Scene times....

[hammerpcp]

Time is trauma yes. Nothing incredibly productive we can do for them in reality...

True. However, as mentioned above, failing to properly secure/immobilize the pt. before moving them for the sole sake of meeting a time deadline is not beneficial either, and can end up causing more harm than good.

[RiderRob89]

Onscene times here on Long Island, NY vary, but we tend to stay on scene longer for a couple of reasons:

1. Alot of non-emergent/ non-urgent cases (not always BS, but nothing we can't handle on the bus)

2. The luxury of being very close to several major trauma centers, and several specialty centers.

From dispatch to back in service times, we are usually out for about an hour, since we usually have to wait at the hospital for some time for a bed, and then to fill out the PCR. Naturally, if it's a trauma or something major, we move fast.

As a side note, whenever we have another call come in when we are at the hospital waiting for a bed (which is quite often), the hospital is somehow able to find a bed alot quicker so we can get back in service.

Naturally, for traumas and such, we scoop and run, and do our interventions en route (as opposed to most calls when we will treat and then roll to the hospital)

[PRPGfirerescuetech]

True. However, as mentioned above, failing to properly secure/immobilize the pt. before moving them for the sole sake of meeting a time deadline is not beneficial either, and can end up causing more harm than good.

Correct. The purpose of my post was highlighting trauma is time sensative. Cervical precautions are still one of the more important standards. Thanks for sharing the obvious.

XoX

[RaceMedic]

we follow a 20 minute scene time guideline for all calls. if we are there for longer than twenty minutes our narrative must show what we did and why we were there for that amount of time. if it does not then we have some splaining to do lucy.

Our QA guy does a good job of calling us in on the carpet when we spend more time than seems to be needed on scene. But as he puts it " your the ones on the street doing the job, if your documentation cant explain why you were there for so long then we have a problem. But if you document well and all bases are covered then you have no worries" Thats the way it should be. IF your doing your job and whats best for your patient it will come out in your PCR. if not you need to work on your documentation or your patient care sucks and you need to work on that as well. :twisted: :twisted: :twisted:

Be Safe

Race

[Spazz3z]

Well I work in Pa and at a retirement home... scene time for us if they dont want to go to the hospital... usually like 20 minutes... if the ambulance is called they time it takes the ambulance to get there about 5-7 mintues for loading then they are off so usually the ambulance is on scene for like 10 minutes and we as EMS at the nursing home are one anywhere from 10-1 hr at most... id say 20 mins maxed

[Ace844]

Hello Everyone,

Here's another component we didn't really discuss that also contributes to our outcomes...Response times. Here's some literature on that part of this debate. What do you all think?

(Paramedic Response Time: Does It Affect Patient Survival?

Peter T. Pons @ MD, Jason S. Haukoos, MD, MS, Whitney Bludworth, MD, Thomas Cribley, EMT-P, Kathryn A. Pons, RN and Vincent J. Markovchick, MD

From the Department of Emergency Medicine, Denver Health Medical Center (PTP, JSH, WB, KAP, VJM), Denver, CO; Department of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (JSH), Denver, CO; Denver Paramedic Division, Denver Health and Hospital Authority (WB), Denver, CO; and Department of Emergency Medicine, South Austin Hospital (TC), Austin, TX.

Address for correspondence and reprints: Peter T. Pons, MD, Department of Emergency Medicine, Denver Health Medical Center, 777 Bannock Street, Mail Code 0108, Denver, CO 80204. Fax: 303-436-7541; e-mail: peter.pons@dhha.org.)

Objectives: One marker of quality emergency medical services care is measured by meeting an 8-minute response time guideline. This guideline was based on results of paramedic response times for nontraumatic cardiac arrest patients and has not been studied in unselected patients. The objective of this study was to evaluate the effect of paramedic response time on survival to hospital discharge in unselected patients in a large urban setting while controlling for a number of potentially important confounders, including level of illness severity. Methods: This was a retrospective cohort study performed in an urban 911-based ambulance service system. Patients transported by paramedics to a single urban county teaching hospital from January 1, 1998, to December 31, 1998, were included. Data collected included patient demographics; paramedic response, scene, and transport times; the nature of the medical complaint; and whether the patient survived to hospital discharge. Multivariable logistic regression models were developed using response time as the primary independent variable and survival to hospital discharge as the dependent variable. Covariates included scene time, transport time, age, gender, and level of illness severity. Results: Of 34,111 calls involving emergency response, 11,078 patients (32%) were transported to the study institution and 10,382 (94%) had response time data available. Of these, 9,559 patients (92%) had data available to categorize them into groups based on their level of illness severity and were thus included in the study. A survival benefit was identified for response times 4 minutes (odds ratio [OR], 0.70; 95% confidence interval [CI] = 0.52 to 0.95). No survival benefit was identified when response time was modeled as a continuous variable (OR, 1.01; 95% CI = 0.98 to 1.04) or when dichotomized at 8 minutes (OR, 1.06; 95% CI = 0.80 to 1.42). Conclusions: A paramedic response time within 8 minutes was not associated with improved survival to hospital discharge after controlling for several important confounders, including level of illness severity. However, a survival benefit was identified when the response time was within 4 minutes for patients with intermediate or high risk of mortality. Adherence to the 8-minute response time guideline in most patients who access out-of-hospital emergency services is not supported by these results.

