HomeStrokeVol. 52, No. 5Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUBRecommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society Edward C. Jauch, MD Lee H. Schwamm, MD Peter D. Panagos, MD Jolene Barbazzeni, RN Robert Dickson, MD Robert Dunne, MD Jenevra Foley, MSL, RHIA, CCP Justin F. Fraser, MD Geoffrey Lassers, PMD, AAS Christian Martin-Gill, MD Suzanne O’Brien, MSN, BSN, RN Mark Pinchalk, MS Shyam Prabhakaran, MD Christopher T. Richards, MD Peter Taillac, MD Albert W. Tsai, PhD Anil Yallapragada, MD and on behalf of the Prehospital Stroke System of Care Consensus Conference Edward C. JauchEdward C. Jauch Correspondence to: Edward C. Jauch, MD, Mission Research Institute, 1 Hospital Dr, Asheville, NC 28801. Email E-mail Address: [email protected] https://orcid.org/0000-0002-3533-4364 Mission Health System, Asheville, NC (E.C.J.). , Lee H. SchwammLee H. Schwamm https://orcid.org/0000-0003-0592-9145 Massachusetts General Hospital, Boston (L.H.S.). , Peter D. PanagosPeter D. Panagos Washington University of St. Louis, MO (P.D.P.). , Jolene BarbazzeniJolene Barbazzeni https://orcid.org/0000-0002-1019-6372 Penn Highlands Healthcare, DuBois, PA (J.B.). , Robert DicksonRobert Dickson Baylor College of Medicine, Houston, TX (R. Dickson). , Robert DunneRobert Dunne Detroit East Medical Control Authority, MI (R. Dunne). National Association of EMS Physicians (R. Dunne, C.M.-G.). , Jenevra FoleyJenevra Foley University of Michigan, Wyoming (J. Foley). , Justin F. FraserJustin F. Fraser University of Kentucky, Lexington (J.F.F.). American Association of Neurological Surgeons, Society of NeuroInterventional Surgery (J.F.F.). , Geoffrey LassersGeoffrey Lassers Oakland County Medical Control Authority, Pontiac, MI (G.L.). , Christian Martin-GillChristian Martin-Gill University of Pittsburgh, PA (C.M.-G.). , Suzanne O’BrienSuzanne O’Brien Michigan Stroke Registry, Lansing (S.O.). , Mark PinchalkMark Pinchalk City of Pittsburgh Emergency Medical Services, PA (M.P.). , Shyam PrabhakaranShyam Prabhakaran https://orcid.org/0000-0003-0724-1694 University of Chicago, IL (S.P.). American Academy of Neurology (S.P.). , Christopher T. RichardsChristopher T. Richards https://orcid.org/0000-0003-3728-3860 University of Cincinnati, OH (C.T.R.). , Peter TaillacPeter Taillac University of Utah, Salt Lake City (P.T.). National Association of State EMS Officials (P.T.). , Albert W. TsaiAlbert W. Tsai Minnesota Department of Health, St. Paul (A.W.T.). , Anil YallapragadaAnil Yallapragada VA National Telestroke Program, Palo Alto, CA (A.Y.). , and on behalf of the Prehospital Stroke System of Care Consensus Conference Originally published11 Mar 2021https://doi.org/10.1161/STROKEAHA.120.033228Stroke. 2021;52:e133–e152is corrected byCorrection to: Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care SocietyNoteworthy advances in the care of patients with acute ischemic stroke (AIS) have occurred in the past 5 years. In 2015, studies of endovascular therapy (EVT) for patients with AIS due to large vessel occlusions (LVOs) demonstrated unequivocal benefit in carefully selected patient populations using stent retriever devices. As a result, in 2015, the American Heart Association (AHA)/American Stroke Association (ASA) released a guideline update reiterating the importance of intravenous (IV) alteplase and recommending “patients should receive EVT with a stent retriever if they meet all the…criteria.” However, the benefits of treatment from IV alteplase and EVT are both time sensitive. Thus, the previous AHA/ASA 2005 Recommendations for the Establishment of Stroke Systems of Care required significant revision to ensure timely access to both critical therapies and to reflect the full range of stroke center certifications, including the recently created Joint Commission–approved thrombectomy-capable stroke center (TSC) certification program, intended to serve regions without comprehensive stroke centers to perform EVT. In response to the identified need to develop a set of consensus recommendations for prehospital destination plans tailored to specific population environments, a committee of leading national experts in prehospital acute stroke care was convened at the AHA/ASA International Stroke Conference in January 2018. There was consensus on the need for regional customization of stroke systems of care (SSOCs) to address differences in resources, hospital certifications, geography, and population density and to educate prehospital providers on new models of AIS care, particularly thrombectomy, and how they impact the SSOCs. This article outlines their recommendations