Robert Vroman, M.Ed., BS NREMT-P

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Q&A: Chicago’s medical director talks mobile integrated healthcare

Eric Beck shares his thoughts on where mobile integrated healthcare is headed, and how it goes beyond community paramedicine to connect healthcare providers

7 eye-catching EMS products and services

The Pinnacle EMS conference featured about 40 vendors offering up-and-coming products and services for EMS leaders

Video: Car plows through Comic-Con 'zombie walk' crowd

A deaf father drove forward because his kids in the car were afraid; marchers began pounding on the car and when he tried to get through again he hit a 64-year-old woman

Boy thanks FDNY medics at 7th birthday party

His parents tracked down the medics who saved him from a near-fatal anaphylactic attack and invited them to his birthday bash

Stalking charges dropped against former ambulance company president

After months of "living hell" he was prepared to fight accusations that he followed and harassed a neighbor over two years

Pa. woman gets 8 years in jail for Medicare fraud

Her scheme through Penn Choice Ambulance involved more than $3.6 million in fraudulent Medicare claims

N.M. firefighters chase down ambulance thief

Gonzalo Tellez-Santilla, 34, was arrested on charges of aggravated assault on a police officer, aggravated fleeing, unlawful taking of a motor vehicle and assault on a healthcare worker

Ambulance strikes teen on bike

The ambulance stopped immediately and EMTs provided medical aid; the boy suffered bruises and broken bones

U.S. doctor who contracted Ebola in grave condition

After months of treating those with the deadly disease in West Africa, the doctor contracted it.

Md. volunteer responders push for pension changes

Proposals including lowering the age of eligibility to receive pension benefits, as well as lowering the retirement age
Top

EMS1 Topic Articles

Q&A: Chicago’s medical director talks mobile integrated healthcare

Eric Beck shares his thoughts on where mobile integrated healthcare is headed, and how it goes beyond community paramedicine to connect healthcare providers

7 eye-catching EMS products and services

The Pinnacle EMS conference featured about 40 vendors offering up-and-coming products and services for EMS leaders

Video: Car plows through Comic-Con 'zombie walk' crowd

A deaf father drove forward because his kids in the car were afraid; marchers began pounding on the car and when he tried to get through again he hit a 64-year-old woman

Boy thanks FDNY medics at 7th birthday party

His parents tracked down the medics who saved him from a near-fatal anaphylactic attack and invited them to his birthday bash

Stalking charges dropped against former ambulance company president

After months of "living hell" he was prepared to fight accusations that he followed and harassed a neighbor over two years

Pa. woman gets 8 years in jail for Medicare fraud

Her scheme through Penn Choice Ambulance involved more than $3.6 million in fraudulent Medicare claims

N.M. firefighters chase down ambulance thief

Gonzalo Tellez-Santilla, 34, was arrested on charges of aggravated assault on a police officer, aggravated fleeing, unlawful taking of a motor vehicle and assault on a healthcare worker

Ambulance strikes teen on bike

The ambulance stopped immediately and EMTs provided medical aid; the boy suffered bruises and broken bones

U.S. doctor who contracted Ebola in grave condition

After months of treating those with the deadly disease in West Africa, the doctor contracted it.

Md. volunteer responders push for pension changes

Proposals including lowering the age of eligibility to receive pension benefits, as well as lowering the retirement age
Top

EMS1 Columnist Articles

7 eye-catching EMS products and services

Unless you own an ambulance company, you may not be familiar with the Pinnacle EMS conference coordinated by Fitch and Associates. The conference brings together executives from ambulance services across the nation to talk about the state of the EMS industry and upcoming trends. Field employees and mid-level management are nowhere to be found.

This year the conference was held just 10 minutes from my home in Scottsdale, Ariz., so I decided to attend. The sessions were interesting, and the exhibit hall featured about 40 — the number was purposely kept small, but the price for each booth was high because of the attending audience.

I walked through and talked to several vendors with the hopes of learning how their products and services would affect field employees. Here's some of what I saw that might soon be coming to an ambulance operation near you.

1. Patient surveys

There were a handful of vendors offering survey services of patients and customers to help ambulance companies make improvements and increase stats. RSQ911 Solutions uses a strategy where crews hand each patient/family a card with a special number to track the transport and response.

EMS Survey Team takes an approach where patients are contacted after the incident by phone or email around the time when a bill is sent. Both scenarios aim to drill directly down to the caregivers and help determine how each crew member performed on a customer service level, not just a clinical level.

2. Training and behavior modification

CentreLearn Solutions is well known for offering online public safety training and was a popular booth at the conference. EMS1 columnist Bryan Fass’ company FitResponder was also interesting.

FitResponder works with agencies to help stop the cycle of bad habits by teaching simplified techniques such as simple stretches that can help reduce workplace injuries. It’s very cost effective for agencies, so expect to see more efforts to improve workplace safety by encouraging proper habits for daily work functions.

3. Technology updates

InMotion Technologies by Sierra Wireless is a company that improves the internet/communication backbone between the ambulance, dispatch, and health care facilities. Basically they’re trying to end the issue that crews experience when the telemedicine equipment can’t get a signal or loses connection.

The communication tech box is built into the ambulance and is designed to keep the information flow constantly open and moving. It works with your equipment regardless of the maker, and includes Bluetooth connections.

4. Inventory tracking

Operative IQ is trying to simplify the inventory process by making it paperless. The electronic method allows crews to instantly request restocking, and creates a record of the request that alerts managers to the product need. Each crew member can be on separate devices doing different shelves for the same vehicle at the same time.

The program also tracks expiration dates so that crews don’t need to do it manually, and allows them to open vehicle maintenance work tickets. It’s a great way to document that a crew member reported an issue, and eliminates any blame if something that was properly reported has a stop gap.

5. Deployment tracking tools

InterMedix helps managers track, analyze and understand employee and ambulance utilization. The idea is that by better understanding human fatigue issues, managers can create a better deployment and process that benefits the company, employees and patients.

6. Improved dispatch technology

Medlert is a mobile app that allows facility nurses and case managers to directly request transports, bypassing the dispatch center and submitting their own face sheets within the app.

Another company that caught my attention was Medapoint, whose product makes it possible for crews to assign themselves to different GT transports, rather than having dispatch assign each transport. Medapoint also recently announced a partnership with TomTom GPS for CAD and AVL integration.

