Prehospital Emergency Care最新文献

Objectives: Emergency medical services (EMS) clinicians' management of agitated patients have recently been highlighted by several high-profile events and the update of a National Association of EMS Physicians (NAEMSP) Position Statement. Our objective was to assess changes in EMS statewide treatment protocols (STP) for agitation over a 7-year period considering these events.

Methods: We performed a cross-sectional review of STPs in the U.S. in 2018 and 2025. We examined protocols related to agitation and extracted data regarding 11 recommendations from the NAEMSP Position Statement, including 1) specific protocols, 2) a standardized agitation score, 3) assessment for medical causes of agitation, 4) do not restrain a patient solely by law enforcement request, 5) verbal de-escalation, 6) physical restraint protocol, 7) pharmacologic management protocol, 8) prohibited restraint techniques, 9) patient monitoring, 10) prioritization of EMS clinician safety, and 11) when law enforcement should be involved. We calculated the proportion of states with each protocol recommendations. An EMS Physician adjudicated any discrepancies in data collection.

Results: There were 29 STPs in 2018 and 31 STPs in 2025. Between 2018 and 2025, a larger proportion of STPs with 10 of the 11 recommendations: standardized agitation score (10% vs 29%), assessment for medical causes of agitation (90% vs 97%), do not restrain a patient solely by law enforcement request (0% vs 16%), verbal de-escalation (66% vs 100%), physical restraint protocol (97% vs 100%), pharmacologic management protocol (97% vs 100%), prohibited restraint techniques (72% vs 80%), patient monitoring (55% vs 71%), prioritization of clinician safety (93% vs 97%), and when law enforcement should be involved (76% vs 81%). The proportion of STPs with specific protocols for agitated patients remained similar between 2018 and 2025 (97% vs 97%). Three states included all 11 assessed recommendations from the revised NAEMSP Position Statement.

Conclusions: Changes from 2018 to 2025 in STPs reflect limited implementation of recently updated national guidelines, including increased recommendations for verbal de-escalation, limited recommendations for objective agitation assessment and patient monitoring, and increased recommendations for use of ketamine. Based on our findings, STPs have an opportunity to align with national recommendations on agitation management.

Objectives: Emergency medical services (EMS) workforce challenges impact prehospital care provision in many United States communities. One potential strategy to address this challenge is for clinicians to actively promote the EMS profession. However, there is limited data regarding the likelihood of EMS clinicians recommending others to join the EMS profession. We aimed to describe professional promotion among EMS clinicians and factors that impact their likelihood of recommending.

Methods: We performed a cross-sectional analysis of nationally certified civilian EMS clinicians (ages 18-85) recertifying between 10/2023 and 04/2024. Applicants completed a voluntary survey regarding EMS professional promotion measured using the Net Promoter Score®. This validated tool measures the likelihood of recommending a field to others (classified as promoters, passives, or detractors). Surveys were merged with demographic and workplace characteristics from the National EMS Certification database. We calculated descriptive statistics (n, %) and (median, interquartile range [IQR]) and performed multivariable logistic regression (odds ratio, 95% confidence interval) to identify factors associated with likelihood of promoting EMS by clinicians, including age, sex, race, certification, education, years experience, agency and service type, and self-reported burnout and job satisfaction as covariates.

Results: We included 33,335 clinicians for analysis (response rate = 28.8%); respondents reflected the nationally certified EMS population (male [74.2%], non-Hispanic White [86.1%], median age 36 [IQR: 29, 49], patient care [90.8%]). Promotion score distribution balanced between promoters (33.8%), passives (33.1%), and detractors (33.1%), yielding a NPS = 0.7 (possible range: -100 to +100), indicating near-zero net promotion. Odds of promoting EMS across agency types were lower than fire agencies (p < 0.05). Odds of promotion were also lower for higher education levels (associate [0.90,0.82-0.98], bachelor's [0.80,0.73-0.87]; [referent: ≤high school/General Educational Development]) and more years experience (3-7 [0.86,0.81-0.93], 8-15 [0.76,0.70-0.82], >15 [0.83,0.75-0.91]; [referent: 0-3]). Clinicians reporting burnout had significantly lower odds of promoting EMS (0.31,0.29-0.33), while clinicians with high levels of job satisfaction had increased odds of promoting EMS (6.27,5.08-7.74).