and is intended to augment the most recent AHA SSOC policy statement published in 2019.The Food and Drug Administration approval of IV alteplase in 1996 transformed treatment for AIS and remains the cornerstone of care to this day. This was the first acute therapy focused on reperfusion of ischemic tissue in AIS, potentially reducing stroke morbidity and mortality. To increase access to this new reperfusion therapy for as many eligible stroke patients as possible, it was necessary to integrate all regional stakeholders, especially Emergency Medical Services (EMS), involved in the care of patients with AIS into an effective SSOC.1 In 2015, AIS care dramatically changed again when several randomized clinical trials reported the benefit of EVT for patients with AIS secondary to LVOs. Soon thereafter, EVT received a class 1 level A recommendation from the AHA/ASA and became a standard of care for select patients with severe AIS.2–4 The demonstration of the efficacy of endovascular reperfusion therapy prompted the need to update SSOC to recognize regional stroke center reperfusion capabilities and to address unique regional geographic circumstances.In response to the identified need to develop a set of consensus recommendations for prehospital destination plans tailored to specific population environments, a committee of leading national experts in prehospital acute stroke care was convened at the AHA/ASA International Stroke Conference in January 2018. Attendees of this Prehospital SSOC Consensus Conference were selected by the societies represented and reflected the diversity of health care providers and settings found in the United States (see the participant list). The conference specifically focused on SSOC with an emphasis on the needs of the prehospital community. With the addition of EVT for LVO, the prehospital community now had to incorporate LVO scores in the initial assessment and make transport decisions based on the potential eligibility for IV thrombolysis and EVT. This document represents the final consensus recommendations of the conference attendees and their respective supporting or endorsing societies. The recommendations are intended to serve as a resource for those involved in creating and overseeing regional SSOCs (eg, EMS directors, hospitals, stroke advisory groups, and local and state government regulatory authorities). Lastly, these recommendations reflect the current needs and opportunities relevant to SSOCs in the United States, yet similar challenges and solutions exist globally.Background—SSOCsIn 2019, the AHA published an update to the first policy statement in 2005 from the ASA Task Force on the Development of Stroke Systems, Recommendations for the Establishment of SSOCs, to reflect the changes needed in this new environment of stroke care, with sections explicitly addressing prehospital stroke screening tools and severity scales and preferential triage of selected patients with suspected severe stroke due to LVO to the nearest EVT-capable stroke center.1,5 Similarly, under the auspices of the AHA/ASA national initiative to advance systems of care for patients with acute, high-risk, time-sensitive disease states, the AHA/ASA also updated its Mission: Lifeline Stroke EMS Acute Stroke Routing Algorithm (Figure 1; also available at https://www.stroke.org/-/media/stroke-files/ems-resources/ems-algorithm-acute-stroke-routing.pdf?la=en) to incorporate potential EVT eligibility into prehospital transport considerations, thus supporting regional SSOC efforts to facilitate appropriate and timely care for all AIS patients. These updates reviewed the framework for the 4 levels of stroke care facilities utilized in the current SSOC. In response to the perceived need for greater access to thrombectomy in areas distant from comprehensive stroke centers (CSCs), several of the organizations that certify or accredit stroke centers introduced the fourth level of certification for hospitals that can effectively perform EVT but do not meet all the criteria for CSC. We will refer to this level as a TSC but other terms referring to similar centers include “Thrombectomy Stroke Center” and “Primary Stroke Center Plus.” In particular, the policy statement recommended that (1) “in prehospital patients who screen positive for suspected stroke, a standard prehospital stroke severity assessment tool should be used to facilitate triage. In the absence of new data, it is reasonable to tailor the Mission:Lifeline Stroke algorithm to the needs of the community,” and (2) “when several hospital options exist within similar travel times, EMS should seek