The pre-implementation time period used for comparison was November 1, 2014, to May 1, 2015. The post-implementation time period was November 1, 2015, to May 1, 2016. We defined TTVS documented as the time from quick registration to first vital sign documented in the electronic medical record. The pilot phase was initiated in May 2014 for eight hours/day, five days/week, excluding weekends. This was extended to 16 hours/day, seven days/week in November 2014, which was the study period. During the implementation period, a vital signs station was created and a personal care assistant was assigned to the waiting area with the designated job of obtaining vital signs on all patients upon arrival to the ED and prior to leaving the waiting area. PCAs are part of the ED team and perform duties under the supervision of doctors and nurses. They assist with numerous tasks. This vital sign station was directly adjacent to the quick registration desk. After patient arrival and sign-in, a quick registration including name, date of birth, and chief complaint was completed. Subsequently, patients were directed to a PCA with a portable vital signs machine and a computer on wheels with access to the EMR. The PCA’s sole task was to obtain vital signs on all patients before they left the waiting area and then enter this information in the EMR. Patients who arrived via EMS had vital signs entered by the ED triage nurse and were also included in this analysis. PCAs were also empowered to obtain vital signs on patients who were waiting in line for registration.The implementation of DTR has had countless benefits, including faster turnaround times, improved door-to- doctor times, and decreased LWBS rates.3 By reducing ED crowding, decision-making time can be reduced as well as reducing over-use of the laboratory and computed tomography.9 However, our experience has shown that an unintended consequence of DTR is both a delay and inconsistency in obtaining initial vital signs. In this study, we demonstrated that the implementation of a vital sign station at ambulatory registration reduced the TTVS, an unintended consequence of DTR, by a mean time of nearly six minutes. When we coupled a vital signs station with our already existing quick registration process,vertical rack the department experienced no delays in overall throughput. Although this now adds a few minutes to the quick registration, we found that the overall benefits far outweigh this short delay.
For EDs that have some form of quick registration and DTR process and experience similar delays in obtaining vital signs, we believe that creating a vital sign station in the waiting room is a feasible and effective solution that could be implemented by any ED. Our ED has two portals of entry: an ambulance entrance, where the patient is immediately triaged and has his vital signs obtained by a nurse who then enters them in the patient chart; and a quick registration desk in the waiting room where all ambulatory patients must sign in prior to being brought to the treatment area. At the quick registration desk, brief demographic information and chief complaint is obtained, which allows the patient to be entered into the EMR and receive a medical record number. After undergoing a quick registration, there are three subsequent pathways for the patient: 1) taken directly into the treatment area by a nurse, PCA, or pavilion coordinator ; 2) taken to a triage station for formal nursing triage, 3) queued in the waiting room for either the next available DTR or formal triage availability. At our institution the pavilion coordinator is an ED greeter who helps the nursing staff facilitate our DTR process. Quick registration with chief complaint and vital sign assessment is markedly different from formal triage, in that formal triage requires nursing resources and a significant amount of time. Quick registration only requires patient demographics and chief complaint, whereas traditional formal triage includes expanded history-taking and a medical assessment including allergies, medications, surgical history, etc. which can lead to a delay in initial clinical assessment in treatment areas. There are many potential benefits to this new process besides the decrease in TTVS. Obtaining earlier vital signs enhances patient safety since it allows for earlier recognition of potentially abnormal vital signs and therefore prompt treatment and intervention. This is especially true in the patient who may appear stable. Second, patient satisfaction is improved since they recognize that they are being taken care of from the moment they walk into the ED. Implementation may be limited due to PCA competing priorities and unanticipated staffing needs within the department. While there were no extra personnel costs as staffing did not increase to fill the vital signs station, we did decrease the availability of existing PCAs in the clinical arena. Annually over 400,000 people suffer non-traumatic out-of hospital cardiac arrest in the United States.This represents the third leading cause of death in industrial nations and accounts for eight times as many deaths as motor vehicle collisions.
There have been steady, albeit modest, improvements in the survival of patients with OHCA over the past decade.Other improvements including higher rates of bystander CPR, dispatch directed CPR, deployment of automatic external defibrillators in the community, and improved CPR quality have also contributed to increasing survival rates.Recently the American Heart Association and other subject matter experts have advocated for the development of regional systems of cardiac arrest care with designation of cardiac arrest centers.A cardiac arrest center is a hospital that provides evidence-based practice in resuscitation and post-resuscitation care, including 24/7 percutaneous coronary intervention capability and targeted temperature management , as well as an adequate annual volume of OHCA cases and a commitment to performance improvement and bench marking. There is a similar precedent in the establishment of ST-segment elevation myocardial infarction centers over the past decade to improve outcomes in that time-dependent disease.Observational studies suggest a benefit of regionalization; therefore, the establishment of regional care systems may optimize access to and delivery of care for patients with OHCA. A prospective study demonstrated improved outcomes in patients with OHCA transported to a cardiac arrest center compared to non-cardiac arrest centers.There have been numerous observational studies with differing hospital characteristics as well as a number of studies that compared outcomes before and after the implementation of regionalized systems of care,microgreen flood table all suggesting an association between improved survival and routing of select patients to cardiac arrest centers. A regionalized cardiac arrest system involves a systematic approach to the care of the OHCA patients across a geographic area. This would include consistency in prehospital care, selective transport to designated cardiac arrest centers, consistent policies on the post-resuscitation care, and participation in a regional performance improvement process to address any potential disparities in care. Currently, most cardiac arrest centers in the U.S. are self-designated academic centers.The extent to which regionalization of cardiac arrest care has been established is not well quantified.