Related to the dispatch center, Atrus was another interesting company from a community involvement perspective, and offers an add-on to the normal dispatch process. When a cardiac arrest occurs, the Atrus database looks for registered AEDs located nearby an incident and then “dispatches” trained community responders at the same time that the EMS crew is dispatched. Dispatch can also track who confirmed that they are responding with the AED and alert crews en route.

7. Software and equipment

Several ePCR companies were offering demos, as were many back-end, cloud-based software solutions (with various modules like billing, scheduling, HR, certifications, etc.). One new piece of equipment you may not have heard of from Advanced Circulatory Systems Inc. was promoting Intrathoracic Pressure Regulation (IPR) therapy, which is enhanced negative pressure for someone in shock or cardiac arrest.

Many of the vendors I spoke with said that Pinnacle EMS is a valuable show for them since it’s attended primarily by company leaders and decision makers. Only time will tell if these new products and services will affect you in the field.

Clinical solution: Near-amputation in a boating accident

In the previous scenario, you responded to a 23-year-old male who was struck and run over by a boat while water skiing. The patient had suffered a near amputation of his right leg above the knee. He was bleeding significantly even though bystanders had been applying direct pressure.

Treatment

One of the first treatment priorities in trauma patients after ensuring a patent airway is the control of major hemorrhage. EMS trauma classes teach the ABCs of patient assessment with “C” standing for circulation and including perfusion and hemorrhage.[1]

EMS providers were previously advised to use a tourniquet only as a last resort for fear of causing tissue death in the part of the limb beyond the tourniquet. However, the experience of military physicians over the last 10 years has demonstrated that a tourniquet may be safely applied for up to two hours with little to no risk of nerve or tissue damage.[2]

Based on these findings, tourniquets have been deployed with increasing frequency among civilian EMS agencies. Many agencies have altered protocols to encourage early use of tourniquets in the control of hemorrhage.

Given the distance of this patient from a hospital, the difficulty in extricating him back to a transporting unit and the extent of his injury, use of a tourniquet is indicated. While a folded cravat was traditionally used in EMS as a tourniquet, several commercial options have become available.

Regardless of which method is used, the guidelines for applying a tourniquet are consistent: The device should be applied just proximal to the wound (within three or four inches) and should be tightened to the point that arterial flow is stopped.

Hemorrhaging may actually increase in severity and volume if the tourniquet only stops venous flow. If one tourniquet is not sufficient to stop blood flow a second one may be used as well.[3]

The goal of most pre-hospital trauma care is to stabilize a patient and allow him to survive to reach definitive care. Definitive care in this instance means surgical services.

Patients suffering from major trauma were once treated under a concept called the golden hour. While there has been some question about the accuracy of the term, time is still extremely important.

Given that this patient is in need of emergency surgical intervention, it is more appropriate for him to be transported directly to the regional trauma center. Since that facility is 90 minutes away by ground the use of air medical services may be beneficial.

Outcome

After performing a rapid trauma assessment on your patient, you apply a commercial tourniquet to his leg above the site of the injury. While you begin treatment, you ask dispatch to start the air ambulance to the landing zone at the ranger’s station.

With the bleeding stopped, you and the sheriff’s deputy transfer the patient to your boat and start back to the dock. The ALS crew meets you as you pull up and you provide a turnover report.

The patient’s blood pressure has remained stable since the tourniquet was placed so the paramedic elects to start an IV TKO. Ten minutes after your arrival at the dock the air ambulance is overhead. The patient is loaded and transported to the regional trauma center.

Given the extent of the patient’s injuries, surgeons at the trauma center are forced to amputate above the knee. While there was initially a significant amount of blood lost, surgeons credit the application of the tourniquet with allowing the patient to survive through surgery.

The patient recovers quickly and has been discharged to a rehabilitation facility for physical and occupational therapy and fitment of a prosthesis.

References

1. American College Of Surgeons Committee On Trauma. "Patient Assessment and Management." Prehospital Trauma Life Support. Burlington, MA: Jones & Bartlett Learning, 2011. 114-115.

2. Kragh, JF, TJ Walters, DG Baer, CJ Fox, CE Wade, J Salinas, and JB Holcomb. "Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma." J Trauma 64(2008): 49-50. Web.

3. American College Of Surgeons Committee On Trauma. "Patient Assessment and Management." Prehospital Trauma Life Support. Burlington, MA: Jones & Bartlett Learning, 2011. 200

Inside EMS Podcast: Why can't EMS and dispatch get along?

Download this week's episode on iTunes, SoundCloud or via RSS feed

In this week's Inside EMS podcast, hosts Chris Cebollero and Kelly Grayson discuss the recent story about medics being placed on modified duty after a fatal arrest.

"It doesn't’t reflect well on EMS in the video, because there seemed to be no great sense of urgency in resuscitating the guy," Kelly said.

Chris and Kelly also talk about the challenges between the EMS field and dispatch and how to fix that relationship.

"I think one of the big things that go into this love/hate relationship is the fact of how we talk to the dispatchers over the radio,” Chris said. “There’s too much ego that goes into both sides of this business and we need to be able to remember that we work for the same organization and have the same mission."

Chris asks Kelly his thoughts on the best way to bridge the relationship between both sides.

"Part of the problem lies within management, because they put us both in a no-win adversarial situation," Kelly said. "Better management policies would probably smooth a lot of that over."

They also interview Mike Miller, Program Director for Creighton (Neb.) University, to set the record straight about their paramedic bridge program that’s awarding certain allied health care professionals to achieve their paramedic certification in two weeks.

Here are links to some of the articles and other items mentioned on the show:

Crash video: Woman at stop sign thought ambulance would also stop

Father beats babysitter molesting his son, calls 911

Modified duty for medics after fatal NYC arrest

Inside EMS Podcast: Can you become paramedic in 2 weeks"

Top 10 signs your EMS dispatcher hates you

Why the younger generation shies from leadership

“I can’t make anyone do anything,” a frustrated young EMS supervisor recently complained. His struggle centered around getting the current FTOs and senior management to support needed changes to the FTO program he had been tasked with running.

The supervisor, whom I’ll call Jason, had a reputation for being smart, innovative, hardworking and a solid manager — all labels he was willing to accept. But when I pointed out that rallying people around a needed improvement was a leadership issue, he said, “I don’t really think of myself as a leader.”