care at the facility capable of offering the highest level of stroke care. Further research is needed to establish travel time parameters for hospital bypass in cases of prehospital suspicion of LVO.”5Download figureDownload PowerPointFigure 1. Mission: Lifeline Stroke Emergency Medical Services (EMS) Acute Stroke Routing Algorithm. ABC indicates airway, breathing and circulation; ASRH, acute stroke-ready hospital; CSC, comprehensive stroke center; EVT, endovascular therapy; LKW, last known well; LVO, large vessel occlusion; POC, point of care; PSC, primary stroke center; and TSC, thrombectomy-capable stroke center. Reprinted from the American Heart Association with permission. Copyright ©2021.The 2019 Stroke System of Care recommendations article recognized this new level of EVT capability, “The proper role of TSCs in communities without any access to thrombectomy is straightforward; its role in a community that already has access to a CSC is more controversial, and plans for patients with suspected LVO should always seek the center of highest capability when interfacility travel time differences are short.” Challenges exist in implementing this doctrine due to concerns over the practicality of such triage, large shifts in patient allocation between hospitals, market/health care system forces, and risks of harm from overcrowding at CSCs due to overtriage. An accompanying editorial by Dr Robert Harrington, AHA President, highlighted the need for 3 areas of consideration. (1) Independent third-party organizations should “create and apply the standards for certification and accreditation.6” (2) Local SSOCs, not national accrediting bodies, should identify “how best to implement these elements into a SSOC that meets their needs and resources and to define the types of hospitals that should qualify as points of entry for patients with suspected LVO strokes…” (3) In areas with long travel times to a CSC, “TSC programs should be part of the SSOC…” and “…they should have criteria for performance that are similar to that of a CSC for the subset of patients with ischemic stroke.” Lastly, Dr Harrington recognized “Ideally, when geography permits, locales will identify a CSC as the ideal choice for a suspected LVO patient if an ambulance needs to choose among several destinations, including Primary Stroke Centers and TSCs.”With varying levels of stroke center certifications and unique regional and geographic considerations, local SSOC plans and implementations will vary widely. Regional stakeholders must collaborate to consider local prehospital and health care resources, individual stroke center capabilities and performance, and geographic considerations to create an optimally adapted SSOC and destination protocol to ensure effective and efficient stroke care. When the initial Mission: Lifeline Stroke algorithm was introduced, it conservatively recommended triaging patients with suspected LVO to an EVT-capable center only when this added no more than 15 minutes of additional travel time and recognized that nonurban areas may need to modify these recommendations. While this was reasonable for urban areas with multiple nearby hospitals, more explicit guidance for how to modify these approaches for suburban and rural environments was urgently needed, and this consensus document was an effort to address that need. Formal and informal feedback was solicited through multiple avenues as the consensus conference proceedings were shared. These include the Joint Commission (JC) public comment period for the TSC certification program, and formal presentation to multiple AHA committees (Stroke Council, Mission: Lifeline Stroke Committee, AHA JC Stroke Technical Expert Panels, Hospital Accreditation Science Committee, and the SSOC Advisory Group). The most current Mission: Lifeline Stroke algorithm has modified transport time considerations incorporating longer transport times based, in part, on several triage models.The coronavirus disease 2019 (COVID-19) pandemic further emphasizes the need for flexible adaptation of prehospital triage and interfacility transport in response to local and regional factors. Preferential routing of suspected LVO patients to centers with thrombectomy capability may be of even greater importance when in-hospital and interfacility delays are amplified in conditions such as the COVID-19 pandemic. Continuous assessment of local resources and challenges by those administering SSOC are necessary to ensure locally optimal performance.Background—Health Care ResourcesTo best design a regional SSOC, a detailed understanding of hospital stroke capabilities