METHODS

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REFERENCES

In October and November 2003, in-depth interviews were conducted with a purposive sample of 20 experienced paramedics (16 men) from nine ambulance stations serving a large District General Hospital (DGH). The participants, who were mostly aged 30–50 and had a mean length of service of 19 years, were selected to represent the sex and age distribution of paramedics in the trust, all the ambulance stations serving the DGH, and the range of experience and length of service. Interviews were semi-structured and informed by a loose topic guide (box 1) which encouraged paramedics to describe their attitudes to their job as a whole and to thrombolysis in particular, so that they were encouraged to raise issues which they themselves considered salient. Interviews were tape recorded, transcribed, and analysed according to the constant comparative method using QRS N6 software.

Box 1 Paramedic study topic guide

How long have you been in the ambulance service?

How long have you been a paramedic?

How did you get to be a paramedic?

What do you like best about your job?

Have you seen a lot of changes in the time you have been a paramedic?

How do you feel about doing pre-hospital thrombolysis (PHT)?

How did you find the training?

What factors do you think affect people’s attitudes to doing PHT?

Do you foresee a time when you’ll feel confident to give PHT without back up from the hospital?

Do you feel management is supportive?

Are there any down sides to the job? (What are they)?

Is there anything else you’d like to add?

The constant comparative method is an accepted method of analysing qualitative data which involves systematically coding interview transcripts for initial emergent themes. These are compared repeatedly with previous codings and classifications to provide a conceptual map of the interrelationships between themes.3 Coding was checked for reliability by a researcher from an academic institution independent of the study.

The study was approved by the local research ethics committee.

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In common with other ambulance service trusts in England and Wales, the ambulance trust serving the study area had recently introduced strategies to attempt to meet the 8 minute response time target for category A emergency calls. This target was a particular challenge for the area which has a dispersed rural population and long journey times. Measures introduced to meet the target were (1) the use of rapid response vehicles (RRVs) which are ordinary cars staffed usually by a single person but not always a paramedic;* (2) the use of "standby" in which emergency vehicles wait for calls at strategic locations in the community rather than at the ambulance stations; and (3) the use of "community first responders", volunteer members of the public trained in basic life support and equipped with a defibrillator. There was no increase in the number of fully staffed ambulances. These strategies should be seen in the context of a year on year increase in emergency calls (there was an increase in emergency calls in the study ambulance trust of nearly 60% between 1994/5 and 2000/1) which has increased the workload of emergency crews to such an extent that they are under constant time pressure and breaks and mealtimes are frequently missed. Paramedics’ accounts of response time targets and their attendant strategies had three main strands:

Their inadequacy as a performance indicator, the extent to which they dominated ambulance service culture and practice at the expense of other quality indicators, and their vulnerability to "fiddling" by the trust because of a lack of standard criteria for measuring timings and for deciding on whether or not a call is an emergency.

Their detrimental effects on patient care.

Their detrimental effect on paramedics’ health, safety and wellbeing.