His comment framed something I’ve been noticing: Many supervisors and middle managers are reluctant to view themselves as leaders. I wanted Jason to help me understand this better, so I invited him to coffee and asked him why he didn’t consider himself a leader.

“Leadership kind of sucks,” he began shyly — and over the course of an hour, he helped me see more deeply into leadership and the younger generation.

The idea of being a leader didn’t appeal to Jason. He couldn’t name a single leader he admired, and he was adamant that he didn’t want to be this larger-than-life person, the type who is often talked about in terms of dead presidents, political leaders, sports figures and the obscenely rich. He doesn’t identify with those people and does not aspire to their achievements.

As we talked, it became clear that his life experience with the older generation, people in positions of power and bosses had left him untrusting of leadership. He talked about the empty promises of his upbringing that said he could be or earn anything he wanted — that if he simply worked hard and educated himself, he would do well in life. “My brother moves furniture and makes more than I do,” he pointed out.

And while respectful in his approach, Jason made it clear that the leadership style of the baby boomers has left him jaded. His reality is educational debt, few jobs to choose from, the need to work multiple jobs, and the chronic failure of local and national leaders to solve the multitude of social ills he witnesses daily as a paramedic. It is evident that he does not see much leadership around him — and what he does see is not inspiring.

Jason views his own boss as “not too bad” but as being primarily focused on self-promotion and protection. He sees him as a lone operator primarily motivated by fear, and he does not want to be like that. Jason has not received any leadership mentoring and scoffs at the idea that there would ever be time in busy EMS organizations to mentor young leaders.

His basic view of leadership is of someone he does not trust trying to convince him to do something he does not want to do.

“Kind of like sales"” I asked.

“Exactly,” he said. “I can’t stand salesmen. Just leave me alone and let me decide for myself.”

He went on to explain that he’d hoped the people above and around him would simply see the importance of improving the FTO program and help him implement the changes. But he also confessed to being reluctant to take on the responsibility and consequences of pushing or promoting something that might fail.

I am grateful for Jason’s insights and candor, and I can’t blame him for not wanting to lead. But I’m also concerned about the future. There are many like Jason who are being lost as potential leaders because too few are leading the new generation toward leadership.

We are failing to influence promising young people toward leadership, and in many ways: by not having a good handle on leadership and how it differs from management; by making leadership something too large, onerous, lonely and unappealing; by neglecting to be models of leadership that young people want to emulate; and by refusing to do the self-revealing and time-intensive work of mentoring young new leaders.

Next month I’ll discuss how we can begin to remedy this situation.

Charting the course of community paramedicine

Despite the unexpected snow outside, more than 100 EMS providers and administrators gathered in a Washington, D.C., ballroom on March 25, 2013, to learn more about mobile integrated healthcare — and how to get paid for it.

As mobile integrated healthcare (MIH) and community paramedicine (CP) programs expand around the country, so do the ways in which agencies get reimbursed for these programs. The path forward is at the same time murky — as almost no two systems seem to have the same funding model — but also promising, since so many have figured out ways to get paid for providing these innovative programs.

“Every patient coming into [our MIH] programs is now attached to a funding source,” said Matt Zavadsky, public affairs director for MedStar Mobile Health in Fort Worth, Texas.

Zavadsky and Eric Beck, D.O., associate chief medical officer for American Medical Response (AMR) and Evolution Health, opened up the meeting with a brief overview of some of the changes occurring in EMS and healthcare across the country. Beck talked about more than a dozen MIH programs currently in place or in development, while Zavadsky presented the results of a survey in which more than 230 agencies said they currently have some type of MIH or CP program.

The highlights of the summit — which was sponsored by EMS World and its new sister publication, Integrated Healthcare Delivery, in partnership with Medtronic Philanthropy, the American Red Cross and the National Association of EMTs — came during the second session, when speakers from across the country talked about their experiences with starting and funding MIH programs.

Challenges abound, yet payoffs loom

Chris Cebollero struggled to convince his hospital system that EMS could provide the types of services he was suggesting. Convincing them was critical not only because successful MIH programs rely on partnerships with hospitals but also because in his case, the hospital is also his employer. Cebollero is the chief of EMS for Christian Hospital in St. Louis County, Mo.

“My hospital system was not listening to me when I told them how I could help them and how we could move forward,” he said. “I was talking to the president, I was talking to the vice presidents.” One of those vice presidents was his boss, but even “she wasn’t hearing it,” he explained.

But when he met with a member of the hospital system’s process improvement team, Cebollero said, he gained some insights into how to convince those executives. In that meeting, he learned that more than half of the hospital’s patients stay too long, and that one extra day in the hospital was costing $4.4 million each year — significantly more than the readmission penalties.

“I finally sat down with the process improvement guy, and he said, ‘You’re looking at it all wrong,’” Cebollero told the audience. “You need to affect the length of stay. And that’s going to get you to the high-risk readmission people.”

Cebollero’s story, like others told at the summit, demonstrated the importance of meeting with the right people at the right time and bringing the right information. Some hospital executives, for example, might be less than thrilled to hear that a CP program will keep patients out of the emergency department. After all, the ED has traditionally been how the hospital brings in patients … and dollars.

“Right now, today, in the fee-for-service world" They get really nervous,” said Brent Myers, M.D., director of Wake County (N.C.) EMS.

And while the world where hospitals get rich from emergency patients may be nearing an end (“This is the end of fee-for-service” was a refrain heard more than once during the half-day session), some hospital executives are not quite ready to take that leap. So EMS systems may need to think of other ways to pitch these programs — such as reminding the hospitals that the Centers for Medicare and Medicaid Services (CMS) ranks hospitals based on some of these factors on its Hospital Compare website.

“The incentive [for hospitals] at the moment may not be financial,” Myers added, “it may be to keep yourself off the bad list.”

But if convincing the hospitals has its challenges, the insurers and accountable care organizations (ACOs) have been, perhaps surprisingly, very interested in what MIH can deliver. Cebollero, for example, said that five different payers are interested in what his agency is doing, and they have several contracts pending.