is required. To do so, most SSOCs will rely on independent third-party assessments of regional hospital capabilities before they are incorporated in prehospital destination plans. To promote the optimal quality of care and patient safety provided by health care facilities, various agencies or organizations periodically monitor and assess the quality of care at health care facilities. State departments of health, professional organizations, and third-party independent organizations frequently provide assessment and review services for both overall care (accreditation) and disease-specific care (certification). In the United States, the Centers for Medicare and Medicaid Services utilizes third-party organizations such as the JC to recognize health care facilities that meet the Centers for Medicare and Medicaid Services standards for patient safety and overall quality of care. Recognition by these accreditation and certification organizations is a condition of licensure for receiving Medicare and Medicaid reimbursements. Regional health care planning entities design disease-specific systems of care building, in part, on these platform accreditation and certification programs. It is important to understand the accreditation, certification, and designation definitions and roles as SSOCs are developed.AccreditationHealth care facilities achieve accreditation by undergoing an internal self-assessment, as well as a third-party, external review process to measure the level of performance against established standards. The accreditation process focuses on quality of care and patient safety by measuring a facility’s performance and the impact of its quality improvement (QI) programs as required for meeting the Centers for Medicare and Medicaid Services Medicare conditions of participation. Hospital accreditation remains the cornerstone process to ensure health care facilities are committed to meeting overall high patient safety standards. Hospitals in the United States may receive core accreditation from 1 of the 4 Centers for Medicare and Medicaid Services–approved organizations: the JC, Det Norske Veritas, Healthcare Facilities Accreditation Program, and Center for Improvement in Healthcare Quality. To avoid duplication in services, confusion over differing standards and the risk of lower quality often observed in self-attestation programs, state departments of health, or other regulatory bodies should utilize nationally recognized accreditation programs in the development and implementation of local, regional, and state SSOC.CertificationHealth care facilities may also apply for certification in specific clinical/disease areas. Certification typically builds upon an existing facility’s accreditation and recognizes unique programs or services it provides (eg, ischemic stroke, heart disease, total joint replacement, and perinatal care). The process of certification is similar to accreditation in that it involves an internal self-assessment of care quality and patient safety that is measured against established standards, and an onsite review by a third party, and is provided by multiple independent organizations. It is essential that when multiple organizations provide certification for the same level of center recognition, the standardized performance measures used should be consistent across the certifying organizations to ensure those parties responsible for center designation can make accurate comparisons of capabilities and avoid a race to the bottom of lowering requirements to capture greater certification market share. Unfortunately, certification organizations do not currently utilize fully harmonized criteria for stroke center certification, particularly as it relates to minimum case volumes or physician training and experience. Regulatory authorities in each state should endorse a uniform set of standards that all hospitals must meet regardless of which certifying body they select to ensure an equal playing field for all centers.The groundwork for stroke center certification was introduced by the National Institute of Neurological Disorders and Stroke in 1996, and many of its recommendations and time targets were incorporated into the AHA/ASA Advanced Cardiac Life Support program in 2000 as the Stroke Chain of Survival7 and the Brain Attack Coalition programmatic structures in 2000.8 In 2002, a second National Institute of Neurological Disorders and Stroke symposium focused on barriers to delivering acute stroke treatment and encouraged stakeholders “to create stroke care networks to match and optimize patient needs and available resources.”9 