Response time targets as a performance indicator

Paramedics described the role of response time targets in ambulance service culture as "an obsession", "ludicrous", and "impossible". They felt the 8 minute target had its own dynamic which was separate from and often in opposition to the ethos of patient care, and yet which now seemed to dominate service delivery, taking priority over factors which they saw as more important such as the quality of care provided or patient outcomes:

"You see, it’s an unfortunate situation. With this eight minutes, if you arrive in seven minutes and the patient dies it’s a success. If you arrive in nine minutes and the patient lives and it’s a good outcome, you’ve failed. Which to me is absolute rubbish. And we are now treating the clock and not the patient. The patient care, in my view, is gone, absolutely. Well it’s terrible. It’s awful." (Andy)

"Eight minutes, that’s all we hear is eight minutes. At the end of the day when we book off we can see our ‘A’ category performance on the screen. That the trust has done 75% eight minute responses, not how many lives we’ve saved, how many people you know ... how many babies we’ve delivered ... It’s not that on the screen, it’s the eight minutes." (Rob)

Response time targets and patient care

Many of the paramedics felt strongly that response time targets put patients at risk. The use of RRVs to meet the 8 minute target could considerably delay the transport of patients to hospital as, once the target was met, the arrival of a back up ambulance ceased to be a priority and there could be long waits. Paramedics reported sometimes waiting an hour or more for ambulance back up to arrive, giving examples of doing so in highly distressing circumstances—for example, where the patient was dying or where there had been a cot death.

"I think on one occasion this year where I didn’t sleep for a few nights, I was on my own in an isolated area with somebody that I knew was going to die, but if I’d had the facility to move her I could have made a bit of a difference. And there was no facility because I was in a car and not an ambulance." (Barry)

RRVs, with their single person crew, were believed to offer an inferior level of patient care. A paramedic on his or her own cannot move or transport the patient, nor provide the full range of advanced life support skills because a car is not as well equipped as an ambulance and some procedures need two people to perform. The use of RRVs can delay thrombolysis, for example, as cars do not carry the necessary ECG and telemetric equipment.

"Because you’re getting RRVs which aren’t fully equipped and there is only one person on them. So one person can only deal with a certain amount. If you’re on a big resuss job you can only do CPR. You can’t use your extended skills because you need more than one person to do that. Especially people out in the [rural areas] aren’t getting the care ..." (Maggie)

"But I think in major trauma or road traffic accidents, there’s a lot of things which need doing and it’s not good for one person. And that’s the only time I’d say I get stressed out, with that type of thing." (Tom)

Paramedics also felt that community first responders, originally introduced to ensure timely defibrillation for patients in cardiac arrest, were now being deployed in a range of inappropriate emergency situations solely to meet the target.

"We’re trying to prop the service up now with our first responders. So now you’ve got someone knocking on your door who’s had four or five days training, and to me that is a total retrograde step. Absolutely. Because as I understood it, this scheme started off ... where you had a cardiac arrest where they would turn up with a defibrillator. And you know as well as I do, that’s what you want. You want a defibrillator. But it’s not. They’re now turning them out for anything which is, to me, a retrograde step and they are representing the ambulance service and I’m against that." (Andy)

The inappropriate use of first responders was considered an affront to paramedics’ own advanced skills and dangerous for patients because of the very basic level of training of these volunteers.

"Say, for instance, someone is hyperventilating; they’re not exactly trained. A first responder will go to somebody who’s hyperventilating, they’ve been trained if somebody’s short of breath give them oxygen. So it’s the wrong treatment for hyperventilation, but they haven’t been taught that so they think the patient’s having difficulty breathing and they’re treating what they see." (Rob)

Despite their advanced life support skills which they valued highly, paramedics still believed that rapid transport to hospital, where definitive care is available, was the aspect of their role which was of most benefit to patients, and that this important standard had been lost from view in the scramble to meet response time targets.

"And we were looking at the figures and they’ve also reduced people getting into hospital because of the cars. They were saying that it’s actually doubled the times that patients are getting in. So that seems a step backwards." (Judy)

The use of standby to meet targets was a source of particular contention as very few paramedics believed it achieved this purpose, relating experiences of standing by in the wrong place for the call, ambulances crossing or overtaking each other, and of sometimes covering hundreds of miles driving from one standby point to another without answering a single call. There was little doubt that standby was not benefiting patients.

"I have not seen any evidence from my management that any of the standby points has actually saved one life. They have not been able to produce or they have not come up with any evidence whatsoever." (Nick)

Standby was believed to be a source of inequitable provision as standby points were located in the more populous areas where response times were more likely to be achieved at the expense of the less populated rural areas. Thus, standby served a culture which was target led rather than needs led, and which they believed created a "postcode lottery". In addition, some paramedics expressed scepticism about the reliability of response time statistics, believing that they could be manipulated by the trust in various ways to give the appearance of meeting the time target. The practice of manipulating response time statistics was also highlighted by the report from the Commission for Health Improvement (CHI), lending credence to these suspicions.4

