Prehospital Emergency Care最新文献

Objectives: Sepsis is a time-sensitive condition, and many rural emergency department (ED) sepsis patients are transferred to tertiary hospitals. The objective of this study was to determine whether longer transport times during interhospital transfer are associated with higher sepsis mortality or increased hospital length-of-stay (LOS).

Methods:  A cohort of rural adult (age ≥ 18 y) sepsis patients transferred between hospitals were identified in the TELEmedicine as a Virtual Intervention for Sepsis Care in Emergency Departments (TELEVISED) parent study. We collected data on the time spent between triage and disposition at the rural ED (ED LOS), time from rural ED disposition to arrival at the destination hospital (transport duration), and overall time from rural ED triage to arrival at the destination hospital (total transfer time). We used a zero inflated negative binomial model with log link for the primary outcome (28-day hospital-free days), and a logit model for secondary outcomes of Surviving Sepsis Campaign (SSC) bundle adherence and in-hospital mortality. We included clinical and demographic covariates in model development.

Results:  We included 359 transferred rural sepsis patients. There was no association between ED LOS (aRR: 1.00; 95% CI: 0.98-1.02), transport duration (aRR: 1.03; 95% CI: 0.99-1.07), or total transfer time (aRR: 1.01; 95% CI: 0.99-1.03) and 28-day hospital free days. Similarly, we found no association between ED LOS, transport duration, and total transfer time with secondary outcomes.

Conclusions:  Longer total transfer time showed no association with 28-day hospital free days in rural sepsis patients. Future work will seek to better understand how rural ED sepsis care can be optimized to maximize outcomes in transferred patients.

Objectives: In out-of-hospital cardiac arrest (OHCA), prehospital time is crucial and can be divided into response time, from emergency call to emergency medical service (EMS) contact, and time from EMS contact to hospital arrival. To improve prehospital strategies for pediatric OHCA, it is essential to understand the association between these time intervals and patient outcomes; however, detailed investigations are lacking. The current study aimed to examine the association between response time and time from EMS contact to hospital arrival as well as survival and neurological outcomes in pediatric OHCA.

Methods: This nationwide retrospective analysis used data from an OHCA registry in Japan between June 2014 and December 2021. Pediatric patients aged <18 years who had OHCA were included in the analysis. The primary outcome was 1-month survival, and the secondary outcome was 1-month favorable neurological outcome. Generalized additive model analyses and logistic regression analyses, adjusted for confounders, were performed to examine the non-linear and linear relationship between response time and patient care time (time from EMS contact with the patient to hospital arrival) and outcomes, respectively.

Results: In the generalized additive model analyses of response time, both survival and neurological outcomes worsened with response time, with outcomes appearing to further decline with a response time of approximately 15 minutes. On the other hand, there was a linear association between patient care time as well as 1-month survival and favorable neurologic outcomes. In logistic regression analyses, shorter response times were significantly associated with survival (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.79-0.91]) and a favorable neurological outcome (OR: 0.75, 95% CI: 0.59-0.93). In contrast, time from EMS contact to hospital arrival was not significantly associated with survival (OR: 0.99, 95% CI: 0.97-1.02) and favorable neurological outcomes (OR: 1.02, 95% CI: 0.97-1.07).

Conclusions: A response time of <15 minutes can be associated with better survival and neurological outcomes. However, there is no significant association between time from EMS contact to hospital arrival as well as survival and favorable neurological outcomes.

Objectives: Out-of-hospital births are associated with a 2- to 11-fold increased risk of death compared to in-hospital births and are growing. Emergency Medical Services (EMS) clinicians have limited exposure to hospital birth emergencies, and there is no standardized prehospital neonatal resuscitation curriculum. Neonatal Resuscitation Program (NRP) guidelines are the standard of care for infants born in the United States but focuses on in-hospital births and is not easily applied to EMS. There is a need for tailored NRP training to meet EMS clinicians' specific needs, context, and systems.

Methods: This was a prospective observational study of a virtual EMS-tailored, newborn resuscitation curriculum focused on initial steps of newborn resuscitation in the out-of-hospital setting. The initial content (90-minute) was pilot tested virtually among 350 urban EMS clinicians, with favorable feedback (89% survey response rate). Based on feedback, we created a 60-minute interactive, virtual curriculum that includes NRP-based didactic and memory aids to reinforce how NRP differs from pediatric resuscitation designed specifically for EMS. The course also includes video demonstrations with pauses for hands-on self-directed skills practice. We delivered the curriculum to clinicians from 17 EMS agencies in rural Oregon. To assess neonatal resuscitation knowledge acquisition and retention, participants completed the same 10-question test before, after, and 3 months following the training. Questions were adapted from the 8^th Edition NRP Textbook and NRP test questions.

