Emergency Medicine Journal最新文献

Background: It has been recommended that prehospital rapid sequence intubation (PH-RSI) be performed in locations that provide 360-degree access to the patient. We aimed to examine the success and complication rate of PH-RSI by location of intubation as well as the effect on scene time.

Methods: We conducted a single-centre, retrospective cohort study of patients with attempted PH-RSI over a 96-month period. Locations compared were intubation within the road ambulance, outside the vehicle on a stretcher, on the ground and in other locations. The primary outcome was the occurrence of major intubation complications by location. Secondary outcomes were first-pass success, time to intubation from patient contact and total scene time. Modified Poisson with robust SE variance and quantile regressions was used to adjust for confounding variables.

Results: Of 413 patients, major intubation complications occurred in 60 (14.5%, 95% CI 11.3% to 18.3%) patients. Patients intubated on the ground were twice as likely to have complications than patients intubated on a stretcher outside the vehicle (p=0.023) in the unadjusted analysis. First-pass success intubations occurred in 400 (96.9%, 95% CI 94.7% to 98.3%). Adjusted time from contact to intubation was not different (p=0.864) but total scene time was significantly shorter for patients intubated inside an ambulance compared with outside on a stretcher (median difference -4.0 min, 95% CI -6.5 to 1.5; p=0.002).

Conclusions: Intubating selected patients within an ambulance had similar complication rates to intubation on a stretcher outside the vehicle but was associated with a small reduction in on-scene time.

Background: Rising demand and limited capacity in primary care are often cited as reasons for the increasing pressure on emergency departments (EDs). The COVID-19 pandemic further strained but also reshaped healthcare services and their accessibility. However, an equally critical yet often overlooked factor is the increasing complexity of cases. This study assessed ED attendance trends for the Northwest London (NWL) population between February 2017 and September 2023, before, during and after the pandemic lockdown measures (March 2020-March 2021) in the UK as a whole and across sociodemographic and multimorbidity profiles.

Method: We used the Whole System Integrated Care data warehouse in NWL. We conducted a segmented time-series quasi-Poisson regression for weekly ED attendance for two periods, before and after the pandemic lockdown measures, adjusting for seasonality and autocorrelation. We stratified the model by age, sex and quintiles of the 2019 Index of Multiple Deprivation. We analysed ED attendance trends by multimorbidity groups.

Results: There were 3 365 279 ED attendances from February 2017 to September 2023. Before the pandemic, there was a statistically significant annual growth rate of 3.4% (rate ratio (RR) 1.034; CI 1.026 to 1.042), with a rising trend in attendance observed in all patient groups. After the pandemic, the overall trend stabilised (RR 1.002; CI 0.993 to 1.009). However, attendances have continued to rise for older age groups (61-75 years and 76+ years) and have increased for patients with multimorbidity and complex multimorbidity. Meanwhile, attendance has declined for the least deprived. For the other patient groups, attendance has plateaued.

Conclusion: Following the pandemic, total ED attendances stabilised, but have continued to rise for older people, particularly those requiring complex care. This has implications for hospital capacity and places an increased strain on urgent and emergency care. We used high-quality representative population-level linked patient records data. The study was observational with limited causality. Further research should explore specific reasons behind these changes.

Background: The establishment of an emergency medical services (EMS) pathway into a virtual emergency service-the Victorian Virtual Emergency Department (VVED)-introduced a video-enabled telehealth consultation service for patients assessed and treated by paramedics. This study examined the utilisation of the VVED by EMS in Victoria, Australia, including its impact on rates of non-transport to hospital and EMS reattendance.

Methods: A retrospective study of all presentations (aged ≥12 years) to EMS between October 2021 and May 2023. EMS data were linked to VVED records. Surveys were distributed following VVED consultation to explore patient experience. Interrupted time-series analyses were used to evaluate the impact of VVED on non-transport rates and EMS reattendance within 24 hours. Multivariable logistic regression analyses were used to determine predictors of non-transport and EMS reattendance.

Results: There were 914 747 EMS presentations within the study period, of which 30 433 (3.3%) were referred to VVED. Compared with those not referred, those referred to VVED were older with fewer vital sign derangements. Of VVED referrals, the median case time was 23 min shorter compared with cases not referred to VVED, and 74% were not transported. Compared with baseline, the VVED phase-in period was associated with a non-significant change in level (incident rate ratios (IRR): 1.03, 95% CI 0.99 to 1.06) and significant change in trend per 30 days (IRR: 1.01, 95% CI 1.01 to 1.02) for non-transports. Full implementation of VVED was associated with a step-reduction (IRR: 0.96, 95% CI 0.92 to 0.99) and downward trend per 30 days (IRR: 0.99, 95% CI 0.98 to 0.99). In both the VVED phase-in and full implementation periods, no associations were found for reattendance to EMS. After adjustment for clinical presentation and acuity, VVED referral was associated with a 16-fold (adjusted OR: 15.97 95% CI 15.53 to 16.43) increase in the odds of non-transport. Among the 8.9% of patients who responded to the survey, satisfaction of the VVED was high (91.1%).

Conclusion: The EMS-VVED referral pathway contributed to significant improvements in ambulance non-transports and case-time savings.

Background: Corticosteroids are recommended for the treatment of septic shock but are understudied in Africa. We aimed to determine (1) characteristics of patients with sepsis in Uganda who received corticosteroids, and (2) the association between receiving corticosteroids and outcomes.

Methods: We conducted a single centre retrospective observational cohort study of patients with sepsis at the Mbarara Regional Referral Hospital in Uganda. We included patients admitted from the emergency ward with suspected infection and ≥2 quick sequential organ failure assessment criteria. We determined predictors of receiving corticosteroids with logistic regression and predictors of 28-day mortality using Cox proportional hazards regression. We adjusted models for severity of illness using the Universal Vital Assessment (UVA) mortality risk score.

Results: Of the 300 patients analysed, 141 (47%) were female, and the median (IQR) age was 55 (43-66) years. Corticosteroids were received by 71 (23%) patients at a median (IQR) of 1 (0-2) day from admission. The UVA score (adjusted OR (aOR) 1.16, 95% CI 1.03 to 1.30) and meningitis (aOR 4.31, 95% CI 2.04 to 9.12) were predictors of receiving corticosteroids. The UVA score (adjusted HR (aHR) 1.14, 95% CI 1.02 to 1.26) and receiving corticosteroids (aHR 0.43, 95% CI 0.21 to 0.91) were predictors of increased and decreased 28-day mortality, respectively. Receiving corticosteroids remained an independent predictor of decreased 28-day mortality when entered into the model as a time dependent variable (aHR 0.33, 95% CI 0.13 to 0.83, p=0.02). In a sensitivity analysis adjusted for age, sex and severity of illness, receiving vasopressors (aHR 3.48, 95% CI 1.88 to 6.43, p<0.001) and receiving corticosteroids (aHR 0.40, 95% CI 0.19 to 0.85, p=0.02) were independent predictors of increased and decreased 28-day mortality, respectively.

Conclusions: In patients with sepsis in Uganda, receiving corticosteroids was associated with severity of illness and meningitis, and receiving corticosteroids was associated with improved outcomes.