What do payers want"

A few of MedStar’s partners spoke at the summit, giving the audience a chance to hear from the payers themselves. Dan Bruce, the administrator of Klarus Home Care in Fort Worth, Texas, explained why his agency chose to partner with an EMS MIH program at a time when similar home health organizations across the country see these programs as a threat.

“We instruct our patients to call us, but they don’t always do that,” Bruce said. “They just call 911, and there they are, back in the hospital.”

Instead of simply increasing staffing to the point where each Klarus customer had a nurse in the home 24 hours a day, Klarus contracted with MedStar to help assess and treat those patients at home and, when possible, avoid trips to the ED. “That’s probably going to sound like treason in your community,” Bruce said. “There is a lot of turf, a lot of territorialism there. You need to break through those walls.”

But the partnership made sense for both Klarus and MedStar—MedStar has the staffing and the resources, and Klarus wants to keep its patients out of the hospital. While readmission penalties for home health agencies are not a reality yet, they may be soon. And hospitals want to refer their patients to agencies that will keep them from bouncing back.

So now Klarus is paying MedStar to help keep those patients at home, which makes the patients, the hospitals and both agencies happier. MedStar will send its advanced practice paramedics on 911 calls from any Klarus patient, and they will contact the Klarus nurse and access the Klarus medical records to try to avoid transporting the patient to the hospital if possible. If the patient calls the nurse instead of 911, Klarus may contact MedStar and request a home visit in order to do an assessment or provide treatment.

Bruce also suggested that EMS agencies hoping to partner with home care companies may have to think of other ways to sell their services, such as reminding the home health executives that MIH programs can bring in business, not drive it away. After all, EMS providers often see patients, whether through traditional 911 services or MIH programs, who are in need of home health. That can turn into referrals for the company, especially if they choose to partner with EMS on these innovative types of projects.

Options encouraging yet overwhelming

The wide range of MIH programs on display at the summit can be both encouraging and overwhelming to the EMS community. Overwhelming because there are so many different models, potential partners, roadblocks and unsettled questions. Encouraging, though, because while at one time it was thought that EMS reimbursement couldn’t change until Medicare and Medicaid changed, the changing healthcare marketplace has created incentives for other payers to become the innovators.

“Trying to change Medicare is going to take some time,” Myers said, suggesting that in this case, the private sector may be the ones who force the federal government to change how it reimburses EMS. Referring to those private insurers, ACOs, hospitals and other private entities, he added, “Those folks can see the value of what you’re doing.”

While significant policy changes may take time, CMS and state and federal Medicaid administrators have shown interest in exploring ways that EMS can help provide better care at reduced costs. Several conference presenters were scheduled to meet with top officials from CMS and other agencies in the days following the conference.

One speaker, Brenda Staffan from Reno, presented an update on her program, which is currently being funded by a $9.8 million CMS Innovation Grant. Another presenter, from Fort Worth, spoke about a Medicaid waiver program that is allowing her publicly funded health system to partner with MedStar to help patients navigate the healthcare system.

Dawn Zieger, a project director for community health with the JPS Health Network in Fort Worth, spoke about why her system chose to partner with MedStar, giving the summit audience a chance to hear what potential collaborators are looking for. One thing they learned:

EMS systems and their partners might have to invest in a program first before they can lock in external funding sources.

“It really helped us to leverage that pilot program to get the funding moving forward,” Zieger said. After a pilot program appeared successful, however, JPS and MedStar worked together to receive what’s known as a Medicaid Section 1115 Waiver, which authorizes experimental or demonstration projects. The JPS–MedStar waiver is for a five-year program that will try to decrease costs by using MedStar’s MIH program to help JPS patients avoid hospitalizations and other expensive and avoidable services.

Under the program, JPS pays MedStar a monthly fee for each patient in the program, as well as an annual payment based on the outcomes and savings created by the program. At the summit, Zieger announced that JPS had just made its first annual “outcome” payment to MedStar — for $189,000.

Other issues addressed at the summit included education and accreditation for MIH providers and programs, as well as state regulation of these programs. The paths forward on accreditation and regulation both remain uncharted, but the clear message was that in the future, EMS in general — and CP and MIH programs in particular — will need to be evidence-based and will need to measure outcomes.

Changes that hospitals and doctors are seeing today, such as outcomes data being made public on government websites and reimbursement being impacted by patient satisfaction scores, will eventually come to EMS as well, several panelists said.

Ed Racht, M.D., chief medical officer for AMR, put the summit in perspective when he asked members of the audience to take a mental picture of the meeting. “One day everyone in this room is going to be sitting around telling a story,” he said. “You’ll be able to say, ‘I remember when the concept of mobile integrated healthcare [was new] and there were no guidelines, there was no course.’”

Racht compared today’s discussions of community paramedicine to those half a century ago, when EMS transitioned into a system of care with standards for education, equipment and treatment. In 10 years, he said, the people sitting around the tables will be looking at mobile integrated healthcare systems and say, “I was in one of those meetings, where we were trying to plot out what it was going to look like.”

Why EMS needs higher education

Field medicine is evolving faster today than ever before.

External factors such as changes in an aging population, health care reimbursement, evidence-based medicine and a move toward preventive care are affecting the population EMS providers serve. Proactive EMS systems are rising to the challenges, adapting in innovative ways to not just survive, but also thrive in the new environment.

Training EMS providers to perform tasks such as discharge follow up, high-frequency caller reduction, and harm-reduction efforts may result in far more effective care, at a lower cost than the traditional EMS model of being highly reactionary and high cost.

While such efforts are laudable, they fall short of what is needed to sustain long-term growth in the profession. Systems will need to depend upon not only a well-trained workforce, but a well-educated EMS professional to provide increasingly sophisticated medical services in this dynamic environment.

In this regard, EMS education is at a crossroads.

Will it take the more difficult path of growth and change, or will it take the easier path of "if it ain't broke, don't fix it"" This decision has significant consequences for the industry's future.

The tail wagging the dog

In 1996, the National Highway Traffic Safety Administration's EMS section released EMS Agenda for the Future, a consensus document that provided a glimpse of what EMS might look like in the future. The Agenda advocated for continued development of "out of facility" care by focusing on various attributes of an EMS system.

Of particular note was the state of EMS education. The Agenda noted that there were no fewer than 40 types of EMS certification across the country, and that education was being provided in a wide variety of environments and circumstances. Little information regarding public health, management and research principles was offered in initial education programs.

