Prehospital Emergency Care最新文献

Objectives: The Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework is a validated process that is used to identify individuals with substance use disorders (SUDs) and then encourage them to engage in and facilitate entry into treatment. It is not known how well SBIRT can be incorporated into prehospital practice and what barriers to Emergency Medical Services (EMS) implementation of an SBIRT program might arise. The aim of this project was to implement a pilot EMS based SBIRT program. Then, after program implementation, to identify barriers to the prehospital use of SBIRT programs.

Methods: This was a mixed methodology study utilizing a retrospective review of program quality improvement data and structured interviews to collect both objective and subjective data on the prehospital SBIRT implementation. Eight EMS agencies participated in the SBIRT pilot program. Paramedics and Emergency Medical Technicians (EMT) were trained to use the SBIRT process then asked to use the SBIRT tool during their day to day activities. The screening tools utilized were the Drug Abuse Screening Test (DAST) and the Alcohol Use Disorders Identification Test (AUDIT). Referral tools were tailored to the unique SUD treatment programs available in each community. The pilot program was run for 6 months after which time structured focus group meetings were conducted to identify barriers to broader SBIRT program utilization.

Results: In total, 28 EMS clinicians from 8 agencies attended the train the trainer SBIRT education session. None of the agencies subsequently implemented the routine use of the SBIRT model or DAST/AUDIT tools. The agencies reported significant barriers to implementation on EMS calls, including short transport times, current drug and/or alcohol intoxication, and hesitation of patients to participate. Community paramedicine clinicians, who typically spend more time with patients, found the tools more useful but found limited opportunities to implement them. Common cited themes were the lack of local community-based organizations and frequent personnel turnover within local agencies.

Conclusions: Although EMS clinicians found the SBIRT training to be useful, they did not incorporate the use of the SBIRT model into their prehospital patient care, citing too many barriers to its implementation and use.

Objectives: Opioid use disorder (OUD) remains a common cause of overdose and mortality in the United States. Emergency medical services (EMS) clinicians often interact with patients with OUD, including during or shortly after an overdose. The aim of this study was to describe the characteristics and outcomes of patients receiving prehospital buprenorphine for the treatment of opioid withdrawal in an urban EMS system.

Methods: We performed a retrospective chart review of all initial cases of administration of buprenorphine-naloxone from April 2023 to July 2024 during the first 16 months of a program involving prehospital EMS administration of buprenorphine-naloxone by EMS clinicians to patients with OUD experiencing acute opioid withdrawal in San Francisco. The primary outcome involved reduction in Clinical Opioid Withdrawal Score (COWS) and other adverse events including worsened withdrawal (or increased COWS), nausea, patient destination, and loss to follow up were also assessed.

Results: Buprenorphine was administered to 131 patients. In 82 (62.6%) cases, patients presented in withdrawal after receiving naloxone from bystanders or EMS as a treatment for overdose. The average COWS prior to administration was 16.1 ± 6.5 and the median COWS prior to administration was 15 (IQR: 11-19). Of the 78 cases where a COWS was available, 74 (94.9%) experienced symptom improvement, with the median COWS dropping from 15 (IQR: 11-19) to 7 (IQR: 4-13) between first and last recorded values. No adverse effects were reported in prehospital records. There was one reported in-hospital incident of withdrawal in the Emergency Department presumably precipitated by buprenorphine. Data on outcomes after EMS transport were limited. Only six patients were successfully contacted at 30 day follow up, but five of these patients were in long-term OUD treatment programs, and three reported sustained abstinence from opioid use. During case review, we found two cases where physicians assisted EMS personnel in recognizing recent methadone use, but no other missed exclusion criteria requiring physician input.

Conclusions: In San Francisco, prehospital administration of buprenorphine for acute opioid withdrawal by EMS clinicians resulted in symptomatic improvement, and case review suggests administration can be safe without direct EMS physician oversight.

Objectives: Prehospital endotracheal intubation (ETI) is a lifesaving procedure with known complications. To reduce ETI-associated morbidity and mortality, organizations prioritize first-pass success (FPS). However, there are few data evaluating the association of FPS with clinician licensure.