These recommendations were followed by the 2005 AHA/ASA Recommendations for the Establishment of Stroke Systems of Care,1 the 2013 Interactions Within Stroke Systems of Care,10 the 2013 Brain Attack Coalition article on Acute Stroke-Ready Hospitals (ASRHs),11 and the 2019 update to the SSOC5 article, which articulated the foundations for the current 4-level SSOC and corresponding certifications. While the exact names for each level of care vary by certifying organization, we used the AHA/ASA terminology, which represents the majority of certified hospitals and the language emerging in local and regional regulations. The 4 levels, ASRH, primary stroke center (PSC), TSC, and CSC, are described in detail elsewhere and summarized in Table 1.5,10Table 1. Levels and Capabilities of Hospital Stroke CertificationsCharacteristicsASRHPSCTSCCSCLocationTypically ruralOften urban/suburbanOften urban/suburbanTypically urbanStroke team accessible/available 24/7YesYesYesYesNoncontrast CT available 24/7YesYesYesYesAdvanced imaging available 24/7 (eg, CTA/CTP/MRI/MRA/MRP)NoPossiblyYesYesIntravenous thrombolysis capable 24/7YesYesYesYesThrombectomy capable 24/7NoPossiblyYesYesDiagnose stroke etiology and manage poststroke complicationsUnlikelyYes, routineYes, complexYes, complexAdmit hemorrhagic strokeNoPossiblyPossiblyYesClip/coil ruptured intracranial aneurysmsNoUnlikelyPossiblyYesDedicated stroke unitNoYesYesYesNeurocritical care unit and expertiseNoPossiblyPossibly*YesClinical stroke research performedUnlikelyPossiblyPossiblyYesSource: American Heart Association, Inc.5ASRH indicates acute stroke-ready hospital; CSC, comprehensive stroke center; CT, computed tomography; CTA, computed tomography angiography; CTP, computed tomography perfusion; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; MRP, magnetic resonance perfusion; PSC, primary stroke center; and TSC, thrombectomy-capable stroke center.* Access to neurocritical care expertise required and may be provided by telemedicine.Level of Care: ASRHAn ASRH is typically a smaller facility that is unable to provide the full level of inpatient care available at a PSC. This type of hospital provides the majority of stroke care in rural or isolated suburban areas though few have sought formal certification and most rely heavily on telestroke for emergent stroke expertise and thrombolysis. The roles of an ASRH are to stabilize the patient, provide specific acute stroke care therapies including IV thrombolysis, and arrange timely transportation of patients to the nearest stroke center as determined by the patient’s clinical status and further treatment indications. It is anticipated that within any rural region, at least 1 hospital would function as an ASRH and ideally seek formal certification, and EMS should preferentially triage suspected stroke patients to the nearest ASRH in these communities.Level of Care: PSCPSCs are typically small- to midsized community hospitals with dedicated inpatient stroke units that care for the majority of stroke patients with typical ischemic strokes who do not require EVT, neurosurgical interventions, or neurocritical care unit level care or who have multisystem disease. Some rural communities may have access to a nearby PSC, but the majority are located in or near suburban or urban areas. PSCs that perform EVT are not currently required to collect and report metrics on these procedures, although it is highly desirable.Level of Care: TSCTSCs are hospitals as described above that meet all criteria for PSCs but also provide EVT and must meet the same resource requirements, data collection, and reporting for EVT as CSCs.12 Unfortunately, most of the newly certified TSCs have appeared in communities with existing access to a CSC, rather than in areas without access to emergent EVT. This poses a challenge to EMS providers when faced with the choice of multiple destinations and to EMS regulators when deciding whether or not to include TSCs in the local destination plans.Level of Care: CSCCSCs provide the full suite of services 24/7 for all stroke types including all hemorrhagic strokes.13 CSCs provide the full complement of stroke neurology, critical care, and neurosurgical personnel and infrastructure to manage the most complex ischemic and hemorrhagic stroke patients. These tertiary and quaternary facilities serve as centralized centers within mature SSOC and leverage the known volume-outcome relationships in cerebrovascular disease.14 It remains unknown what impact the new TSC designation will have on thrombectomy experience at the proposed TSCs and currently certified CSCs. Although the