Conclusions: Demographic and workplace characteristics are significantly associated with the likelihood of EMS clinicians promoting the profession. The observed associations with satisfaction and burnout suggest areas that may warrant further investigation regarding their relationship to professional promotion and broader workforce dynamics.

Objectives: The utilization of physician response vehicles (PRVs) in emergency medical services (EMS) in the United States (U.S.) is not well described, and previous studies have shown that EMS fellows value a PRV in their program. This study describes the function, staffing, and logistical support for PRVs affiliated with EMS fellowship programs across the U.S.

Methods: We distributed an institutional review board exempt, anonymous, 33-question REDCap online survey to all Accreditation Council on Graduate Medical Education-accredited EMS fellowship programs. The survey collected data on current and planned PRVs in EMS fellowships, including how vehicles are acquired, equipped, used, and barriers to implementation. Deidentified responses were analyzed, and descriptive statistics performed. When appropriate, Chi-square and Fischer's exact tests were used to assess statistical significance.

Results: Ninety-two percent of existing programs responded, with 69% having PRVs and 14% in the process of obtaining them. Finances are a significant obstacle for existing (63%) and planned (70%) programs, which also (70%) worry about institutional support. Programs vary in who purchases, supplies, and maintains the PRVs. Fellows self-dispatch in 45% of programs, while in 13% they are routinely or automatically dispatched to specific calls, or when requested (18%). Fourteen provide 24/7 coverage, with a third offering twelve or fewer hours of coverage per week. Thirty-nine percent have fewer than 100 responses per vehicle, and 10% respond to over five hundred calls annually. The types of advanced procedures [most commonly thoracostomy (86%), ultrasound (86%), field amputation (76%)] performed correlate with the number of fellowship positions, equipment carried, and hours a PRV is in service. Orientation for fellows often (46%) lasts one to two months and varies in requirements. A quarter of the programs allow fellows to take the PRV home at any time. However, there is no correlation between response volume and whether fellows take the PRV home.

Conclusions: Most EMS fellowships have, or will soon have, PRVs, with notable differences in service hours, equipment and medications carried, procedures performed, and response volume. The use of PRVs in EMS fellowships will likely shape how PRVs are integrated into the EMS systems.

Objectives: Recently, the rising frequency and severity of mass casualty incidents further complicate the inherently challenging process of mass casualty triage, revealing the need for remote triage. Accordingly, drone-based triage systems are emerging as an innovative solution, supported by advances in image processing technology and remote photoplethysmography for hemodynamic monitoring. Despite these advances, there is limited scientific research regarding algorithms specifically designed for drone-assisted triage. The aim of this study is to develop the Drone Integrated Mass Casualty Triage Algorithm (DIMaCTA).

Methods: The study was conducted in two stages. In the first stage, a draft algorithm was developed using a comprehensive literature review and disaster field experiences. In the second stage, a two-round modified Delphi study was conducted with the participation of emergency medicine specialists to ensure the validity of the algorithm decision points and evaluation criteria. Content validity ratio (CVR) and content validity index (CVI) were calculated to determine the level of expert consensus and content validity. In addition, participants' opinions on the drone-assisted triage application were collected through a researcher-made questionnaire.

Results: The majority of participants (86.7%) found the drone-based application of the algorithm effective for continuous triage and time-saving in hard-to-reach incidents. In the first Delphi round, more than 80% consensus was reached on the parameters and decision points of the algorithm. Suggestions for pulse and body temperature thresholds were also made in this round. In the second round, the experts agreed on a pulse threshold of 30/min to discriminate between the 'emergency' and 'dead' categories, and a temperature threshold of 28 °C for the same classification. In addition, a pulse threshold of 100/minute was agreed to distinguish between 'immediate' and 'delayed' cases. Content validity ratio and CVI values were found to be in the range of 0.73-1.00 and 0.87-1.00, respectively.

