a three-year period (1987-1989). The study population included 278 patients enrolled by five advanced life support (ALS) units serving a suburban population of 425,000. Field trip sheets were reviewed for diagnosis, intubation method and success, number of intubation attempts, provider experience, reasons for unsuccessful intubations, and complications.RESULTS:A total of 394 invasive airway management attempts were performed on 278 patients. The overall successful intubation rate was 75% (41% orotracheal, 52% nasotracheal, 7% other or unknown). The most common diagnoses were COPD and pulmonary edema (30%) and trauma (24%). Experienced providers were successful on the first attempt in 57% of cases compared to 50% by inexperienced providers (p=.24). Multiple intubation attempts were required in 33% of the patients. There was no statistically significant difference in success rates between the orotracheal and nasotracheal methods (p=.51). The most common reason for unsuccessful intubation was altered level of consciousness. Complications occurred with 7% of successful attempts and in 18% of unsuccessful attempts (p less than .001). Forty-six percent of the patients who were not intubated successfully in the field and required intubation in the emergency department (ED) received a neuromuscular blocking agent prior to successful intubation.CONCLUSION:Prehospital providers can intubate a high but improvable proportion of non-cardiac-arrested patients by both the orotracheal and nasotracheal routes. The use of pharmacologic adjuncts to facilitate the prehospital intubation of selected, non-cardiac-arrested patients is a promising adjunct that needs further evaluation.

STUDY OBJECTIVES:We conducted a study of the prehospital use of inhaled metaproterenol. DESIGN, SETTING, TYPE OF PARTICIPANTS, AND INTERVENTIONS: Advanced life support (ALS) providers were trained with a standardized curriculum to identify patients likely to benefit from prehospital inhaled metaproterenol administration. Unit doses of metaproterenol were used in a small-volume nebulizer. We prospectively included 122 patients in an initial study (71 men; age, 63 +/- 19 years) to evaluate the safety and effectiveness of metaproterenol in the field, and 150 patients (including the original 122) in an additional study to evaluate patient selection criteria. MEASUREMENTS AND MAIN RESULTS:The treatments resulted in an increase in peak flows, a decrease in respiratory rates, and no change in heart rates. In 62% of patients, the increase in peak flow exceeded 15%. Wheezing improved in 59% of the patients, worsened in 4%, and did not change in the remainder. Air entry by auscultation improved subjectively in 59% of patients. Mild tremor occurred in 8% of patients, moderate tremor occurred in 1%, and no tremor occurred in the remainder. Significant dysrhythmias did not occur. CONCLUSIONS:ALS providers correctly identified patients for this therapy. No technical problems were encountered in the field with this treatment approach. We conclude that ALS providers can be taught to identify patients likely to benefit from inhaled metaproterenol, that inhaled metaproterenol can be administered in the field, and that metaproterenol is both safe and effective when used in the prehospital setting.

All out-of-hospital cardiac arrest advanced life support (ALS) trip sheets were collected from January 1980 through December 1985 for this suburban-rural system. Information was extracted according to a uniform reporting format. In our study, 18% of patients with early CPR (less than four minutes) and early ALS (less than ten minutes) survived to hospital discharge, compared with 7% with early CPR and late ALS, 6% with late CPR and early ALS, and 3% with both occurring late. Although 75% of the survivors had ventricular tachyarrhythmias as initial rhythms, bradyasystolic arrests were not uniformly lethal, even with long CPR and ALS times. This study supports the need for early CPR in the prehospital care of potential sudden-death victims. We recommend, with qualification, this reporting format to emergency medical services systems to describe their cardiac arrest experience.

Verapamil was introduced into a hospital-based urban/rural advanced life support (ALS) system for intravenous (IV) use in patients with symptomatic supraventricular tachyarrhythmias. During this trial period, IV verapamil was given to 24 patients, 12 (50%) of which benefited from its use. IV verapamil produced no harmful effects, and there was only one reported adverse effect (nausea) related to its administration. IV verapamil may be useful in the prehospital care of patients with symptomatic supraventricular tachyarrhythmias.

This study evaluated the efficacy of prehospital external cardiac pacing in cardiac arrest patients. From October 1984 to June 1985, 91 patients were paced. Mean time from cardiac arrest to advanced life support (ALS) intervention in this metropolitan-rural ALS system was 14.5 minutes. Electrical capture occurred in 85 (93%), mechanical capture (pulses) occurred in ten (11%), and a measurable blood pressure occurred in three (3%) of the 91 patients. Despite a high rate of electrical capture, palpable pulses were produced only in 11%, and no patients survived to be discharged from the hospital. There was no difference in the frequency of electrical capture, palpable pulses, or outcome for patients receiving pharmacologic intervention before or after pacing. Likewise there was no difference in the frequency of electrical capture, palpable pulses, or outcome for patients receiving ALS therapy within or after ten minutes of their arrest. Although we found that external cardiac pacing was easily used in the prehospital setting, pacing did not result in any increase in survival in cardiac arrest patients.