"But then there is the inference ... I mean far be it from me to say whether category A’s are shuffled around. Whether if there’s a vehicle close to one then it can be category A, but if you’ve got like a 50 minute run perhaps it’s not." (Andy)

"I can manipulate figures and I know when Control put a job on our screen and they know that we can’t make it in eight minutes, they don’t put a code up so it’s unclassified really and you can fiddle things ..., fiddle figures, up to a point." (Clive)

Response time targets and ambulance crews

Ambulance trusts have the highest sickness absence rates in the NHS.5 Paramedics described how response time targets had a profound impact on their own health, safety and wellbeing. Deployment of crews at standby points in the community rather than at ambulance stations sometimes required them to spend hours sitting in their vehicles without access to drinks, toilet facilities, warmth or company, and in poor weather conditions or unsafe areas, unable to leave the vehicles to stretch or walk around. Ambulances are not ergonomically designed for this. Paramedics reported increased prevalence of back pain and discomfort which they felt adversely affected their performance in treating patients.

"Sitting in a vehicle I get lower backache pain and in the backs of my legs and you think ‘Oh blimey’. You know, you just ... it’s not sort of geared up for that and then if you’ve got backache and all that you’re not going to treat your patient properly. And they’re cold, but if you keep the engine on and you’re sat there and you know your diesel fumes just sit in there and there will be air intakes, you know." (Rob)

It is also likely that standby will be detrimental to the psychological health of ambulance crews. Paramedics sometimes have to deal with profoundly distressing incidents in their routine working lives, and a number of studies have recorded high levels of stress related disorders among this occupational group.6,7 An extensive literature testifies to the importance of colleague interaction and support in processing the feelings resulting from these types of "bad jobs".8,9,10 Such ad hoc informal support from respected peers who have had similar experiences is often the type of support preferred by paramedics10 and is highly protective of their mental health. The use of humour (in particular sick or dark humour) is a familiar part of ambulance station culture and has been described as an important strategy for defusing the stress of difficult jobs, and one which can only be used with colleagues. Time target culture is itself a source of stress.7 The lack of crewroom support which is an unregarded side effect of standby, by removing a significant therapeutic strategy for dealing with work related stressors, may have profound long term consequences for the mental health of paramedics. A number of paramedics commented on the loss of this important source of support.

"And the other thing it’s took away from the staff is the downtime in the crew room. There are lots of things that the ambulance service have always managed to do is counsel each other in the crew room. There’s always been that element of banter and sick sense of humour if you like, for want of a better thing." (Mike)

"Um ... mainly ... we talk to each other a lot, which is a shame because the present situation where we don’t get that much contact with each other because they won’t allow two crews to be in the same place at the same time, but you really need to talk to your peers about it, I think anyway. But you get bad jobs, and you just talk and talk and talk about it until it goes away. And by talking about them it makes it sort of quite normal you know, makes it feel normal." (Angela)

As assaults on ambulance crews increase, standby can make them sitting targets for abuse, and RRVs with a single crew member are not considered safe in some circumstances such as scenes of drunkenness or violence. All in all, response time targets were considered to be a major cause of declining morale among ambulance crews.

"Yeah [standby] has ruined the morale. And there has been a lot of talk about people saying ‘We’re not going to do it any more, we’ll have meetings ...’, but it’s never come about." (Nick)

"I think if you were to ask a paramedic like myself who’s done 20 odd years, he would say the morale’s never been lower." (Mike)

DISCUSSION

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RESULTS

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Paramedics’ argument that they have seen no evidence that the response time target improves patient care appears to be supported by the literature. Such literature as exists on ambulance response times and patient outcomes is conflicting, but there are studies suggesting that an 8 minute response would not improve survival after cardiac arrest,11 survival in emergency life threatening calls,12 or survival after traumatic injury.13 These studies suggest that outcomes are improved only where there is a response time of 5 minutes or less. A Swiss study found that cardiac arrest patients defibrillated in hospital an average of 15.6 minutes after arrest were more likely to survive to hospital discharge, to be alive at 1 year follow up, and to survive without neurological impairment than those defibrillated in the community at 5.7 minutes.14 In any case, cardiac arrest represents a very small proportion of emergency calls. The suggestion that reduced response times may improve survival "remains speculative and unreported".12 There is a clear need for targets to be based on rigorous systematic review of the evidence, and where this is absent or inconclusive, for well designed definitive studies to be undertaken.

