Prehospital Emergency Care最新文献

Objectives: Prehospital notification is crucial for reducing door-to-reperfusion time in patients with acute ischemic stroke (AIS). However, evidence remains limited regarding the real-world effectiveness of smartphone-based prenotification systems, particularly when considering variations in system activation and utilization. In Daegu, a metropolitan city in South Korea, a mobile application-based prenotification system has been implemented to streamline acute stroke care. This study aims to analyze the effect of the pre-notification system on the reduction of treatment time delay in acute ischemic stroke.

Methods: This retrospective observational before-and-after study was conducted in Daegu, South Korea. The "before" period spanned December 2018 to November 2019, and the "after" period spanned December 2020 to November 2021. Patients diagnosed with AIS (first abnormal time < 6 h) who arrived at the emergency department via emergency medical service at five hospitals were included. Patients were divided into three groups based on the use of a smartphone application (FASTroke) before and after implementing the prehospital AIS notification system. Outcomes of time variables related to ischemic stroke management included scene-to-door time, Door-to-CT scan time (DTC), Door-to-intravenous thrombolysis time (DTI), and Door-to-endovascular thrombectomy time (DTE). The effect of FASTroke implementation on achieving the target time was analyzed through multivariable logistic regression analysis.

Results: Among the 553 patients included in the final analysis, 177 were managed using the FASTroke system. Compared to the before group, the group that used FASTroke during the after period had significantly shorter DTC (23.0-20.0 min, p < 0.001), DTI (42.5-36.0 min, p = 0.044), and DTE (95.5-87.0 min, p = 0.049). Time reduction was even greater with hospital preregistration, including DTC (14.0 min), DTI (33.0 min), and DTE (66.5 min). Logistic regression revealed that FASTroke use significantly increased the odds of achieving DTC < 20 min (adjusted odds ratio 1.971; 95% confidence interval (CI), 1.319-2.945) and DTE < 90 min (aOR 2.010; 95% CI, 1.014-3.985), with even higher odds in the preregistration subgroup.

Conclusions: The FASTroke system significantly improved in-hospital treatment timelines-DTC, DTI, and DTE-particularly through its preregistration feature.

Wildland fire in the United States has evolved into a sustained public health emergency with direct and escalating implications for emergency medical services (EMS). Once viewed primarily as a forestry issue, modern wildfire is now driven by climate change, decades of fuel accumulation, expansion of the wildland-urban interface, and ecosystem degradation. Fire seasons have lengthened into year-round events, generating substantial health impacts and placing severe strain on out-of-hospital systems. The population health consequences of wildfire exposure are extensive. Acute smoke inhalation increases asthma exacerbations, chronic obstructive pulmonary disease presentations, cardiovascular events, and premature mortality. Repeated or chronic exposure contributes to long-term pulmonary dysfunction, elevated malignancy risk, and behavioral health morbidity. Children, older adults, individuals with preexisting conditions, and socioeconomically disadvantaged communities experience disproportionate harm. Simultaneously, wildfires cause surges in EMS call volume while disrupting communications, transportation, and access to definitive care. Prehospital clinicians and responders also face significant occupational hazards, including extreme heat, prolonged particulate exposure, musculoskeletal trauma, behavioral health stressors, and an elevated risk of sudden cardiac death. As EMS agencies are increasingly tasked with austere fireground support, extended evacuations, and prolonged operations, the role of EMS physicians becomes critical. However, despite the scale of these challenges, prehospital physicians are often underrepresented in regional wildfire mitigation, preparedness, and resilience planning. National recommendations now call for a strategic shift from reactive suppression to proactive, interdisciplinary collaboration. Prehosptial physicians are uniquely positioned to integrate clinical care, disaster medicine, occupational health, and community preparedness. Their leadership is essential to ensure EMS integration into community wildfire protection plans; to strengthen occupational and mental health support for responders; to guide wildfire-specific training, triage, and protocol development; and to inform public education efforts. Prehospital physicians must also advocate for policies that incorporate out-of-hospital perspectives into resilience funding and mitigation initiatives. In summary, wildland fire is a chronic societal crisis with expanding health and EMS implications. Meeting this challenge requires prehospital physicians to broaden their roles as clinicians, educators, advocates, and policy leaders to support a more fire-adapted and resilient future.

Objectives: The Interfacility transportation of critically ill patients is a common practice in modern medical care. Transportation of patients may be necessary for clinical or hospital capacity issues. Patient transfers are typically conducted by specialized teams via ground emergency medical services (GEMS) using emergency medical vehicles (i.e. ambulances) or helicopter emergency medical services (HEMS) using rotary-wing air ambulances. The primary objective of this study is to compare the efficacy of HEMS and GEMS in terms of the duration of time-critical interfacility transfers.

Methods: This is a retrospective observational study of emergency interfacility transfer of critically ill adult patients in Qatar between 2018 and 2022. Data on patient demographics, facilities' locations, and multiple mission-related time parameters were collected from the Ambulance Service database and the hospitals' centralized electronic medical records and analyzed. Patients with non-emergency conditions, incomplete transfer data, or HEMS activation delays exceeding 30 minutes were excluded.

Results: Data of 518 emergency interfacility transfers (355 GEMS and 163 HEMS) was collected and analyzed. Patients' median age was 45 years old. For transfers shorter than 50 km, HEMS was used in 50.2% (109/217) of cases, while for transfers over 50 km, GEMS was used in 82.1% (247/301) of cases (p < 0.001). The GEMS transfers had a significantly shorter call-to-departure time by 21.9 minutes, whereas HEMS had a significantly shorter departure-to-arrival time by 23.6 minutes. However, the difference in total mission time was not significant (p > 0.05). In transfers less than 50 kilometers, HEMS had a longer call-to-departure time by 18.4 minutes and a shorter departure-to-arrival time by 12.3 minutes (both p < 0.001). Similar trends were observed in both short (<50 km) and long (>50 km) transfers.

Conclusions: Ground ambulance may offer a comparably as efficient option for emergency patient transfers over short and medium distances, as no significant difference was found in the total transfer times and clinical patient outcomes were not assessed. The results obtained in Qatar's context may not be universally generalizable. Helicopter ambulance may be advantageous when the patient needs to be transferred very quickly over a longer distance.

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: 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: 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.