Moreover, the nature of education in EMS was unusual in that it drove the development of the industry, rather than the other way around. Typically, new procedures, techniques, and processes in an industry are developed through innovation and research. Educators review the developments and incorporate the new content into the primary education process.

In early stages of EMS education, the industry adopted education content embedded in documents such as the National Standard Curriculum. In essence, it was a case of the tail wagging the dog, creating circumstances that were awkward and limiting to the practice of a local or regional system.

As a result of the discussions related to the Agenda, subsequent efforts of various EMS associations culminated in the release of the 2000 EMS Education Agenda for the Future: A System's Approach. The document outlined a process where the domain of practice was described ( National EMS Core Content) and divided among various levels of field providers ( National EMS Scope of Practice).

A set of National EMS Education Standards was then developed to provide guidance to educators who could develop curricula that was more specific to the practice of their region.

The Education Agenda also details the need for a consistent recognition process (National EMS certification) that would promote license portability across states, and a method to ensure that EMS education programs had the infrastructure to reliably and consistently train new providers (EMS Education Program Accreditation).

The Education Agenda suggested a 10-year timeline to implement the process. With the intent of bringing a level of consistency and quality to EMS education programs and their students, where does the Education Agenda stand today"

Where we are now

Since the release of the Education Agenda, the National EMS Core Content, Scope of Practice, and Education Standards have been completed and released. Many, if not most states have adopted the standards as the basis of education for EMTs and paramedics.[1]

Educational institutions have been transitioning from the old standards since 2010. In March, NHTSA requested input from the national EMS community as to whether to update the Education Standards.[2]

The general consensus was to only slightly modify the standards; most stakeholders felt that ongoing significant developments in EMS practice precluded a major update at this time.

Efforts continue to achieve national EMS program accreditation. There is no current requirement that EMS programs be accredited by a peer-driven, nongovernmental agency similar to all other allied health professions. The most evident trend has been the increasing number of accredited paramedic education programs.

The Commission on Accreditation of Allied Health Education Programs currently recognizes 389 paramedic programs across the United State; another 285 paramedic programs are currently under review for becoming accredited. It is not clear how many paramedic programs exist nationally.

There appears to be a trend toward national EMS certification, at least for EMTs and paramedics. Forty-six states currently require that EMS providers gain initial certification by the National Registry of Emergency Medical Technicians (NREMT) as a condition of state licensure. This may include EMT, paramedic, or both certifications. However, far fewer states require their providers to maintain NREMT certification.

In 2013, the NREMT required that paramedic candidates graduate from CAAHEP-accredited programs. This has accelerated the number of paramedic education programs that are accredited or under a letter of review.

There has been criticism leveled at the accreditation process, mostly by programs and states where accreditation is not mandatory. "It's mostly a case of the unknown," states Dr. Richard Hatch, Executive Director of the Committee on Accreditation of Educational Programs for the EMS Profession. "Once completing the process, nearly all programs report how positive and productive the accreditation process is in helping them better achieve positive student outcomes."

The value of a college degree

At this time, there is no effort to accredit programs that provide other levels of EMS education, such as EMT or advanced EMT. As many states require that paramedic students be certified as EMTs prior to, or during their program, the lack of consistent quality in EMT education programs may result in paramedic students who are underprepared to complete paramedic training.

The Education Agenda and its components do not address how formal higher education relates to EMS training, specifically when it comes to a college degree. While a few states such as Oregon and Texas have degree-based paramedic providers, the vast majority do not.

Most accredited paramedic programs award a significant number of college credit for successful completion; in many circumstances a paramedic student would need to only complete a few general education requirements to receive an associate's degree.

The completion of a degree is significant. Achieving college-level proficiency in English and math skills may improve EMS-related tasks such as patient care, report writing and problem analysis. Liberal studies in philosophy, language or social sciences may help expand the mind and lead to greater possibilities or alternative perspectives on an issue.

The lack of a degree requirement is not lost upon other health care providers. Physicians, most levels of nursing, and nearly all allied health providers require a degree to practice.

These vocations are considered professions; that is, their members possess qualifications gained through extensive learning, demonstrated through rigorous testing, and are self-powered to admit and discipline themselves.

Given that at the paramedic level at least, the level and intensity of education is deemed worthy of at least half to two-thirds of the credits needed to complete an associate's degree, points to a reasonable expectation of a degree requirement.

While a national EMS certification may permit EMS providers to work across state borders, a degree creates portability across the profession. Credits associated with a two-year degree are much simpler to transfer to a four year institution.

Degrees are often required to enter EMS-related fields such as biomedical technology support. Even within the industry, promotion to a supervisorial or administrative leadership position is increasingly at least partially based on the candidate's degree status.

The expense of education

Inevitably, critics point toward the perceived lack of value of a college education in EMS. Superficially, the facts would bear that out; few agencies tangibly recognize the college-degree paramedic through a higher starting salary/benefit level. Employers are also concerned that the additional education and training will result in a higher-cost employee.

Looking beyond the surface, such concerns may be of significant benefit to the industry overall. The provider's dedication to obtaining a degree, coupled with higher employment benefits, may raise the level of organizational loyalty.

The gain in employee longevity may in turn reduce the incidence of mistakes associated with inexperience. Collectively, the body of knowledge gained by the profession through its long-term members may expand far greater than what currently occurs.

Stabilizing the workforce is but one benefit. Recognition and respect among other health professions is gained through the professional recognition of degree awards.

EMS providers work hand in hand with other medical providers, each with their specialized training, education and skill set. There is enough technical, operational and clinical expertise associated with the out-of-facility provider that other health care providers can recognize as a separate and integral medical profession.

This recognition of the individual as a valued member of the health care continuum may translate more importantly at a higher-level service reimbursement.

Government health insurers such as the Centers for Medicare and Medicaid have not been kind to EMS. The fact is, most financial reimbursement is centered on transportation services, not medical care.

It's reasonable to expect this, if the profession itself does not value the investment of education for the benefit of the patient. Current demonstration projects in community paramedicine may change the reimbursement formula — if the industry is prepared to follow through with a greater depth of educational preparation.

The EMS industry faces a decision point in regards to the preparation of its providers. As the education model continues to formalize and create consistency in quality, EMS professionals will need to self-advocate both within and outside of its boundaries.