Results: Eighty-four EMS clinicians completed the pretest, curriculum, and post-test and demonstrated improvement in immediate post-curriculum NRP knowledge (pretest mean score 5.32 ± 1.99; post-test mean score 8.61 ± 1.26; p < 0.001). Forty participants completed the 3-month follow up test and scores remained improved from baseline (3 month-follow up mean score 6.88 ± 1.83, p < 0.001). Prehospital clinicians (N = 84) thought that this EMS-tailored NRP curriculum was easy to complete (100%), valuable to their clinical practice (99%), and filled a gap in their education (98%). They felt that implementing/requiring this training is possible/doable (99%) and recommend the curriculum to other EMS agencies (99%).

Conclusions: A virtual EMS-tailored, NRP-based educational curriculum improved neonatal resuscitation knowledge immediately and was sustained at 3 months compared to baseline. The curriculum is feasible and acceptable to EMS clinicians.

Objectives: Structured data fields, including medication fields involving naloxone, are routinely used to identify opioid overdoses in emergency medical services (EMS) data; between January 2021 and March 2024, there were approximately 1.2 million instances of naloxone administration in the United States. To improve the accuracy of naloxone reporting, we developed methodology for identifying naloxone administration using both structured fields and unstructured patient care narratives for events documented by EMS.

Methods: We randomly sampled 30,000 records from Kentucky's state-wide EMS database during 2019. We applied regular expressions (RegEx) capable of recognizing naloxone-related text patterns in each EMS patient's case narrative. Additionally, we applied natural language processing (NLP) techniques to extract important contextual factors such as route and dosage from these narratives. We manually reviewed cases where the structured data and unstructured data disagreed and developed an aggregate indicator for naloxone administration using either structured or unstructured data for each patient case.

Results: There were 437 (1.45%) records with structured documentation of naloxone. Our RegEx method identified 547 naloxone administrations in the narratives; after manual review, we determined RegEx yielded acceptable false positives (N = 31, 5.6%), false negatives (N = 23, 4.2%) and performance (precision = 0.94, recall = 0.93). In total, 552 patients had naloxone administered after combining indicators from both structured fields and verified results from unstructured narratives. The NLP approach also identified 246 (47.4%) records that specified route of administration and 358 (69.0%) records with dosage delivered.

Conclusions: An additional 115 (26.3%) patients receiving naloxone were identified by using unstructured case narratives compared to structured data. New surveillance methods that incorporate unstructured EMS narratives are critically needed to avoid substantial underestimation of naloxone utilization and enumeration of opioid overdoses.

Objectives: Within paramedic education immersive simulation is widely used to teach technical skills, but its application to non-technical aspects of practice, such as research skills, is limited. This study aimed to explore immersive simulation as a tool to teach specific research skills to paramedic students in higher education to investigate its novel capacity beyond the more traditionally considered technical elements of practice.

Methods: A didactic pre-briefing was delivered to undergraduate paramedic students before they undertook an immersive simulation in which they were expected to assess, extricate, and treat a stroke patient, whilst also assessing whether he was suitable to be enrolled onto a clinical trial, provide information on this, and take consent. A large-scale immersive environment furnished with surround audio-visual display equipment was utilized; the environment also contained an ambulance, a hatchback car, and two actors. After the simulation and debriefing, students completed an online questionnaire comprising open-ended questions and the following scales: Simulation Design Scale (fidelity subscale only), Simulation Effectiveness Tool - Modified, and Satisfaction with Simulation Experience. Data were analyzed using descriptive statistics and a manifest qualitative content analysis.

Results: Data were collected from twenty-eight undergraduate paramedic students. Most students believed simulation fidelity was important (89.3%) and most agreed that the simulation was realistic (82.1%). Pre-briefing (100%) and debriefing (85.7%) opportunities were considered important for increasing student's confidence and learning, and, overall, students enjoyed the simulation (89.3%). Three themes emerged during the qualitative analysis: the significance of an immersive "real" environment, enjoyment as important for engagement and learning, and improved confidence via opportunities for autonomous practice.

Conclusions: Immersive simulation is a valuable pedagogical tool for the delivery of research skills teaching. These findings align with previous research which has investigated immersive simulation for teaching clinical skills, but more broadly, also highlight the compounding positive impact of immersive technology when deployed alongside actors and high-fidelity equipment.

Objectives: Emergency medical services (EMS) clinicians express dissatisfaction with the quality and quantity of clinical feedback received from hospitals, which is exacerbated by the absence of standardized feedback processes. A reported lack of regular feedback impedes their ability to learn and improve care. We evaluated a newly implemented feedback tool's utilization and perceived impact on EMS clinicians and our health system.