total number of LVO cases is expected to increase, insufficient total cases per hospital may dilute local hospital and provider experience and adversely affect patient outcomes because a higher volume of cases is well known to be associated with improved performance.15,16Estimates from ≈1250 PSCs and 250 CSCs that are formally certified and participate in national stroke QI programs suggest that initiatives focused on improving thrombolysis rates and reducing door-to-needle times (eg, AHA/ASA Target: Stroke and CDC Paul Coverdell National Acute Stroke Registry) have increased IV alteplase use to 8% to 15% of US patients hospitalized with AIS.17,18 In 2011, 81% of US residents could access a thrombolysis-capable stroke hospital (Figure 2) within 60 minutes by ground and 56% could access an EVT-capable center within 60 minutes by ground and 83% by ground or air.19 However, though the requirements vary between certification programs, there are limitations on the number of sites that could qualify for CSC certification, based on the current and proposed process and infrastructure program elements, as well as minimal annual patient and procedural volumes or specific services (eg, thrombectomy, neurosurgical interventions, and neurointensive care). Ideally, certification would be based on risk-adjusted outcomes rather than the proxy of process and volumes, but the mechanisms to implement this are currently lacking. All stakeholders in SSOC should advocate for the public reporting of patient-centric quality measures from all elements of their SSOC.Download figureDownload PowerPointFigure 2. Access to thrombolysis-capable hospitals by ground or air medical transport. Access by ground or air to intravenous recombinant tissue-type plasminogen activator (IV r-tPA)-capable hospitals within 60 minutes. Reprinted from Adeoye et al19 with permission. Copyright ©2014, the American Heart Association.It is estimated that roughly 250 US hospitals will be able to achieve CSC certification under current standards. The need for access to EVT outstrips this CSC supply substantially, but it is important that standards for CSCs not be lowered to meet the need for EVT but rather that a TSC standard is developed and implemented that provides all the capacity of a PSC plus the additional elements needed for EVT.20 Given these limitations, it is critical that communities without ready access to a CSC be provided with alternative methods to rapidly and reliably access high-quality EVT (Table 1).The JC and AHA/ASA established a certification process for TSC in 2018 to encourage high-performing PSCs that offered EVT but did not meet all the criteria for CSC certification to seek this new certification to perform EVT in a responsible and data-driven manner in regions without ready access to a CSC. The additional TSC requirements must be met on top of the base PSC certification requirements and include the additional standards, data elements, and measures for performing EVT required for CSC but without the CSC requirements related to the care of patients with hemorrhagic stroke. With the efficacy of EVT now proven up to 24 hours since last known well in imaging selected patients and the introduction of TSC, it has become necessary to provide more nuanced guidance to EMS agencies and public health authorities to create feasible, practical, reliable, and sustainable destination plans for prehospital triage of suspected stroke cases in this era of complex assessment and intervention.DesignationWithin the context of a disease-specific regional system of care, designation typically refers to a hospital recognition process developed at a state or local level with guidance from a multistakeholder advisory committee. State and local governments first establish criteria to categorize hospital capabilities for a specific condition or disease state (eg, adult and pediatric trauma, stroke, and myocardial infarction).21 Some states independently conduct their own certification programs (eg, stroke certification in New York22 and Massachusetts23), recognize certification by national organizations, or utilize a certification process combining both. Trauma and ST-segment–elevation myocardial infarction systems of care incorporating hospital destination plans have been established and have demonstrated clear benefits of reduced morbidity and mortality,24–26 with recent data suggesting that independent third-party verification and higher case volumes are associated with improved patient outcomes.27–29 Before the availability of national certification options, several states were pioneers in developing SSOC, but due to limited resources and an abundance of pressing regulatory issues, these early designation or certification programs lacked many of the critical features of independent certification programs such as robust data collection and monitoring, participation in a national QI registry, and third-party verification. Unlike certification organizations that set the standards for sites to gain certification, states can and should be t

