Prehospital Emergency Care最新文献

Objectives: Paramedics in rural and wilderness environments often face prolonged transport intervals and limited resources, increasing the value of diagnostic tools like point-of-care ultrasound (POCUS). This is a prospective, quasi-experimental study with a one-group pretest-posttest design to assess the feasibility and utility of implementing extended focused assessment with sonography in trauma (eFAST) and limited cardiac ultrasound exams in these austere settings.

Methods: Twenty-four paramedics from a National Park Service unit and a local emergency medical services (EMS) agency underwent a blended POCUS training program, including asynchronous modules and hands-on instruction. Knowledge, attitudes, and practices (KAP) were assessed via pre/post-training surveys and tests, with a delayed knowledge test administered at four months. Scan utility was evaluated via post-scan hand-off surveys.

Results: Participants demonstrated a 44% increase in knowledge scores immediately post-training (p < 0.0001), with good knowledge retention at four months post-training. Although KAP scores showed minimal change, qualitative feedback reflected strong enthusiasm for and perceived utility of prehospital POCUS. Twenty-two scans were performed during routine patient care. Four scans (18.2%) were deemed clinically meaningful by receiving physicians, influencing diagnosis and transport decisions.

Conclusions: Point of care ultrasound training for paramedics in rural and wilderness EMS settings is feasible, well-received, and results in successful use of POCUS for patient care and transport decision-making. Broader implementation and research may provide further insight to EMS clinician satisfaction, diagnostic accuracy and impact on patient outcomes in austere environments.

Objectives: The most common invasive procedure performed in the prehospital setting by emergency medical services (EMS) clinicians is intravenous (IV) cannula insertion. We aimed to characterize first attempt and overall success in a nationwide cohort, investigate factors associated with first attempt IV access success, and determine the prehospital utilization rate of successful IV access.

Methods: We conducted a retrospective analysis using the 2023 ESO Data Collaborative research dataset. We included all patients with at least one attempt at peripheral IV access following a 9-1-1 call, and defined success using EMS clinician documentation. We used logistic regression modeling with clustered standard errors at the EMS agency level to estimate the association between sex, race, EMS clinician primary impression, insertion site, attempt interval (on scene vs. during transport) and first attempt success. Among patients with successful IV access, we defined 'prehospital utilization' as any IV medication, blood products, or >250 mL of crystalloid fluid.

Results: We analyzed 3,006,069 IV access attempts. First attempt insertion success was achieved for 2,298,826 (76.5%) patients, and 2,553,731 patients (84.3%) had at least one successful IV attempt. Our cohort was a median 64 (45, 77) years of age, 51.3% female, and 66.0% White, non-Hispanic. The most common first attempt insertion site was the antecubital fossa (n = 1,866,607; 62.1%) and the most commonly utilized cannula size was 20G (1,760,684; 58.6%). First attempt success was associated with sex, race, EMS clinician primary impression, cannula size, and insertion site. Among patients who had any successful IV access established, 1,129,819 (44.6%) received an intravenous medication, blood products, or >250 mL of crystalloid fluid in the prehospital setting.

Conclusions: In this retrospective, nationwide cohort, approximately three of every four first-attempt IV access attempts were successful. First attempt success was associated with patient and encounter characteristics. Less than 50% of the patients with successful IV access received any IV therapy.

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: 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 min 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 min, whereas HEMS had a significantly shorter departure-to-arrival time by 23.6 min. 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 min and a shorter departure-to-arrival time by 12.3 min (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: Chest pain is the most common reason for 9-1-1 calls in the United States. Triage of these patients to a local hospital vs tertiary care facility can be challenging. Our objective was to determine whether a cardiovascular telehealth program that connects rural paramedics with emergency physicians could avoid interfacility transfers in patients with chest pain.

Methods: We conducted a pilot prospective cohort study of adult patients with chest pain who underwent prehospital telehealth evaluation in a single emergency medical services (EMS) system (2/2021-11/2023). A paramedic completed a structured assessment of each patient, then connected with an emergency physician to complete a telehealth call. The physician reviewed the patient's electrocardgram (ECG), discussed the case with the paramedic, and met with the patient to determine risk for emergent conditions. Transport destination was guided by the following framework: local clinic (during operating hours) for stable low-risk patients, local community hospital for stable moderate-risk patients, and tertiary care center for high-risk patients, an ischemic ECG, or instability. The primary outcome was avoided interfacility transfers. Secondary outcomes included transport destination, avoided emergency department (ED) visits, and patient satisfaction assessed with the Short Assessment of Patient Satisfaction (SAPS) score.