The belief of paramedics that response time targets are being achieved at the expense of considerations of quality of care and patient outcomes echoes the findings of the Commission for Health Improvement4 which described the targets as a poor quality indicator and "too simplistic and narrow" for exactly the reasons given by paramedics. Critiques of "target culture"15,16 have included claims that there are others—in particular the A&E standard that patients should be seen within 4 hours—which are being manipulated in ways that may be putting patients at risk.17–19 The problem of contradictory imperatives also needs to be addressed. The 2000 NHS plan, for example, promotes both an 8 minute response time target—which it claims will save 1800 lives a year—and PHT—which it claims will save 3000 lives a year. A source from the Department of Health indicated that this figure was a calculation based on potential lives saved if all eligible patients received timely PHT (personal communication, 2004) but, as the paramedics’ accounts suggest, strategies in place to meet the response time target such as RRVs and first responders will actually delay or prevent PHT for some patients. Unison, the trade union which represents the interests of National Health Service staff, has argued that only ambulance response times and not those of first responders should be counted towards the target, and this might serve as a deterrent to the inappropriate use of minimally trained volunteers which paramedics argue can put patients at risk.

Key messages

Paramedics’ accounts of meeting response time targets, supported by evidence from the medical and official literature, suggest that the 8 minute response time target is not evidence based and is putting patients and ambulance crews at risk.

There is a need for less simplistic quality indicators which recognise that there are many stages between a patient’s call for help and safe arrival in hospital, of which initial response is just one—and one which may not be the most significant in terms of quality of care and patient outcomes.

Performance indicators should take into account the experiences and views of those who deliver the service, not just those of their managers or of the government who may have different agendas.

The government and the ambulance trusts have much to gain from achieving response time targets—the government has hard evidence of "health improvement" and the trusts win prestige and financial remuneration if targets are met. Patients and ambulance crews may have much to lose.

Strategies to meet targets are compromising the health and safety of ambulance crews and adversely influencing morale. Paramedics are the experts in delivery of pre-hospital care, yet there appears to be no mechanism by which their experience can inform policy decisions which are made "in the context of money, political power and precedent",20 and their impact on the working lives of staff members does not appear to be factored in at all.

ACKNOWLEDGEMENTS

The author thanks the paramedics who gave their time to participate in the study, the ambulance trust and the pre-hospital thrombolysis study team, Andy Barton and Jill Russell for their invaluable contributions, and Sue Anderson and Jackie Jude for administrative support.

FOOTNOTES

The pre-hospital thrombolysis study was funded by the Torbay Medical Research Fund.

Competing interests: none.

* Ambulance crews consist of paramedics trained in advance life support skills and technicians who have fewer skills. It is UK government policy that there should be a paramedic on every ambulance, but this does not always happen. On some occasions RRVs may be staffed by a technician.

The names of the respondents are pseudonyms.

REFERENCES

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REFERENCES

Department of Health. Ambulance services, England: 2004–05. Available at http://www.dh.gov.uk/PublicationsAndStatis...mp;chk=dQQp%2BB (accessed 10 January 2006).

Price L, Keeling P, Brown G, et al. A qualitative study of paramedics’ attitudes to providing prehospital thrombolysis. Emerg Med J 2005;22:738–41.[Abstract/Free Full Text]

Strauss AL, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, CA: Sage 1990.

Commission for Health Improvement. What CHI has found in ambulance trusts. Sector report. Commission for Health Improvement. 2003:2–26.

Department of Health. Sickness absence rates of NHS staff in 2004. Available at http://www.dh.gov.uk/PublicationsAndStatis...&chk=hNvc9D (accessed 10 January 2006).

Smith A, Roberts K. Interventions for post-traumatic stress disorder and psychological distress in emergency ambulance personnel: a review of the literature. Emerg Med J 2003;20:75–8.[Abstract/Free Full Text]

Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and coping in ambulance service workers. Br J Clin Psychol 1999;38:251–66.[CrossRef][Medline]

Pisarski A, Bohle P, Callan VJ. Extended shifts in ambulance work: influences on health. Stress and Health 2002;18:119–26.[CrossRef]

Mannon JM. Emergency encounters: EMTs and their work. Boston: Jones and Bartlett, 1992.

Alexander D, Susan K. Ambulance personnel and critical incidents; impact of accident and emergency work on mental health and emotional wellbeing. Br J Psychiatry 2001;178:76–81.