Introduction: Endotracheal intubation (ETI) in the prehospital setting poses unique challenges where multiple ETI attempts are associated with adverse patient outcomes. Early identification of difficult ETI cases will allow providers to tailor airway-man agement efforts to minimize complications associated with ETI. We sought to derive and validate a prehospital difficult airway identification tool based on predictors of difficult ETI in other settings. Methods: We prospectively collected patient and airway data on all airway attempts from 16 Advanced Life Support (ALS) ground emergency medical services (EMS) agencies from January 2011 to October 2014. Cases that required more than two ETI attempts and cases where an alternative airway strategy (e.g. supraglottic airway) was employed after one unsuccessful ETI attempt were categorized as "difficult." We used a random allocation sequence to split the data into derivation and validation subsets. Using backward elimination, factors with a p<0.1 were included in the multivariable regression for the derivation cohort and then tested in the validation cohort. We used this model to determine the area under the curve (AUC), and the sensitivity and specificity for each cut point in both the derivation and valida tion cohorts. Results: We collected data on 1,102 cases with 568 in the derivation set (155 difficult cases; 27%) and 534 in the validation set (135 difficult cases; 25%). O f the collected variables, five factors were predictive of difficult ETI in the derivation model (adjusted odds ratio, 95% confidence interval [CI]): Glasgow coma score [GCS] > 3 (2.15, 1. 19-3.88), limited neck movement (2.24, 1.28-3.93), trismus/jaw clenched (2.24, 1.09-4.6), inability to palpate the landmarks of the neck (5.92, 2.77-12.66), and fluid in the airway such as blood or emesis (2.25, 1.51-3.36). This was the most parsimonious model and exhibited good fit (Hosmer-Lemeshow test p = 0.167) with an AUC of 0.68 (95% CI [0.64-0.73]). When applied to the validation set, the model had an AUC of 0.63 (0.58-0.68) with high specificity for identifying difficult ETI if > 2 factors were present (87.7% (95% CI [84.1-90.8])). Conclusion: We have developed a simple tool using five factors that may aid prehospital providers in the identification of difficult ETI.

AbstrastBackground. Hazardous materials technicians may be required to wear fully encapsulated vapor-resistant (Level A) personal protective equipment (PPE) to contain and mitigate a hazardous materials emergency. It is commonly taught and practiced in hazardous material technician courses that if the wearer's self-contained breathing apparatus (SCBA) fails, the technician can remove the SCBA face piece and breathe the in-suit expired air while exiting the incident or awaiting rescue. Objective. To determine the composition of expired air present within an encapsulating suit during exercise. Methods. Subjects (n = 4) walked on a motor-driven treadmill (3.2 km·h–1) for 30 minutes while wearing encapsulating PPE and SCBA. Oxygen (O2) and carbon dioxide (CO2) levels within the PPE were monitored. Subject vital signs and end-tidal CO2 (EtCO2) were continuously monitored. After treadmill exercise, rescue air from an external source was introduced into the suit. Results. Mean oxygen levels inside the PPE fell below the Occupational Safety and Health Administration (OSHA) definition of oxygen-deficient environment (< 19.5% O2) after 2 minutes of treadmill walking and were below 17% at the end of 30 minutes. Carbon dioxide levels inside the PPE exceeded 3% in all subjects by the end of the exercise protocol. Rapid return to a room-air composition of oxygen and CO2 within the suit was accomplished with introduction of positive-pressure air from an alternate external air source. Conclusion. A toxic atmosphere is rapidly created within fully encapsulating PPE during treadmill exercise of moderate intensity. Breathing the expired air within the PPE cannot be recommended during technician training. Application of an external air source to flush the suit can return the PPE atmosphere to safe limits, but requires an intentional suit breach to accomplish.

