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Harmonization and Standardization of Drugs Supplied to the Advanced Rescue Means of the EMS in Lombardy

Abstract

Harmonization and Standardization of Drugs Supplied to the Advanced Rescue Means of the EMS in Lombardy

Authors

ESTENSORI
E. Perego**, G.F. Villa*, P. Minghetti**
COADIUTORI
C. Frigerio*, A. Brancaglione*, S. Campi*, S. Zerbi*, A Calini*, A. Mariotti*, L. Colombi*, F. Kette*, O. Valoti*, A. Andreassi*
* AREU Lombardia
** Università degli Studi di Milano

Background

Drugs supplied for advanced rescue means of AREU.

Design and setting

Observational, retrospective, analytical, single cohort study on drugs supplied to the advanced rescue means (ARM) of the Lombardy region.

Objective

Regional analysis and subsequent standardization of mandatory drugs supplied to the Advanced Rescue Means (ARM) in Lombardy.

Methods

A retrospective analysis related to the quality and quantity of drugs administered by the AREU 118 (EMS) staff to the adult population in emergency situations showed a very diverse regional situation. The need to draft a standardized list of drug supplies followed specific criteria: drugs commonly used in most provincial EMS', data related to specific scientific literature, validated, practical rescue experience, guidelines of the Italian Society EMS Systems (SIS 118). The individual drugs were evaluated for one year by a specific AREU study group that drafted appropriate data sheets.

Results

The final standardized list of medications included 71 drugs that were selected for advanced rescue by ARM. The examination of their storage conditions, which was done in order to optimize their management, highlighted the six most critical drugs (adrenaline [1 mg / 1 mL], adrenaline [5 mg / 5 mL], insulin, oxytocin, rocuronium and succinylcholine). These drugs need to be stored at a temperature between 2 ° C and 8 ° C, and have to be kept in the refrigerator of the rescue stations and in appropriate refrigerated containers on board the ARM.

Conclusions

The choice of a single, standardized drug list supplied at regional level for the ARM offers obvious advantages in terms of unified patient treatment based on the same guidelines and staff training. This choice also allows better control of consumption and costs, ensuring the unique management of the drugs and the critical aspects of their storage.

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OHCA in the Mantua province

Abstract

OHCA in the Mantua province: data analysis and relevance of EMS staffed by nurses (MSI)

Authors

G. Castelli*, G. P. Castelli**, A. Iasci**, M. Masotto**
* UNIVERSITÀ DEGLI STUDI DI BRESCIA. CORSO DI LAUREA IN INFERMIERISTICA
** AAT 118 MANTOVA AREU [Azienda Regionale Emergenza e Urgenza] Lombardia

Background

OHCA evaluation in Mantua province

Design and setting

Observational, retrospective, analytic, single cohort study on the Mantua population

Objective

To analyze the incidence of OHCA in the province of Mantua (area of around 2340 sq. km, population of 415.000 people with density of 177 inhabitants per sq. km.) in 2012-2014, the correlations with the times of arrival at the scene of the first EMS (and / or early CPR), and results of OHCA managements by vehicles staffed by nurses.

Methods

we proceeded to extract data from the System Management Emergency Management (EmMa) of Mantua Emergency Control Room from 2012 January 1 to 2014 August 31. For each patient we collected data related to age, sex, time between call and arrival of the EMS, OHCA witnesses, CPR performed by bystanders, the time between the call and delivery of the first shock in the presence of VF / pulseless VT, presentation rhythm and time of return to spontaneous circulation (ROSC). Age was calculated using the median and percentiles, the time in minutes and seconds. In a subgroup of patients with ROSC (2013-2014) we calculated the GCS (Glasgow Coma Score) and survival at 24 hours, the CPC (Cerebral Performance Category) at discharge or at 30 days. The EMS vehicles are equipped with: advanced vehicles (MSA) with physicians, intermediate vehicles (MSI) with nurses trained to administer drugs during CPR and to supraglottic airway management, basic vehicle (MSB) with rescuers.

Results

There were 1381 adults with OHCA; the median age of patients was 77 years (63-85, 25th- 75th percentiles, respectively). Males were 813 (58.9%) and the incidence of OHCA was 1.25 per 1,000 inhabitants. The RCP was applied to 989 patients (71.6%): 833 with intervention of MSA (62 in support to MSI), 88 with intervention of MSI, 68 only by the MSB. Patients who died in place were in total 1137, those transported to the emergency department with CPR in progress 93 (9.4%) and 151 the ROSC (15.3%). The rhythm of presentation of the 989 resuscitated patients was asystole in 674 cases (68.1%), PEA in 153 (15.5%), VF / pulseless VT in 150 (15.2%), other rhythms in 12 (1, 2%). In the subgroup of resuscitated patients (n = 989), the median time between collapse and start of CPR was 5'49 '' in ROSC (0-11'6 ''; 25th-75th percentile) and 12'05 '' in patients who died (n = 745) (7'35 '' - 15'38 ''; 25th-75th percentile). In a subgroup of 83 ROSC in the period 2013- August 2014, the 30-day mortality was similar comparing the missions managed by MSI and MSA (50 vs. 54.5%); CPC 1-2 at 30 days was found in 32.14% and 25.45% of the ROSC respectively for MSI and MSA.