Pell JP, Sirel JM, Marsden AK, et al. Effect of reducing ambulance response times on deaths from out of hospital cardiac arrest: cohort study. BMJ 2001;322:1385–8.[Abstract/Free Full Text]

Blackwell TH, Kaufman JS. Response time effectiveness: comparison of response time and survival in an urban emergency medical services system. Acad Emerg Med 2002;9:288–95.[Abstract/Free Full Text]

Pons PT, Markovchick VJ. Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome? J Emerg Med 2002;23:43–8.[CrossRef][Medline]

Stotz M, Albrecht R, Zwicker G, et al. EMS defibrillation-first policy may not improve outcome in out-of-hospital cardiac arrest. Resuscitation 2003;58:277–82.[CrossRef][Medline]

Select Committee on Public Administration. Fifth Report. Available at http://www.parliament.the-stationery-offic...adm/62/5203.htm.

British Medical Association. Measuring performance in the National Health Service. April 2003. Available at http://www.bma.org.uk/ap.nsf/Content/measureper (accessed 10 January 2006).

British Medical Association. Speech from the Chairman of Council Sir Ian Bogle CBE. June 2003. Available at http://www.bma.org.uk/ap.nsf/Content/ARM03chcouncil (accessed 10 January 2006).

Gulland A. NHS staff cheat to hit government targets, MPs say. BMJ 2003;327:179.[Free Full Text]

Locker TE, Mason SM. Analysis of the distribution of time that patients spend in emergency departments: BMJ 2005;330:1188–9.

Cooke ME. Conflicts to the implementation and commissioning of evidence based health care. Available at http://www.asancep.org.uk/EBM%20Final%202%20col.pdf (accessed 10 January 2006).

(Acad Emerg Med Volume 9 @ Number 4 288-295,

© 2002 Society for Academic Emergency Medicine This Article

CLINICAL PRACTICE

Response Time Effectiveness

Comparison of Response Time and Survival in an Urban Emergency Medical Services System

Thomas H. Blackwell, MD and Jay S. Kaufman, PhD

From the Center for Prehospital Medicine (THB), Departments of Emergency Medicine (THB), Epidemiology (JSK), and Statistics (JSK), Carolinas Medical Center, and Mecklenburg EMS Agency (THB), Charlotte, NC. Dr. Kaufman is currently in the Department of Epidemiology, UNC School of Public Health, Chapel Hill, NC.

Address for correspondence and reprints: Thomas H. Blackwell, MD, Department of Emergency Medicine, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232-2861. Fax: 704-355-7047; e-mail: tom.blackwell@carolinashealthcare.org)

Emergency medical services (EMS) administrators seek methods to enhance system performance. One component scrutinized is the response time (RT) interval between call receipt and arrival on scene. While reducing RTs may improve survival, this remains speculative and unreported. Objective: To determine the effect of current RTs on survival in an urban EMS system. Methods: The study was conducted in a metropolitan county (population 620,000). The EMS system is a single-tier, paramedic service and provides all service requests. The 90% fractile RT specifications required for county compliance include 10:59 minutes for emergency life-threatening calls (priority I) and 12:59 minutes for emergency non-life-threatening calls (priority II). All emergency responses resulting in a priority I or priority II transport to a Level 1 trauma center emergency department over a six-month period were evaluated to determine the relation between specified and arbitrarily assigned RTs and survival. Results: Five thousand, four hundred twenty-four transports were reviewed. Of these, 71 patients did not survive (1.31%; 95% CI = 1.04% to 1.67%). No significant difference in median RTs between survivors (6.4 min) and nonsurvivors (6.8 min) was noted (p = 0.10). Further, there was no significant difference between observed and expected deaths (p = 0.14). However, mortality risk was 1.58% for patients whose RT exceeded 5 minutes, and 0.51% for those whose RT was under 5 minutes (p = 0.002). The mortality risk curve was generally flat over RT intervals exceeding 5 minutes. Conclusions: In this observational study, emergency calls where RTs were less than 5 minutes were associated with improved survival when compared with calls where RTs exceeded 5 minutes. While variables other than time may be associated with this improved survival, there is little evidence in these data to suggest that changing this system's response time specifications to times less than current, but greater than 5 minutes, would have any beneficial effect on survival.

(Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences @ part of the Taylor & Francis Group

Issue: Volume 4, Number 1 / January-March 2000

Pages: 70 - 74

URL: Linking Options

DOI: 10.1080/10903120090941696

DO WARNING LIGHTS AND SIRENS REDUCE AMBULANCE RESPONSE TIMES?