Methods: We employed a mixed-methods study design in a single academic medical center emergency department. Quantitative data collected focused on patients' clinical characteristics and characteristics of utilizers of the feedback tool during implementation (September 2023-July 2024). Qualitative data involved semi-structured interviews with EMS clinicians who had diverse experiences with the feedback tool and years of EMS service Semi-structured interviews applied a phenomenological framework, and were videorecorded, transcribed, and independently coded to identify key themes surrounding the utilization and impact of the implemented tool.

Results: Among the 381 feedback requests, 139 (36.5%) pertained to patients aged ≥65 years, while 44 (11.5 %) included patients <18 years; 343 (90%) had an Emergency Severity Index score of ≥2. Major complaints included traumatic (n = 165; 43.3%), neurologic (n = 90; 23.6%), and cardiac (n = 82; 21.5%). Emergency responder agencies included ground ambulance 227 (59.6%), air medical 90 (23.6%), public safety answering points 37 (9.7%), and fire service 27 (7.1%). The primary response method was e-mail 353 (93.7%). There was an average of 35 feedback requests per month (interquartile range: 27-59). EMS clinicians from multiple agencies with varying levels of knowledge of the feedback mechanism provided qualitative insights regarding the feedback tool, which covered several key areas: application and technological design, utilization, utility of feedback provided, barriers, comparisons to other systems, and areas for improvement.

Conclusions:  The standardized feedback mechanism implemented for EMS clinicians showed engagement, especially among ground responders caring for high-acuity patients, highlighting its importance in patient care. The preference for email emphasizes the need for efficient communication channels. Clinicians found the system accessible and user-friendly. The feedback tool was perceived as crucial for professional development and personal growth, allowing clinicians to gain closure on patient cases and potentially improve future patient care practices.

Objectives: To describe changes in the volume and types of emergency medical services (EMS) calls for children during the COVID-19 pandemic and after availability of the COVID-19 vaccine ("reopening period").

Methods: A retrospective cross-sectional study of EMS 9-1-1 responses to children under 18 years for all causes over a 4-year period (2019-2022) reported in the National Emergency Medical Services Information System (NEMSIS) dataset. Data was stratified into three periods, Pre-pandemic, Pandemic and Reopening. We used generalized linear models to estimate the effect of the pandemic and reopening on daily call volume trends, on-scene mortality and scene disposition, correcting for seasonality and baseline effects. We performed subgroup analyses based on geographic region and diagnosis (trauma, respiratory, mental health, seizure, diabetes).

Results: A total of 4,612,505 pediatric EMS 9-1-1 responses were included. Call volume for EMS showed an increasing pre-pandemic trend (+25.9%/year) followed by an acute drop in volume (-28.9%) and decreased trend (-13%/year) during the pandemic period and a rebound (+17.5%) during the reopening period that was generally conserved across all regions. Subgroup analysis by diagnosis showed similar trends among a wide variety of illnesses. There were increased odds of on-scene death for calls for traumatic (OR 1.77) and respiratory (OR 2.00) illnesses, with partial reversal in the respiratory group (OR 0.66) during the reopening period. During the pandemic, children were less likely to be transported (OR 0.70) and more likely to be non-transported (OR 1.30) and refuse care (OR 1.32), with partial reversal of these trends during the reopening period.

Conclusions: The pre-pandemic increase in EMS call volume was disrupted by an acute pandemic-related decline followed by a rebound during reopening. During the pandemic, children were more likely to present with more severe manifestations of disease processes, particularly increased on-scene death for trauma and respiratory illness, and less likely to be transported - with only partial reversal of trends in reopening.

Objectives: Buprenorphine is becoming a key component of prehospital management of opioid use disorder. It is unclear how many prehospital patients might be eligible for buprenorphine induction, as traditional induction requires that patients first have some degree of opioid withdrawal. The primary aim of this study was to quantify how many patients developed precipitated withdrawal after receiving prehospital naloxone for suspected overdose, as they could be candidates for prehospital buprenorphine. The secondary objective was to identify associated factors contributing to precipitated withdrawal, including dose of naloxone administered, and identify rate of subsequent transport.

Methods: A retrospective cohort study reviewing electronic patient care reports (ePCRs) from March 2019 to April 2023 in a single Emergency Medical Services (EMS) system was performed. Cases were included if naloxone was administered during the prehospital interval and excluded if the patient was in cardiac arrest upon arrival and died on scene. Precipitated opioid withdrawal was defined using reliably available ePCR data points measured by the Clinical Opiate Withdrawal Scale: administration of an antiemetic or sedative, persistent tachycardia, or new tachycardia after naloxone. Descriptive statistics were calculated to quantify the incidence of precipitated withdrawal. Risk ratios were calculated to identify variables associated with outcomes of interest. A subgroup analysis was performed examining patients explicitly diagnosed with an overdose by EMS.