Conclusions

OHCA in the Mantua province during the observation period was 1.25 / 1000 inhabitants; the ROSC had lower median time between collapse and start of CPR (5'49 '' vs. 12'05''); the number of patients with CPC 1-2 at 30 days after ROSC treated by MSI was not lower than the number of those treated by MSA (32.14 for MSI vs. 25.45%).

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Impatto dell'arresto cardiocircolatorio extra-ospedaliero (OHCA) in Lombardia (Italia):

Abstract

Impact of out-of-hospital cardiac arrest (OHCA) in the Lombardy Region (Italy): Analysis of data collected by the Emergency Medical Services (EMS) Registry

Authors

Villa G.F.*, Minoretti V.**, Pagliosa A.*, Canevari F.*, Manera M.***, Solaro N.***, Kette F.*, Salmoiraghi M.*, Zoli.A.*, Executive Staff of AATs*.
* AREU [Emergency Medical System Trust] Lombardia -
** Medicine Faculty, University of Milano-Bicocca
*** Department of Economics, Management and Statistics, University of Milano-Bicocca

Background

Out of Hospital Cardiac Arrest has become a global public health emergency in Western Countries. No data on OHCA in the Lombardy Region have been previously collected..

Design and setting

Observational, retrospective, analytic, single cohort study on the Lombardy population in the Lombardy territory.

Objective

The study aimed at analyzing out-of-hospital cardiac arrest (OHCA) in the population of the Lombardy region, which is a significant sample of the Italian population in terms of quantity and quality. The study was based on the data collected by Medical Dispatch Centers and field rescue medical teams.

Methods

The data on out-of-hospital cardiac arrest in the Lombardy population (9,924,447 people) were collected via Emma Web Operating System and uploaded in the database. The data referred to an overall 30-day period divided as follows: 14-23 October 2013, 14-23 January and 14-23 March 2014. The hospital data and those gathered at the patients' homes were provided by the receiving hospital departments. All the cardiac arrest cases rescued by the Emergency Medical Services (EMS) were considered first; then, in accordance with Utstein Style guidelines, the study excluded the cardiac arrest cases that had not received resuscitation by rescue personnel (269), the cardiac arrest cases with non cardiac aetiology (74) and unwitnessed cardiac arrest cases (176).

Results

Of the 946 OHCA cases initially considered, the study analyzed 428 events (70.9%) of presumed cardiac aetiology. In accordance with Utstein Style evaluation parameters, the outcomes analyzed were sustained Return of Spontaneous Circulation [ROSC] (107 cases – 25%), Survival Events in the Emergency Room (95 cases – 22.2%), Survival Events at 24 hours (88 cases – 20.6%) and at 30 days (46 cases – 11%). The study then evaluated the effect on the outcome of all the variables that occurred throughout the medical event, considering both the unchangeable factors and those strictly depending on the rescue. The most statistically significant variables among those analyzed were: advanced age, correlated to a higher incidence of cardiac attack and a lower ROSC (p<0.001) rate; the quality of the presenting rhythm, in that the rhythms that can be defibrillated have a higher correlation with ROSC (p<0.001) and Survival Events (SE) at 30 days (p<0.05); the rescue medical means with a higher ROSC rate in those cases where the Basic Life Support (BLS) ambulances (volunteer rescuers) were supported by Advanced Life Support (ALS) doctors' cars or nurses' vehicles (p<0.001); early bystander-assisted resuscitation, with Public-Access Defibrillation (PAD) in 1.6% and start of Cardiopulmonary Resuscitation (CPR) in 30% of cases that results in higher ROSC rate (p<0.05) and identification of a rhythm that can be defibrillated (26.4% vs 16.1%). The results of an analysis on the timing, although not supported by statistical data, shows that reduced rescue times (particularly in urban areas) are associated with a greater possibility of identifying rhythms that can be defibrillated. The other situations analyzed, which however have not produced statistically significant results, are the neurological outcome, the effect of seasons and the use of therapeutic hypothermia in the hospital setting. The national and international comparison of the rescue costs is interesting, as those in Lombardy are the lowest compared to other countries.

Conclusions

Apart from the importance of some variables in influencing cardiac arrest outcome, specific differences have been found between the data collected in urban areas (Medical Dispatch Center located in urban areas, SOREU Metropolitana) and those gathered in extra-urban areas (Medical Dispatch Centers located in rural areas, SOREU Provinciali), in particular with regard to the management of rescue operations. The analysis has conditioned the introduction of a new approach to the management of the Medical Dispatch Center for the intervention of doctors' cars and nurses' vehicles that will be studied in the next future. Moreover, the importance of additional training and dissemination of information in the lay population for early rescue and outcome improvement were confirmed.

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