This move toward a profession will benefit its members, their patients and ultimately society as a whole. Higher education serves as the foundation needed to build upon the profession.

Reference

1.National Association of State EMS Officials. A report to the National EMS Advisory Council on Statewide Implementation of the Education Agenda. Retreived 10 July 2014.

2. Letter from NEMSAC to NHTSA EMS Division Chief regarding updates to the National EMS Education Standards. Retrieved 15 July 2014

A weekly agency-wide email sends the right message

By Jay Fitch, EMS1 Contributor

I was listening to the radio the other day when Sting's 1983 song "Every Breath you Take" came on. I'd always thought of it as a tale of a loser stalker, but this time the lyrics resonated with me in a different way.

If you remove the bit of romance introduced in the refrain, it demonstrates a basic principle of good communication — but one that's easy to forget: When you’re a leader, everyone is bit of a stalker.

“Every move you make … Every vow you break … Every smile you fake … Every claim you stake … I’ll be watching you.”

It's not easy being a leader, knowing your every move is being scrutinized for hidden meaning. You can say all the right things and still blow it, because you're being watched.

Your stance, your eye contact, your folded arms, how you're sitting in the chair, and where the conversation is taking place (your office, your employee's office, across a desk or side by side) can transmit something entirely different than what you intended.

The good news is that if your leadership comes from a place that is genuine and personal, people will give you the benefit of the doubt when you occasionally send the wrong message.

Avoid under communicating

Leaders often fail in their communication because they fall into a habit of under communicating — that is, not realizing the need to actively communicate formally and informally, more so than they ever realized.

Just because you sent out one email, doesn't mean everyone in your organization "gets it." And if you don't address an issue, the troops will make up for it by filling in the gaps, often at conflict with the message you really meant to send.

Being a good communicator is an essential part of leadership — and it doesn't mean giving good speeches. You know you're doing well when everyone on your team understands your agency's vision, values, and what is expected of them.

This is easier said than done. I know some EMS agency CEOs and fire chiefs who send out a message every week to everyone in the organization, come rain or shine. For some reason it's usually on a Friday.

The best ones are not long tomes about policy. They're short, simple reminders of mission and values, in the form of stories about the people who work there.

If you decide try this, know you're committed to whatever frequency you promise. Miss one and, well, that sends a message too.

What you can learn from Jack Stout's legendary career

“Our moral obligation to pursue clinical and service improvement is widely accepted. But our related obligation to pursue economic efficiency is poorly understood. Many believe these are separate issues. They are not. Economic efficiency is nothing more than the ability to convert dollars into service. If we could do better with the dollars we have available, but we don’t, the responsibility must be ours. In EMS, that responsibility is enormous — it is impossible to waste dollars without also wasting lives.” — Jack L. Stout

It was in a college classroom in 1990, during an EMS Management 101 class, that I first heard about the concepts of system status management, high-performance EMS, the public utility model — and the name Jack Stout.

We were learning about EMS system design as part of an undergraduate degree in EMS Administration. Our instructor Willie Krasner used Jack's theories as the cornerstone of the course, touting them as the science behind the best systems in the U.S. at the time.

Even today, 24 years later, most EMS management programs teach some form of Jack's concepts (whether they give him credit or not) and many communities still use elements of Jack's original performance-based contracts for their own — typos and all.

So why did Jack's theories resonant on such a fundamental level that they permeated our secondary education system and are at the heart and soul of today's most respected and successful EMS systems"

It comes down to a fundamental EMS leadership competency that my colleague John Becknell so well identifies in his teachings — managing scarcity.

Creating an EMS toolbox

Jack taught us how to manage scarcity, and do it very well indeed. Jack identified that given the economic variables associated with EMS reimbursement, infrastructure management and desired service outcomes, EMS was just like a public utility company, and could therefore operate much the same as one, reaping the benefits of economies of scale and quality reliability through market regulation and performance guarantees.

Jack also showed us that EMS service demand was predictable, and therefore resources could be matched to this demand in order to provide more reliable services at a lower cost.

What set Jack apart from others was that he didn't just sit back and rest on his academic laurels. He implemented his ideas and theories in the real world, in places like Oklahoma City, Tulsa, Kansas City, and Pinellas County, with measurable outcomes that have impacted millions of lives.

Identified as high-performance EMS systems, they were able to deliver quality care that was highly reliable and economically efficient, to the great benefit of the communities that adopted his concepts.

Unfortunately, much of Jack's work has been demonized over the years as nothing more than better, faster, cheaper at the expense of the people in the field. This is so far from the truth.

What Jack did was create a set of tools that converted a limited set of resources (dollars) into the highest level of service and quality possible. Just as any tool can be used for something good (like using a hammer to build a house) or something bad (like using a hammer to bludgeon someone), it's the tool's end user who makes all the difference in terms of outcomes.

Many well-respected communities and EMS agencies with the courage and stamina to change have used Jack's theories and concepts with unparalleled results. Countless lives have been positively impacted while multiple millions of taxpayer dollars were saved.

Ahead of his time

As irony would have it for the naysayers, much of what Jack dedicated his life's work to in the 1980s and 1990s is what all of health care is aggressively seeking today: finding a way to simultaneously balance economic efficiency, quality patient care and employee well-being.

Why" Because health care is starting to experience the early forms of scarcity, driven by health care reimbursement reform and consumerism, due to our nation's unsustainable and highly ineffective systems of care delivery.

Jack's ultimate achievement and gift to society was recognizing that many of the pioneering concepts used by manufacturing for process improvement — like Deming's Total Quality Management, Six-Sigma, and Lean Manufacturing — could be translated for use in a service industry like EMS to improve outcomes.

This is also what we see happening at the root of health care reform, which promises eventual sustainability and improved reliability and quality.

The triple aim of health care reform, as defined by the Institute of Healthcare Improvement, is not far removed from Jack's original vision of balancing patient care, employee well being and economic efficiency.

Jack's lifetime of accomplishments shows us that even with limited resources, we can achieve amazing results that can reliably and effectively improve service outcomes — and most importantly, enhance the lives of the patients we serve.