Results: During the study period, 4561 individuals were given naloxone, and 2124 (46.2%) met our proxy criteria for precipitated withdrawal. Patients who received multiple doses of naloxone were more likely to meet our precipitated withdrawal definition versus those who received a single dose (RR 1.2, 95% CI 1.12-1.28). Patients who experienced precipitated withdrawal were more likely to accept transportation than those who did not experience withdrawal (RR 1.08 95% CI 1.04-1.12). Persistent tachycardia (80.3%) was the most common criterion met for our definition of precipitated withdrawal.

Conclusions: Almost half of patients who received a dose of prehospital naloxone for suspected overdose met our proxy criteria for precipitated withdrawal. Patients who met our precipitated withdrawal definition were more likely to have received greater doses of naloxone and were more likely to accept transport to an emergency department.

Objectives: Cardiopulmonary resuscitation (CPR), which is used in cases of life-threatening cardiopulmonary arrest, is a physically exhausting procedure. Adding to that, sometimes, even before performing CPR, interventions to rescue the injured person from a challenging environment have caused significant fatigue. In this study, taking a novel research approach, we generated a scenario of fatigue during a rescue from earthquake debris and aimed to measure the effect of that fatigue on the quality of CPR performed by paramedics.

Methods: The research followed an experimental design with 2 groups (experimental/control) and 2 measurements (pretest/post-test). The study population was selected using power analysis. The sample, consisting of 84 paramedic students, was randomly divided into 42 control and 42 experimental participants. Current American Heart Association (AHA 2020) and European Resuscitation Council (ERC 2021) guidelines were strictly followed when performing CPR. In order to assess the accuracy of CPR, a General Doctor GD-CPR200S-A (2010 standard) simulator was utilized. The participants were fatigued by practicing the process of extracting and transporting earthquake victims from rubble. A personal information form with 20 questions and a CPR measurement form were used to obtain the data.

Results: In the analysis performed to measure the differences between the CPR indicators for the control and experimental groups in the post-test and pretest, the difference in compression (control: 6.5 ± 50.1 and experimental: -10.3 ± 46.0) was not significant. Meanwhile, we found that the difference in ventilation (control: 0.3 ± 5.4 vs. experiment: 8.1 ± 4.6) and the difference in CPR completion times (control: 0.2 ± 1.2 vs. experiment: -0.7 ± 0.7) between the post-test and pretest were significant.

Conclusions: There was no significant difference in correct compressions between the control and experimental groups, but there was a significant difference in ventilation and CPR completion times. For this reason, it is recommended to focus on the effect of fatigue on CPR quality, especially on the ventilation process. It is also recommended to include fatigue scenarios in CPR trainings.

Objectives: Previous research demonstrated that the numerical Cincinnati Prehospital Stroke Scale (CPSS) identifies large vessel occlusion (LVO) at similar rates compared to dedicated LVO screening tools. We aimed to compare numerical CPSS to additional stroke scales using a national emergency medical services (EMS) database.

Methods: Using the ESO Data Collaborative, the largest EMS database with linked hospital data, we retrospectively analyzed prehospital patient records from 2022. Each EMS record was linked to corresponding emergency department (ED) and inpatient records through a data exchange platform. Prehospital CPSS was compared to the Cincinnati Stroke Triage Assessment Tool (C-STAT), the Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and the Balance Eyes Face Arm Speech Time (BE-FAST). The optimal prediction cut points for LVO screening were determined by intersecting the sensitivity and specificity curves for each scale. To compare the discriminative abilities of each scale among those diagnosed with LVO, we used the area under the receiver operating curve (AUROC).

Results: We identified 17,442 prehospital records from 754 EMS agencies with ≥1 documented stroke scale of interest: 30.3% (n = 5,278) had a hospital diagnosis of stroke, of which 71.6% (n = 3,781) were ischemic; of those, 21.6% (n = 817) were diagnosed with LVO. CPSS score ≥2 was found to be predictive of LVO with 76.9% sensitivity, 68.0% specificity, and AUROC 0.787 (95%CI 0.722-0.801). All other tools had similar predictive abilities, with sensitivity/specificity/AUROC of: C-STAT 62.5%/76.5%/0.727 (0.555-0.899); FAST-ED 61.4%/76.1%/0.780 (0.725-0.836); BE-FAST 70.4%/67.1%/0.739 (0.697-0.788).

Conclusions: The less complex CPSS exhibited comparable performance to three frequently employed LVO detection tools. The EMS leadership, medical directors, and stroke system directors should weigh the complexity of stroke severity instruments and the challenges of ensuring consistent and accurate use when choosing which tool to implement. The straightforward and widely adopted CPSS may improve compliance while maintaining accuracy in LVO detection.