Vasopressin administration has been suggested during cardiopulmonary resuscitation, and a previous clinical trial has suggested that vasopressin is most effective when administered with epinephrine. Adult subjects (n = 325) who received > or =1 dose of intravenous epinephrine during cardiopulmonary resuscitation for nontraumatic, out-of-hospital cardiac arrest were randomly assigned to receive 40 IU of vasopressin (n = 167) or placebo (n = 158) as soon as possible after the first dose of epinephrine. The rate of return of pulses was similar between the vasopressin and placebo groups (31% vs 30%), as was the presence of pulses at the emergency department (19% vs 23%). No subgroup appeared to be differentially affected, and no effect of vasopressin was evident after adjustment for other clinical variables. Additional open-label vasopressin was administered by a physician after the study drug for 19 subjects in the placebo group and 27 subjects in the vasopressin group. Results were similar if these subjects were excluded or were assigned to an actual drug received. Survival duration for subjects admitted to the hospital did not differ between groups. In conclusion, vasopressin administered with epinephrine does not increase the rate of return of spontaneous circulation.

Airway management, including endotracheal intubation, is considered one of the most important aspects of prehospital medical care. This concept paper proposes a systematic algorithm for performing prehospital airway management. The algorithm may be valuable as a tool for ensuring patient safety and reducing errors as well as for training rescuers in airway management.

(2004). A PASSIVE REMINDER INCREASES THE RATE OF PREHOSPITAL ASPIRIN ADMINISTRATION FOR SUSPECTED CARDIAC CHEST PAIN. Prehospital Emergency Care: Vol. 8, No. 1, pp. 93-94.

BACKGROUND:The nature of the trauma patient's injuries may compromise the airway and ultimately lead to death or neurological devastation. The same injuries complicate protecting the airway in these patients by preventing manipulation of the cervical spine for direct laryngoscopy. A recent study has shown that misplaced endotracheal tubes occur significantly more often in trauma patients than in medical patients.OBJECTIVES:The authors hypothesized that elevating the long spine board would reduce the amount of time required for paramedics to intubate a simulated trauma patient.METHODS:Paramedics from an urban emergency medical services division were given up to two opportunities to intubate a manikin in a type I ambulance in each of two positions in random order: supine and with the head elevated. The manikin was secured to a long spine board with three straps, a semi-rigid cervical collar, and a cervical immobilization device. An investigator maintained cervical spine alignment and provided cricoid pressure. The elevated position was accomplished by raising the head of the stretcher 27 degrees, resulting in 7 degrees of spine board elevation. Each attempt was timed. If the first attempt was unsuccessful, the times for both the first and second attempts were totaled to determine the total time required for intubation. Times for successful intubation in each position were compared with a Mann-Whitney test. First-attempt success rates for each position were compared with chi2 analysis. Multinomial regression was used to determine whether experience, paramedic height, or previous intubation success influenced intubation time in either position.RESULTS:Fifty-five paramedics provided informed consent and completed the study. Average time to intubate the supine manikin was significantly longer than needed to intubate the head-elevated manikin (35.6 +/- 19.0 seconds vs 27.9 +/- 12.8 seconds, p = 0.025). The manikin was successfully intubated on the first attempt 84% in the supine position and 95% in the head-elevated position (p = 0.200). Regression analysis identified intubation position as the only significant predictor of intubation time (p = 0.007).CONCLUSIONS:Modest elevation of the head of an immobilized patient appears to allow more rapid intubation. With the spine board properly secured to the stretcher, this technique potentially offers improved intubation time without additional cost or equipment.