Conclusions: The DIMaCTA is a drone-assisted triage algorithm based on image processing technology and can also be used as a primary triage tool in the field. Its drone-based application is expected to accelerate the prioritization of the most critical cases. Further research is needed to validate the algorithm and assess its potential impact on mass casualty management.

Objectives: Severe traumatic brain injury (TBI) is a leading cause of mortality among the pediatric population, and the impact of emergency medical services (EMS) prehospital times on patient survival remains unclear. The objective of this study was to determine associations between EMS time-on-scene and mortality during transport (i.e., dead-on-arrival [DOA] status) among pediatric patients with severe TBI. We also sought to investigate potential effects of social determinants of health on prehospital care practices.

Methods: This was a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program (2017-2022). Pediatric (<18 years old) patients with severe (Glasgow Coma Scale ≤8) TBI were included in our analyses. We constructed a hierarchical logistic regression model for associations with DOA status. Expecting a potential non-linear relationship between EMS time on scene and odds of presenting DOA, we trained a random forest model to predict survival probability as a function of time on scene and visualized the results with a locally estimated scatterplot smoothing (LOESS) plot. Secondary analyses were performed to investigate demographic associations with EMS time on scene and dispatch of a helicopter ambulance.

Results: Among 1,225 pediatric patients with severe TBI (median age, 13 years), 5.6% (N = 69) presented with DOA status. Longer EMS time on scene was associated with decreased odds of DOA (odds ratio [OR], 0.92; 95% CI, 0.85-0.99; p = 0.025). The LOESS plot revealed a non-linear relationship between EMS time on scene and survival probability, with EMS times associated with increasing survival up to approximately 12 min, then plateauing and subsequently decreasing. Black and Hispanic patients experienced shorter EMS scene times (p = 0.008 and p = 0.018, respectively), and all non-White patients had lower odds of air medical service dispatch (all p < 0.001).

Conclusions: Longer EMS time on scene, to a certain point, was associated with lower odds of presenting DOA among pediatric patients with severe TBI, potentially due to increased stabilization measures performed on scene. These results challenge the assumption that expedited transport to a trauma center alone optimizes patient outcomes. Moreover, racial disparities in EMS scene times and ambulance dispatch type highlight a need for further research into prehospital care practices.

Objectives: Emergency medical services (EMS) clinicians rarely perform pediatric critical procedures, necessitating continued education for skill maintenance, which presents unique challenges. This study transitioned a previously reported, traditional, simulation-based training (SBT) curriculum delivered by on-site pediatric simulation experts (On-Site Phase 1), into a program delivered by agency Pediatric Emergency Care Coordinators (PECCs) supported by remote pediatric experts (Remote Phase 2). Primary outcome was non-inferiority of Remote Phase 2 compared to On-Site Phase 1 as analyzed using bag-valve-mask (BVM) ventilation, supraglottic device (SGD) placement, and intraosseous (IO) catheterization assessment tool scores.

Methods: This was a non-randomized, prospective study of simulated procedural outcomes by emergency medical technicians and paramedics recruited from the same three EMS agencies that participated in On-Site Phase 1, along with their PECCs. Without additional on-site simulation staff, PECCs incorporated the program into their regular training schedule over the one-year study period and submitted participants' first-person-view videos for remote expert assessment across two sessions. Assessment data were analyzed longitudinally across both phases for non-inferiority testing, and between agencies. Qualitative comments from participants and PECCs were solicited via e-mail.