Lawrence H. Brown A1, Christa L. Whitney A1, Richard C. Hunt A1, Michael Addario A1, Troy Hogue A1

A1 Department of Emergency Medicine (LHB, RCH) and the College of Medicine (CLW), State University of New York Health Science Center at Syracuse, Syracuse, New York; and Rural/Metro Medical Services (MA, TH), Syracuse, New York.)

Abstract:

Objective. To determine the time saving associated with lights and siren (L&S) use during emergency response in an urban EMS system. Methods. This prospective study evaluated ambulance response times from the location at time of dispatch to the scene of an emergency in an urban area. A control group of responses using L&S was compared with an experimental group that did not use L&S. An observer was assigned to ride along with ambulance crews and record actual times for all L&S responses. At a later date, an observer and an off-duty paramedic in an identical ambulance retraced the route--at the same time of day on the same day of the week--without using L&S and recorded the travel time. Response times for the two groups were compared using paired t-test. Results. The 32 responses with L&S averaged 105.8 seconds (1 minute, 46 seconds) faster than those without (95% confidence interval: 60.2 to 151.5 seconds, p = 0.0001). The time difference ranged from 425 seconds (7 minutes, 5 seconds) faster with L&S to 210 seconds (3 minutes, 30 seconds) slower with L&S. Conclusion. In this urban EMS system, L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases. A large-scale multicenter L&S trial may help address this issue on a national level.

(Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences @ part of the Taylor & Francis Group

Issue: Volume 5, Number 2 / April–June 2001

Pages: 159 - 162

URL: Linking Options

DOI: 10.1080/10903120190940056

Special Issue: NAEMSP 2001 ANNUAL MEETING

TIME SAVED WITH THE USE OF EMERGENCY WARNING LIGHTS AND SIREN WHILE RESPONDING TO REQUESTS FOR EMERGENCY MEDICAL AID IN A RURAL ENVIRONMENT

Jeffrey Ho A1 and Mark Lindquist A1

A1 Department of Emergency Medicine, Hennepin County Medical Center (JH), Minneapolis, Minnesota; and the Department of Emergency Medicine, St. Mary's Regional Health Center (ML), Detroit Lakes, Minnesota.)

Abstract:

Objective. To determine whether the use of warning lights and siren saves a significant amount of time for ambulances responding to requests for emergency medical aid in a rural emergency medical services (EMS) setting. Methods. A prospective design was used to determine run times for ambulances responding to calls with lights and siren (code 3) and for a similarly equipped “chase” ambulance traveling to the same destination via the same route without lights and siren, while obeying all traffic laws (code 2) within a rural setting. Data were collected for run time intervals, distance traveled, visibility, road surface conditions, time of day, and day of the week. Descriptive statistics, a paired Student's t-test, and analysis of variance were used to test for significant differences between code 2 and code 3 operations, as well as the other variables listed above. Results. Sixty-seven runs were timed during a 21-month period. The average code 3 response interval was 8.51 minutes. The average code 2 response interval was 12.14 minutes. The 3.63 minutes saved on average represents significant time savings of 30.9% (p < 0.01). Shorter runs had higher time savings per mile than the longer runs. Run distance was the only variable that was statistically significant in affecting time saved during a code 3 response. Conclusion. Code 3 operation by EMS personnel in a rural EMS setting saved significant time over code 2 operation when traveling to a call.

Now here's something that shows the patients perspective.

(Prehosp Emerg Care. 1999 Jan-Mar;3(1):11-4. Related Articles @ Links

Actual vs perceived EMS response time.

Harvey AL, Gerard WC, Rice GF Jr, Finch H.

Department of Emergency Medicine, Richland Memorial Hospital, Columbia, South Carolina, USA. allison.harvey@rmh.edu)

OBJECTIVE: To compare patients' perceptions of ambulance response times with the actual ambulance response times to aid quality assurance efforts in EMS management. METHODS: A convenience sample of patients presenting to an urban ED via EMS were asked a series of four questions pertaining to response time, scene time, time to definitive care, and their expectations of response time. These times were then compared with actual times from the EMS dispatch center. Times were analyzed using multivariate analysis of variance (MANOVA) followed by discriminant analysis. RESULTS: There was a significant difference between the perceived and actual times for all three questions, by both multivariate analysis and univariate analysis (p < 0.0001). Patients tended to overestimate the actual response times (12.4 min vs 9.1 min) but underestimate the on-scene times (9.1 min vs 12.4 min) and times to definitive care (29.4 min vs 35.0 min). CONCLUSION: Patients are inaccurate in their estimations of time. Response times are generally overestimated, while scene times and times to definitive care are underestimated. Actual response times often meet patients' expectations (mean 10.8 min), although the patients may not perceive that they have.

