Prehospital Emergency Care最新文献

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.

Objectives: Patients receiving extracorporeal membranous oxygenation (ECMO) support often have fragile conditions that make them susceptible to physiological deterioration during interhospital transport (IHT). This study aimed to assess the safety of IHT for ECMO-supported patients, utilizing a dedicated critical care transport team.

Methods: A retrospective analysis was conducted on patients who underwent IHT while receiving ECMO support in a metropolitan city between January 2016 and April 2024. The primary outcome was the occurrence of abnormal physiologic parameters during IHT, including hypotension (mean arterial pressure <65 mmHg), desaturation (pulse oximetry <90%), tachycardia (heart rate >120/min), and bradycardia (heart rate <50/min).

Results: A total of 151 patients were included in the study, with 96 (59.6%) on Veno-arterial (VA)-ECMO and 55 (40.4%) on veno-venous (VV)-ECMO. Of these, 37.1% had experienced cardiac arrest prior to ECMO initiation. The median transport time from departure at the referring hospital to arrival at the receiving hospital was 25 minutes (interquartile range, 19-37 minutes). Several adverse events occurred during transport, including ECMO console shutdown in 8.9% of cases (n = 10 spontaneous shutdowns, n = 3 due to human error), all of which were appropriately managed by the trained transport team. Physiological parameters remained stable between the start and end of IHT, with a significant reduction in the prevalence of tachycardia (p < 0.01).

Conclusions: Interhospital transport for ECMO-supported patients by a dedicated critical care transport team is safe. These findings support the implementation of specialized transport systems to facilitate the safe transfer of critically ill patients receiving ECMO support.

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: This study aims to characterize the national prehospital trends in primary supraglottic airway use in non-cardiac arrest patients with various methods, including rapid sequence airway (RSA), defined as administration of a sedative and paralytic to facilitate supraglottic airway (SGA) placement. We compared this SGA-first practice to other methods of prehospital airway management.

Methods: This was a retrospective analysis of a national emergency medical services (EMS) database containing 9-1-1 calls over a five-year period. Only ALS-level calls were included. We compared the incidence of SGA- and tracheal-intubation-first attempts by paramedics. We excluded interfacility transfers, patients in or near cardiac arrest, and surgical airways before intubation.

Results: There were 355,511 encounters with endotracheal tube (ETT) or SGA placement, of which 316,392 patients were excluded, most commonly for cardiac arrest and peri-cardiac arrest, leaving 36,058 (92%) managed with tracheal intubation first and 3,061 (8%) managed with a SGA first. Trauma was the primary reason for encounter for approximately 28% of both groups. SGA-first approaches increased over the five-year period from 3.5% to 8.7% of invasive airway attempts. The type of SGA changed substantially over the study period, with use of the iGel increasing (42% to 82%), and the King LTSD decreasing (50% to 14%). Neuromuscular blocking agents were used in 74% of encounters.

Conclusions: Among prehospital patients not in cardiac arrest, supraglottic airway devices comprise 8% of initial advanced airway management, with increasing use over time. Placement is usually facilitated by use of a sedative and neuromuscular blocking agent.

Objectives: On November 28, 2017, the fire at the Guadeloupe University Hospital created an exceptional health care crisis, due to the loss of critical care units, operating rooms, and emergency department at the island's main hospital. Large-scale air medical evacuations were organized to the University Hospital of Martinique, another nearby French island. This unprecedented event posed unique challenges in terms of feasibility and risks inherent to these emergency medical evacuations of critically ill patients.

Methods: It was a retrospective, observational, monocentric study, including all patients with initial medical care provided in Guadeloupe archipelago, Saint-Martin and Saint-Barthelemy islands and which required medical evacuation to the Martinique University Hospital during the following 6 wk after fire at the Guadeloupe University Hospital.

Results: During the study period, 93 patients were included which corresponds to 2.2 patients transferred per day, with a highest transfers occurred during the first week (n = 30). Median age was 52 [22-64] years-old, and 54 were male (58.1%). All transfers were conducted by air 58 patients were admitted in ICU (62.3%) and diseases were mainly cardiovascular (n = 18, 19.4%), neurosurgery (n = 16, 17.2%) and pediatric (n = 15, 16.1%). Nine patients (9.7%) experienced complications or clinical deterioration during air transfer. Median length of hospital stay was 11 [7-17] days. Seven patients died during hospitalization (7.5%) and 81 patients (87.1%) returned in home territories after care in Martinique.

Conclusions: This event demonstrates the feasibility of conducting multiple air medical evacuations during a health crisis in a French overseas territory, with the appropriate medical and logistical resources for the safety and quality of care for evacuated patients.

Objectives: To explore the long-term effect of intelligent first-aid training based on virtual reality (VR) technology on cardiopulmonary resuscitation (CPR) skill proficiency.

Methods: The convenience sampling method was used to select a total of 100 non-medical volunteers from Nanchang, China, and this cohort was randomized to either the VR training group (VR group) or the traditional simulation scenario training group (traditional group). Relevant data were collected for comparative analysis. Participants were evaluated by measuring mean chest compression depth, chest compression pauses time, the proportion of compressions with correct compression depth, mean chest compression rate, and mean ventilation volume.

Results: After initial training, the two groups of participants showed similar results in terms of chest compression depth and chest compression rate. There were significant differences in chest compression pauses time, proportion of compressions with correct compression depth, and ventilation volume (p < 0.001). Long-term follow-up (12 months) after training showed that both groups of participants showed differences in the above indicators (p < 0.001). After training, the VR group had higher pass proportions for mean chest compression rate (p = 0.047) and mean ventilation volume (p = 0.043) than the traditional group. After training, the VR group had higher pass proportion for mean chest compression depth (p < 0.001), mean chest compression rate (p < 0.001), and mean ventilation volume (p < 0.001) than the traditional group.

Conclusions: Training with VR can significantly improve CPR knowledge and skill levels and help learners master and maintain high-quality CPR skills.

Objectives: To examine the impact of migration across the United States southern land border on the mental health of emergency medical services (EMS) clinicians in the border region.

Methods: We conducted 67 in-depth interviews with fire-based EMS clinicians in three communities. Interviews took place from June 23 to 27, 2024. We conducted thematic analysis using inductive, latent coding in NVivo 14© software.

Results: Primary themes identified were that EMS clinicians were emotionally impacted by helping migrants, that calls to provide care to migrants often led EMS clinicians to feel overwhelmed, and that EMS clinicians have developed support systems and coping mechanisms for the mental health impacts of their job.

Conclusions: Given the complex environment of the border region and the uniqueness of migrant-related emergency calls, EMS clinicians in the border region need greater mental health support.