Results: Remote Phase 2 was found to be non-inferior to On-Site Phase 1 for each procedure (p = 1.0). Procedural performance during Remote Phase 2 Session 1 was similar to the end of On-Site Phase 1 (BVM p = 0.62; SGD p = 0.87; IO p = 0.60); by Remote Phase 2 Session 2, BVM (p = 0.01) and SGD (p = 0.01) performance improved, but IO (p = 0.19) performance remained the same. Performance across sites was similar at all time points, except for higher BVM scores at the rural site during Session 2 (p = 0.00). Qualitatively, PECCs reported scheduling difficulties due to competing educational and administrative tasks.

Conclusions: In this prospective study of EMS clinicians, we found non-inferiority between a traditional on-site approach and a remotely-supported approach in simulation-based pediatric procedural training. Skill overall was high and BVM and SGD performance improved. This demonstrates a viable method for PECCs to deliver recurring evidence-based education while receiving curricular and assessment support from remote pediatric experts. While still effort-intensive, this methodology may help to address several barriers of time, cost, and accessibility for pediatric prehospital education.

Objectives: Pediatric patients represent a high-risk, low frequency population in emergency medical services (EMS) systems. Quality improvement (QI) is the backbone of high-quality care delivered in EMS and engagement in pediatric-specific QI work is a core domain of the National Prehospital Pediatric Readiness Project (PPRP). There is no widely accepted set of quality measures that focus on the full scope of pediatric prehospital care. Our objective was to establish core PPRP Quality Measures for a National EMS Information System (NEMSIS)-derived pediatric prehospital dashboard to support pediatric QI initiatives.

Methods: We convened a 16-member technical expert panel (TEP) from national professional societies and federal entities. The TEP included physicians, nurses, EMS clinicians, federal partners, state EMS officials, and NEMSIS staff. Candidate measures were identified through a review of national resources and a survey of TEP members. The TEP employed a modified Delphi process to establish consensus priorities and scored measures based on the National Quality Forum Measure Evaluation Criteria. Candidate measures were prioritized based on scientific acceptability, importance to patient outcomes, utility in driving improvements, and feasibility of collection. Candidate measures were scored on a scale of 1 (lowest priority) to 5 (highest priority). Consensus was defined as 75% of the TEP rating a measure ≥ 4.

Results: The TEP identified 65 candidate measures. After three rounds of voting, consensus was achieved on 24 measures addressing a range of common pediatric prehospital conditions, including airway management (5 measures), trauma (4), pain control (3), respiratory emergencies (3), cardiac arrest (2), anaphylaxis (1), shock (1), seizures (1), hypoglycemia (1), newborn emergencies (1), non-transport (1), and safe transport (1). Thirteen (54%) of these measures apply to basic life support (BLS) teams. Common reasons for excluding measures included: limited scientific evidence, measure complexity, and redundancy.

Conclusions: A TEP identified 24 quality measures in pediatric EMS that emphasize foundational practice and relevance across a range of volumes and service models. Future validation of these measures with NEMSIS data are needed to establish benchmarks of care across variably resourced EMS agencies and develop effective strategies to support adherence to high-quality pediatric prehospital emergency care.

Objectives: We sought to decrease pediatric prehospital dosing errors by implementing a bundled drug dosing safety system (DDSS). Multiple studies have demonstrated that pediatric prehospital drug-dosing errors occur at rates of > 30% for all drugs.

Methods: We used a quality improvement (QI) design and instituted a DDSS in emergency medical services (EMS) agencies that included bi-monthly online pediatric drug dosing training, a pediatric drug dosing checklist, a length-based tape with no drug references, patient weight relayed to the crew from dispatch and a drug dosing reference in the ambulance cab. Comparison agencies continued their usual processes. Four simulation cases: infant cardiac arrest, infant seizure with hypoglycemia, child anaphylaxis and child burn were carried out before and 27 months after DDSS implementation in both groups. Descriptive statistics with p values and relative risks were calculated.