Two studies describing established regional cardiac arrest care systems demonstrated improved patient outcomes with regionalization.This survey of local EMS agencies in California was intended to determine the current practices regarding the treatment and routing of OHCA patients and the extent to which EMS systems have regionalized care across California. The State of California has a population of 39 million, and EMS care is regulated by the California EMS Authority. Oversight of local care is provided by 33 LEMSA. These government agencies establish uniform policies and procedures for a countywide or region-wide system of first responders and EMS providers. While all LEMSA must have an EMS plan that conforms to California EMS Authority mandates, policies and protocols vary among them.We surveyed all 33 California LEMSA on three topics: 1) local policy regarding routing of OHCA patients to designated cardiac arrest centers; 2) specific interventions for post-resuscitation care available in those centers; and 3) access to data on OHCA treatment and outcome measures. We also requested system metrics on frequency of OHCA and patient outcomes. Of note, our survey inquired about the policies and protocols pertaining to all OHCA patients, not only those who achieved ROSC. We developed a 37-question survey in three sections: field treatment and routing policies ; specialty centers ; and system data. Prior to dissemination, the survey was reviewed by several LEMSA administrators and subsequently edited for clarity. The survey was distributed by email to the California LEMSA administrators and medical directors in August 2016, available online via Qualtrics software. Reminders were sent until all LEMSA completed the survey. We clarified incomplete or inconsistent survey responses by email and/or phone. The primary objective was to describe management of OHCA throughout California in terms of current treatment guidelines and specifically to determine the extent to which systems have regionalized care. Responses were submitted by either the LEMSA director or representative and downloaded or input into Excel for analysis. The findings of this study will be shared with the EMS Medical Directors Association of California ,an advisory body to the California EMS Authority comprised of all EMS medical directors of the 33 LEMSAs, who meet quarterly to advise the state on issues pertaining to prehospital scope of practice and quality of care. This study was submitted to the Institutional Review Board at the University of California at San Francisco and was deemed to not involve human subjects as to require continuous IRB review.
All 33 California LEMSA participated in the survey for a response rate of 100%. Table 1 provides a summary of LEMSA routing policies. Two LEMSA reported a fully developed regional cardiac arrest care system with specific clinical protocols to direct patients to cardiac arrest centers, a role in influencing hospital policies about post-cardiac arrest care, and participate in a regional performance-improvement process. The Los Angeles regional cardiac arrest system has been described previously.In LA, all OHCA with ROSC and those transported with presumed cardiac etiology are routed to designated centers, which double as STEMI and cardiac arrest centers. All have 24/7 PCI capability, written internal protocols for TTM, and take part in a regional performance-improvement process. Alameda County operates a similar system, routing all OHCA patients with ROSC at any time to cardiac arrest centers. A large number of LEMSA , comprising a population of 14 million, have specific protocols to direct all OHCA patients with ROSC to designated PCI-capable hospitals. They have a limited role or no role in influencing hospital policies about post cardiac arrest care and do not have a regional performance-improvement process. There was inconsistency among agencies regarding the protocols and reporting required from these hospitals. Nearly all LEMSA have a termination of resuscitation protocol for OHCA. Eight LEMSA have policies and protocols that direct the use of TTM during post-resuscitation care, requiring hospitals to have a written TTM protocol, and five have a memorandum of understanding to enforce the requirement and allow them a role in determining the inclusion and exclusion criteria.Seven LEMSA have policies that require receiving hospitals to have a written protocol for emergent PCI after OHCA. Of these, four have memoranda of understanding with the hospitals and three have a role in determining inclusion and exclusion criteria. The use of PCI for patients with persistent cardiac arrest was rare. Fifteen agencies reported that this occurred in their system, but none reported more than 3-5 patients. Eleven LEMSA have hospitals with extracorporeal membrane oxygenation capability, but it was rarely used for this indication and there were no LEMSA with specific routing or regional policies for its use. Mechanical CPR devices were optional for 18 local EMS agencies. One agency required the use of mechanical CPR devices during transport and another required them for all OHCA patients. The majority of LEMSA report collecting process measures for system quality improvement, with EMS response time the most commonly measured , followed by the time to CPR , the time to defibrillation , and the rate of dispatcher-assisted CPR. However, the measurements of in-hospital outcomes were significantly lower with survival to hospital discharge the most commonly measured. The frequency of reported treatment and outcome measures are listed in Table 2. We present the current policies for treatment and routing of all OHCA patients throughout California with a 100% survey response rate.