QUALITY OF ON-SITE PERFORMANCE IN PREHOSPITAL ADVANCED CARDIAC LIFE-SUPPORT (ACLS)

The aim of our prospective study was to assess the structural and proc edural quality of an urban emergency medical services (EMS) system pro viding prehospital basic and advanced cardiac life support (BLS/ACLS), to compare the on-site performance of physicians and non-physicians i n ECG diagnosis and defibrillation, and to identify incidence and caus es of avoidable delays in the initial treatment sequences. Methods: Be tween 1 February 1991 and 1 July 1992, 162 on-line tape recordings of prehospital cardiopulmonary resuscitation (CPR) efforts performed by t he staff of the EMS system of the city of Mainz were evaluated. After arrival at the patient's side, time intervals to initial ACLS steps (f irst ECG-diagnosis, first defibrillation, endotracheal intubation, fir st epinephrine administration) were measured. Times to rhythm identifi cation and countershock by EMT-Ds vs. physicians were compared (Mann-W hitney U-test). Time intervals are presented as median values. One-hun dred sixty-two adult patients with out-of-hospital cardiac arrests (ve ntricular fibrillation [VF] or ventricular tachycardia [VT], 72; asyst ole or electromechanical dissociation [EMD], 90) receiving CPR by EMTs , EMT-Ds, and physicians of the Mainz EMS were included. Patients with arrests due to non-cardiac aetiologies were excluded. Results: After arrival at the patient's side, for patients with VF/VT, the EMT-Ds too k 1:36 min and the physicians took 1:00 min to obtain the first ECG di agnosis (P = 0.004). The first countershock was delivered within 1:42 min by both EMT-Ds and physicians of the mobile intensive care unit (M ICU). After diagnosis was established, the EMT-Ds took 0:08 min to def ibrillate, whereas the physicians took 0:36 min (P = 0.0001). Endotrac heal intubation was performed within 3:30 min, and epinephrine was adm inistered within 3:56 min. In patients with asystole or EMD, the first ECG-diagnosis was obtained within 0:48 min by both EMT-Ds and physici ans. Patients were intubated within 2:44 min, and received epinephrine within 3:24 min. Conclusions: Since there is no consensus yet about t he methods of EMS evaluation and comparison of ACLS time intervals, re liable reference data are lacking. Yet we found that in cases of VF/NT , physicians equipped with manual defibrillators obtain the diagnosis earlier than EMT-Ds equipped with semi-automatic devices, but deliver the first shock later. Another delay manifested itself in cases of asy stole or EMD, between ECG-diagnosis and intubation or epinephrine admi nistration. Possible causes for such delays in ACLS sequences are prob lems in communication between physicians and EMTs. As a result of this study, our EMS system has implemented rehearsals of taped real codes in our megacode training.