Results: During the study, 112 patients were accrued, of which 45.5% (51/112) were female and 9.8% (11/112) were non-white with a mean age of 60 ± 17 years. Among these patients, 67.8% (76/112) were triaged to the local hospital, 19.6% (22/112) to a tertiary care center, 2.7% (3/112) to the clinic, and 9.8% (11/112) refused transport. Telehealth triage resulted in in 9 out of 112 patients (8.0%; 95% CI 5.0-13.0%) adjudicated as likely to have avoided subsequent interfacility transfer and avoided ED visits in 2 out of 112 patients (1.8%, 95% CI 0.0-4.3%). Mean SAPS score was 23.4 (±2.8), consistent with strong overall satisfaction with telehealth calls.

Conclusions: Among rural patients with chest pain, an EMS telehealth program was associated with avoided interfacility transfers and strong patient satisfaction.

Objectives: Optimal analgesic in acute coronary syndrome (ACS) remains debated, particularly in the prehospital setting. Opioids, particularly morphine, are widely used despite concerns over adverse effects and potential drug interactions. Sub-dissociative ketamine represents a potential alternative, but evidence in ischemic chest pain is lacking. In November 2023, our physician-staffed emergency medical services (EMS) implemented a new protocol recommending ketamine as first-line analgesia for patients with ST-segment elevation myocardial infarction (STEMI) and a Numeric Rating Scale (NRS) ≥5. Our study objective was to describe analgesic practices and early outcomes after implementation.

Methods: We conducted a single-center, retrospective, chart review of patients managed by Rennes Mobile Intensive Care Unit (MICU) team with a prehospital diagnosis of STEMI, between November 10, 2023, and November 10, 2024. Case identification was performed through telecommunicator records and electronic patient care reports. Data abstraction followed a standardized tool with dual independent review. Only patients who received an analgesic were included. The primary outcome was the first-line analgesic administered. Secondary outcomes included pain scores, use of rescue therapy, multimodal analgesia, and adverse events. Analyses were descriptive.

Results: Among 279 prehospital STEMIs, 74 patients met inclusion criteria. First-line analgesics were acetaminophen (n = 23, 31%), ketamine (n = 21, 28%), and morphine (n = 30, 41%). Median initial NRS was 5 (3-5) for acetaminophen, 8 (6-8) for ketamine, and 7 (6-10) for morphine. Post-analgesia NRS were 5 (1-5), 4 (2-7) and 7 (3-8), respectively. Rescue analgesia occurred in 3 ketamine patients (14%) and 2 morphine patients (7%). Multimodal analgesia with acetaminophen was used in 38% of ketamine patients and 50% of morphine patients; nitroglycerin was administered in 5 cases. Adverse events were infrequent; no respiratory depression or hemodynamic instability were reported.

Conclusions: After introducing sub-dissociative ketamine into the STEMI protocol in our physician-staffed EMS agency, it was administered as frequently as morphine for prehospital STEMI analgesia and was associated with low rates of documented adverse effects. These initial results demonstrate the feasibility of using ketamine for the prehospital management of cardiac ischemic pain and suggest the need for a prospective multicenter randomized controlled trial.

Objectives: Emergency medical services (EMS) workforce challenges impact prehospital care in many United States communities. One potential strategy to address this challenge is clinicians actively promoting the EMS profession. However, there is limited data regarding the likelihood of EMS clinicians recommending others to join the 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 October 2023 and April 2024. Applicants completed a voluntary survey regarding EMS professional promotion measured by 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, %; 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 demographics, workplace characteristics, 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. Compared with fire agencies, all other agency types exhibited lower odds of promotion. 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]) had lower odds of promotion. Clinicians reporting burnout had significantly lower odds of promoting EMS (0.31, 0.29-0.33), while clinicians with high job satisfaction had increased odds of promoting (6.27, 5.08-7.74).

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

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: 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 1 to 2 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.