The do’s and don’ts of social media in emergency services

By Dr. Shana Nicholson and Joseph Heaton
InPublicSafety.com

Social media has become a staple in today’s society. It is hard to find someone who does not participate in at least one service, whether it is Facebook, Twitter, Instagram, etc. Using social media for personal reasons is socially acceptable, however, when social media and emergency services mix, an explosive concoction begins to form. A simple Google search uncovers multiple examples of emergency responders being suspended, fired, and sued for their participation—as first responders—in postings on social media.

What to Consider Before You Post

First, you have to understand how you are going to be perceived: Are you posting on your personal account or on an (un)official department page"

Posting in an Official Capacity

When posting in an official capacity, always make sure your content is respectful (and grammatically correct!). Great examples include training announcements and pictures, awards to local first responders, promotional events for local departments, general public-relation announcements, and emergency alerts. Be sure that the information posted on official accounts is respectful and reflects positively on the department.

Read full story: The Do’s and Don’ts of Social Media in Emergency Services

Prove it: Does a delay between AED shock and compressions reduce survival rates?

Case review

Rescue 18 and Engine 12 respond to an office building where bystanders are reported to be doing CPR. Engine 12 arrives first, verifies no pulse and takes over CPR. An AED applied by the firefighters recommends a shock. After the shock, the firefighters resume CPR.

Rescue 18 arrives and transfers the patient to a manual defibrillator, while medic Williams verifies the presence of ventricular fibrillation and begins charging the device. When he does, the firefighters stop CPR as one of them yells, "Clear!"

Williams asks the crew to resume chest compressions while the machine is charging; however, the firefighters seem reluctant to do so. After a short period of no compressions, Williams delivers the shock and the firefighters resume CPR.

Over the next 15 minutes, they establish an IV and administer epinephrine, amiodarone, and two additional countershocks. Each time Williams charged the defibrillator, the firefighters clear the patient’s chest.

At the 20-minute mark, the patient is asystolic. Since the arrest occurred in a public place, the local protocol does not allow the medics to terminate resuscitation efforts on scene. After the 10 minute ride to the hospital, the emergency department physician terminates the resuscitation effort.

Study review

In 2011, researchers from the Resuscitation Outcomes Consortium found the odds of survival significantly decreased when out-of-hospital rescuers stopped CPR for more than 20 seconds before delivering a shock. [1] However, the authors of that study identified a number of limitations that affected the final interpretation of the data, not the least of which was the small sample size of patients (n = 815).

In 2007, the ROC began enrolling patients for a randomized controlled trial called ROC PRIMED, which sought to examine what effects several different resuscitation strategies had on survival. [2] The authors of the current study used the more robust patient database from the ROC PRIMED study to examine the effects that peri-shock pauses in chest compressions has on outcome. [3]

From that database, the current researchers selected all adult patients who suffered an out-of-hospital cardiac arrest and presented in a shockable rhythm to the first arriving EMS crews. All patients received at least one shock from either a manual or automated defibrillator.

The research team excluded patients who either received their first shock from non-EMS personnel using a public access defibrillator or arrested in the presence of EMS crews.

Including these patients in the analysis could make the intervention appear more effective than it really is since survival in both of these patient groups is generally higher than when EMS arrives to find patients in cardiac arrest or when EMS delivers the first shock. The researchers also excluded the patients if the CPR process data was incomplete.

All of the participating EMS agencies used monitor/defibrillators equipped with impedance sensors. These devices recorded changes in electrical resistance across the chest that occurs when rescuers perform various interventions, such as chest compression or artificial ventilation.

As resistance changed, reviewers could determine the exact moment when rescuers delivered each chest compression. This allowed exact measurements of the time when no one was performing compressions before and after a shock, or the hands-off period.

The interval between the moment the rescue team stops compressions and delivers the shock is the pre-shock pause. The interval between delivery of the shock and the moment when the rescue team resumes chest compressions is the post-shock pause. Adding these intervals together gives the peri-shock pause. [4]

The primary outcome measure for this study was survival to hospital discharge. A secondary outcome measure was the neurological status of the patient. Researchers considered survival to be neurologically intact if upon discharge from the hospital the patient scored less than or equal to three on a Modified Rankin Score.

About 3,500 patients in the ROC PRIMED study presented to EMS in a shockable rhythm, or about 10 percent of all the patients in the ROC PRIMED study database. After excluding patients who did not meet the inclusion criteria or had missing data, the final patient population for this study was 2,006.

A comparison between the group with complete CPR process records and the excluded group found no significant differences with respect to gender, witnessed vs. unwitnessed arrest status, the presence of bystander CPR, or the location of the arrest. This suggests that excluding those patients likely had little effect on the outcome.

An unadjusted data analysis showed that the highest survival to hospital discharge rates occurred in patients with a pre-shock pause of 10.1 to 15.0 seconds. Survival was highest in patients with a post shock pause of 5 seconds or less.

Overall, survival was highest when the peri-shock pause was less than 20 seconds. However, unadjusted data includes the simultaneous effects of many variables, some of which could blur the true effect of the pauses.

Using a mathematical technique known as multivariate logistic regression analysis, the researchers isolated the effects that each of these variables had on the outcome.

After adjusting for the Utstein predictors of survival, chest compression fraction, compression rate and ROC site, the researchers found both the odds of survival and being neurologically intact were about 50 percent higher if rescuers keep the pre-shock interval to less than 10 seconds when compared to a pre-shock pause of greater than 20 seconds. These adjusted results represent the true effects of the intervention.

If rescuers kept the peri-shock interval under 20 seconds, both the odds of survival and the odds of being neurologically intact at survival almost doubled compared with peri-shock intervals over 40 seconds.

The researchers could not find any survival benefits associated with the post shock pause.

What this means for you

Animal studies published over a decade ago demonstrate that prolonged or frequent interruptions in chest compression caused by AED analysis or rescue breathing resulted in worsened myocardial perfusion and neurological impairment. [5, 6, 7]

Another study conducted in the out-of-hospital environment found an association between frequent interruptions in chest compression and a decreased probability of successful conversion from ventricular fibrillation to a perfusing rhythm. [8] Shortening the pre-shock pause by even a few seconds can improve the probability of a successful conversion following delivery of a shock. [9, 8]

EMS providers can have a positive influence on survival from out-of-hospital cardiac arrest by adopting any strategy that reduces the pre-shock and subsequent peri-shock pauses in chest compressions. This includes coordinating (with practice) the actions of the team so that the defibrillator operator can deliver the shock immediately after the chest compressor (and other team members) "clears" the patient’s chest.