Here are some other articles to read as well.

http://intl.aemj.org/cgi/content/abstract/7/5/476-b

http://intl.aemj.org/cgi/content/abstract/6/3/191

http://www.defrance.org/artman/publish/article_1395.shtml

Hope this helps,

ACE844

[Ace844]

Hello Everyone,

To show I haven't forgotten about the original' topic' here's some interesting reading for you.

http://pdm.medicine.wisc.edu/17-3%20pdf/167-169%20Birk.pdf

http://pdm.medicine.wisc.edu/brown.htm

http://www.fresnohumanservices.org/Communi...t/CQIreport.pdf

http://www.trauma.org/archives/scooop.html

What do you all think of the 'points' made in these articles?? How does it change your response to your previous answers?

Hope this helps,

ACE844

[Ace844]

(On-scene time in advanced trauma life support by anaesthesiologists.

ORIGINAL ARTICLES

European Journal of Emergency Medicine. 13(3):156-159 @ June 2006.

Hoyer, C. Christian S. a; Christensen, Erika F. a; Andersen, Niels T.

Abstract:

Objectives: Severe injury is the leading cause of death among the young. Trauma systems have improved management of the severely injured and increased survival rates, but there is no level-1 evidence of advanced prehospital trauma care. Advanced prehospital trauma care prolongs on-scene time, which may imply a risk of significant delay in definitive trauma care. The aim of this study was to evaluate on-scene time and influence of (1) the presence of an anaesthesiologist on-scene, (2) prehospital intubation, (3) entrapment, and (4) injury severity.

Methods: A cohort of registry-based patients brought to Aarhus Trauma Centre. Data were consecutively reported. On-scene time was defined as the time from vehicle arrival to departure. Severe injury is defined by an injury severity score >15. The study was conducted over the period 1998-2000; only patients brought primarily to the trauma centre were included. Statistical tests used include [chi]2, Kruskal-Wallis, Wilcoxon's rank sum and Spearman's [rho].

Results: Seven hundred and forty-one patients triaged to Aarhus Trauma Centre from which we obtained all information in 596 cases constituted the study group. In 472 cases, an anaesthesiologist was present. On-scene times, median and 95% confidence interval, were as follows: entire study group (n=596) 15.5 min (15-17); ambulance only: 14.0 min (12-15); anaesthesiologist present, no intubation, no entrapment: 15.0 min (14-16); intubation, no entrapment: 21.5 min (16-27); entrapment, no intubation: 21.5 min (17-25); both intubation and entrapment: 22.0 min (16-36).

Conclusion The: presence of an anaesthesiologist prolonged the median on-scene time by 1 min and in cases of prehospital intubation by 7.5 min. This result was no different from the prolongation caused by entrapment.

[Ace844]

http://www.emtcity.com/phpBB2/viewtopic.php?t=4290

(Injury. 1994 May;25(4):251-4. Related Articles @ Links

Comment in:

· Injury. 1995 Apr;26(3):215.

· Injury. 1995 Apr;26(3):215-6.

The golden hour and prehospital trauma care.

McNicholl BP.

Accident & Emergency Department, Royal Victoria Hospital, Belfast, UK.)

A 1-year prospective study of 12 hospitals, and approximately 1 million people, was carried out to predict the effectiveness of prehospital advanced life support (ALS) for major trauma in Northern Ireland. Inclusion criteria were an Injury Severity Score (ISS) > 15 and reaching hospital alive. Two hundred and thirty-nine patients had mean prehospital times of 24 and 35 min for urban and rural hospitals, respectively. Most patients (75 per cent, N = 179) were within 10 minutes of a hospital. Of the other patients (25 per cent, N = 60), only 1/2 would have benefitted from prehospital ALS. Fifteen patients aspirated (for a mean time of 7 minutes) before ambulance arrival and eventually died. Seventy per cent of patients who died and who either aspirated or were apnoeic had severe primary brain injuries; the other 30 per cent were considered unsalvageable by both TRISS and peer review. ALS for major trauma will be appropriate for less than 50 patients with ISS > 15 per annum in Northern Ireland. Skill maintenance will be difficult for paramedics.