Results: There was no significant difference in the drug dosing error rate for the QI intervention group (65.6% correct) vs the comparison group (67.2% correct) p = 0.84 relative risk = 0.98. In the anaphylaxis case, there were significantly fewer errors of omission in the QI intervention group, (73.7% vs 21.4% correct, p = 0.005). There were three large overdoses of D10 in the seizure case (830%, 557% and 540%), which may have been fatal to a real patient. All occurred by attaching the D10 intravenous (IV) line to the patient's IV instead of drawing the needed volume into a syringe. Crews in the QI intervention group that used the pediatric drug dosing checklist had significantly fewer dosing errors (80.8% correct) vs those that did not (53.3% correct) p = 0.015.

Conclusions: A multi-component DDSS did not improve drug dosing error rates. It did demonstrate a decrease in errors of omission for anaphylaxis. The QI intervention crews who used the DDSS checklist had significantly lower drug dosing error rates. Further study of checklists and additional strategies are needed for error reduction. This study identified a serious, potentially fatal, latent safety threat-the administration of D10 to pediatric patients. System-based interventions such as replacing D10 with D10 normal saline are needed.

Objectives: Patients living in residential aged care homes (RACH) frequently experience acute health episodes prompting contact with emergency medical services (EMS). To improve health care access and reduce unnecessary emergency department (ED) presentations, a referral pathway to the Victorian Virtual ED (VVED) was introduced to EMS secondary triage (comprehensive telephone-based assessment of lower acuity cases). This study evaluates the impact of the pathway on referral outcomes, ED diversion, and patient safety indicators.

Methods: A retrospective cohort study of patients living in RACH who underwent EMS secondary triage in Victoria, Australia was conducted. Data were compared between an 18-month pre-implementation period and an 18-month post-implementation period following the introduction of the referral pathway. Descriptive analyses, interrupted time-series and multivariable logistic regression were used to assess changes in referral outcomes, ED diversion, and recontact within 72 h.

Results: A total of 59,546 secondary triage cases from RACH were included. Referrals to alternate care pathways increased from 6.8% pre-implementation to 11.2% post-implementation, largely driven by referrals to the VVED (6.7%), while ED diversion also increased (18.7% to 28.9%). Interrupted time-series analysis showed introduction of the VVED pathway was associated with an increase in referrals to alternate care pathways (IRR: 1.349 (95%CI: 1.182, 1.539)). In the post-implementation period, referral to the VVED was associated with increased age (AOR 1.12 (95%CI: 1.04,1.20), per 10 year increase), metropolitan event location (AOR 1.18 (95%CI: 1.04,1.34), compared with regional location), out-of-hours calls (AOR 1.55 (95%CI: 1.39,1.72), compared with calls between 0800 and 1700), complaints of external injury (AOR 1.50 (95%CI: 1.13, 1.98) compared with generally unwell), and lower acuity care timeframes (AOR 19.13 (95%CI: 15.01, 24.39) compared with recommendation for immediate care). Seventy-two-hour recontact to EMS increased, from 3.1% to 3.5% (p = 0.002) while lights and sirens transports to ED remained stable (2.5%).

Conclusions: The introduction of the VVED referral pathway to secondary triage was associated with increased use of alternate care pathways and a significant increase in ED diversion for RACH residents. Specific patient and call time characteristics were associated with VVED referral, suggesting the VVED has a targeted role in meeting access needs out of hours and for select clinical presentations.

We present the case of an 18-year-old male who was found unresponsive at home with profound cyanosis and shock. On-site suspicion of methemoglobinemia -suggested by chocolate-colored blood1 and refractory hypoxemia despite 100% oxygen - prompted early administration of methylene blue by emergency medical services. A second dose of methylene blue was given after patient's admission at the emergency department, resulting in a marked reduction in methemoglobin levels and rapid clinical improvement. This case highlights the importance of early recognition of toxicologic emergencies and timely administration of antidotes, including in the prehospital setting. It also underscores the need for ongoing education and training of health care professionals - especially first responders - on the identification and management of acute intoxications.