To accomplish this, the defibrillator must be ready to deliver the shock even before the chest compressor has finished pushing on the patient’s chest. Rescuers who perform compressions while the AED is charging can reduce the pre-shock pause to less than three seconds. [10] Rescuers who charge a manual defibrillator during chest compressions can achieve similar results. [11]

Limitations

Although the current findings support earlier work, EMS agencies must recognize what the research does not say. Although the data was collected as part of a randomized controlled trial for other interventions, this analysis was observational only.

Thus, it is only possible to state there is an association between the variables. Associations do not imply causation; one cannot state the reductions in the pre- and peri-shock intervals caused the increase in survival.

The researchers also report that many of the participating ROC sites did not collect data on chest compression depth. Thus, more than half of the compression depth data in the study group was missing. It is therefore not possible to know whether there was a difference in chest compression depth between patients who received the shortest or the longest hands-off intervals.

Since chest compression depth is known to influence survival [12], it is possible the current results reflect the compression depth effects rather than the effects of the hands-off interval.

Similarly, the researchers excluded 11 percent of the eligible patients because of missing shock pause data. The analysts could not find any significant differences between those with complete data and those with missing data suggesting the exclusion likely did not influence the outcome.

However, without the data, one can never be sure.

This is the largest study to examine the relationship between peri-shock pauses and survival following out of hospital cardiac arrest presenting in a shockable rhythm. The researchers replicated the findings from their previous work, and their results further support the American Heart Association recommendation to minimize interruptions in chest compressions, especially in the peri-shock interval. [13]

References

1. Cheskes, S., Schmicker, R. H., Christenson, J., Salcido, D. D., Rea, T., Powell, J., Edelson, D. P., Sell, R., May, S., Menegazzi, J. J., Van Ottingham, L., Olsufka, M., Pennington, S., Simonini, J., Berg, R. A., Stiell, I., Idris, A., Bigham, B., & Morrison, L. (2011). Peri-shock pause: An independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation, 124(1), 58-66. doi:10.1161/CIRCULATIONAHA.110.010736

2. Stiell, I. G., Nichol, G., Leroux, B. G., Rea, T. D., Ornato, J. P., Powell, J., Christenson, J., Callaway, C. W., Kudenchuk, P. J., Aufderheide, T. P., Idris, A. H., Daya, M. R., Wang, H. E., Morrison, L. J., Davis, D., Andrusiek, D., Stephens, S., Cheskes, S., Schmicker, R, H., Fowler, R., Vaillancourt, C., Hostler, D., Zive, D., Pirrallo, R. G., Vilke, G. M., Sopko, G., & Weisfeldt, M. (2011). Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. New England Journal of Medicine, 365(9), 787-797. doi:10.1056/NEJMoa1010076

3. Cheskes, S., Schmicker, R. H., Verbeek, P. R., Salcido, D. D., Brown, S. P., Brooks, S., Menegazzi, J. J., Vaillancourt, C., Powell, J., May, S., Berg, R. A., Sell, R., Idris, A., Kampp, M., Schmidt, T., & Christenson, J. (2014). The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation, 85(3), 336-342. doi:10.1016/j.resuscitation.2013.10.014

4. Kramer-Johansen, J., Edelson, D. P., Losert, H., Kohler, K., & Abella, B. S. (2007). Uniformed reporting of measured quality of cardiopulmonary resuscitation (CPR). Resuscitation, 74(3), 406–417. doi:10.1016/j.resuscitation.2007.01.024

5. Berg, R. A., Sanders, A. B., Kern, K. B., Hilwig, R. W., Heidenreich, J. W., Porter, M. E., & Ewy, G. A. (2001). Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation, 104(20), 2465–2470. doi:10.1161/hc4501.098926

6. Kern, K. B., Hilwig, R. W., Berg, R. A., Sanders, A. B., & Ewy, G, A. (2002). Importance of continuous chest compressions during cardiopulmonary resuscitation: Improved outcome during a simulated single lay-rescuer scenario. Circulation, 105(5), 645– 649. doi:10.1161/​hc0502.102963

7. Yu, T., Weil, M. H., Tang, W., Sun, S., Klouche, K., Povoas, H., & Bisera, J. (2002). Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation, 106(3), 368–372. doi:10.1161/01.CIR.0000021429.22005.2E

8. Eftestol, T., Sunde, K., & Steen, P. A. (2002). Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation, 105(19), 2270–2273. doi:10.1161/01.CIR.0000016362.42586.FE

9. Eftestol, T., Sunde, K., Aase, S. O., Husoy, J. H., & Steen, P. A. (2000). Predicting outcome of defibrillation by spectral characterization and nonparametric classification of ventricular fibrillation in patients with out-of-hospital cardiac arrest. Circulation, 102(13), 1523–1529. doi: 10.1161/​01.CIR.102.13.1523

10. Edelson, D. P., Robertson-Dick, B. J., Yuen, T. C., Eilevstjonn, J., Walsh, D., Baries, C. J., Vanden Hoek, T. L., & Abella, B. S. (2010). Safety and efficacy of defibrillator charging during ongoing chest compressions: A multi-center study. Resuscitation, 81(11), 1521–1526. doi:10.1016/j.resuscitation.2010.07.014

11. Thim, T., Grove, E. L., & Lofgren, B. (2012). Charging the defibrillator before rhythm check reduces hands-off time during CPR: A randomised simulation study [Letter]. Resuscitation, 83(11), e210–e211. doi:10.1016/j.resuscitation.2012.07.034

12. Vadeboncoeur, T., Stolz, U., Panchal, A., Silver, A., Venuti, M., Tobin, J., Smith, G., Nunez, M., Karamooz, M., Spaite, D., & Bobrow, B. (2014). Chest compression depth and survival in out-of-hospital cardiac arrest. Resuscitation, 85(2), 182-188. doi:10.1016/j.resuscitation.2013.10.002

13. Berg, R. A., Hemphill, R., Abella, B. A., Aufderheide, T. P., Cave, D. M., Hazinski, M. F., Lerner, E. B., Rea, T. D., Sayre, M. R., & Swor, R. A. (2010). Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(suppl 3), S685-S705. doi:10.1161/CIRCULATIONAHA.110.970939

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