Methods: We performed a retrospective chart review of all paramedic and nurse ETI attempts by a multi-state air and ground critical care transport service between January 1, 2008, and December 31, 2023. Our outcomes of interest were FPS and last-pass success (LPS). The exposure of interest was clinician license. We performed a multivariable logistic regression controlling for multiple common patient/operational confounders: age, sex, referring/procedure location, medical category, year, paralytic use, and proceduralist experience. As an exploratory analysis we assessed FPS by licensure and years of experience using time since first patient mission as a surrogate (<1 year, 1 to <2 years, 2 to <3 years, and 3+ years).

Results: Of 171,804 encounters over the study period, 8,307 (4.8%) required ETI. Included encounters were mostly adult (≥18 years old; 91.0%), male (64.0%), and victims of trauma (57.4%). Most intubations were performed on primary retrieval (scene) missions (70.5%) with neuromuscular blockade (93.3%). Nurses and paramedics intubated with similar success on the first (88.8%; 95% confidence interval [CI] 87.9-89.8 vs. 89.7%; 95% CI 88.7-90.7) and last (97.4%; 95% CI 96.9-97.9 vs. 97.3%; 95% CI 96.7-97.8) attempts. Multivariable analysis revealed no significant difference between two groups for FPS (aOR 0.90; 95% CI 0.77-1.04]) or LPS (aOR 1.00; 95% CI 0.76-1.32). FPS was also similar for nurses (74.7%; 95% CI 69.8-79.7) and paramedics (80.6%; 95% CI 75.6-85.6) within the first year, and after 3 years of experience (91.6%; 95% CI 90.6-92.5 vs. 91.5%; 95% CI 90.5-92.6).

Conclusions: Critical care paramedics and nurses perform ETI with similar proficiency. In this analysis of 7,812 intubations, clinician licensure was not associated with FPS nor LPS after controlling for multiple common confounders. Further research evaluating training schemes especially in early years of experience is needed.

Objectives: Buprenorphine has recently emerged as a prehospital treatment for opioid use disorder. Limited data exist regarding the implementation of prehospital buprenorphine programs. Our objective was to describe the development, deployment, lessons learned, and ongoing evolution of the Wake County EMS buprenorphine program using data from the first year following implementation.

Methods: We developed a protocol to provide buprenorphine in the prehospital setting to patients who 1) suffered an opioid overdose with reversal using naloxone, or 2) experienced withdrawal symptoms at least 72 hours after last opioid use. Measures included encounters with screening for buprenorphine induction, successful inductions with buprenorphine, successful follow up with outpatient treatment, and successful continued outpatient treatment. For the period 7/5/2023-7/4/2024, we report descriptive statistics.

Results: We identified 1,378 encounters for adult patients who received naloxone, of which 953 had documentation of opioid overdose as the primary impression. During the same timeframe, 342 encounters included screening for prehospital buprenorphine induction. Of encounters with screened patients, 66 (19.3%) encounters were eligible for buprenorphine induction and of these, 61 encounters (92.4%) resulted in buprenorphine induction. Of encounters with induction, 29 (47.5%) resulted in successful follow up with our outpatient provider, and 7 (11.4%) remained in treatment at the end of the review period.

Conclusions: Our prehospital buprenorphine induction program successfully inducted eligible patients and connected them with follow up. Almost half of inducted patients were able to follow up with our outpatient provider. One in ten patients who received buprenorphine from EMS remained in treatment. There exists an opportunity for EMS to screen more patients for buprenorphine induction as only one in four patients who received naloxone were screened for buprenorphine induction. Lessons learned include the need for recurrent EMS clinician education regarding buprenorphine screening, the need for a "buprenorphine champion" to follow up with inducted patients and addressing early administrative and technological barriers to ensure data exchange.

Objectives: Paramedic services face increasing challenges due to delays in patient transfer of care (TOC) at emergency departments (EDs). Prolonged TOC times directly impact paramedic services' ability to provide emergency response, though the patient and clinical factors contributing to these delays remain unclear. We examined TOC times for all transports to the ED and analyzed factors associated with prolonged TOC.

Methods: We conducted a retrospective cohort study using paramedic call data from Toronto Paramedic Services from September 1, 2022, to July 31, 2024. We included all paramedic-transported patient records to EDs following a 9-1-1 call, excluding inter-facility transfers and records with missing TOC timestamps. The TOC times were categorized into four intervals: 0-29, 30-59, 60-89, and ≥ 90 min. We conducted a cohort and subgroup analysis of patients aged 60 years or older using multivariable binary logistic regression models to identify factors independently associated with TOC times exceeding 60 min, using odds ratios (OR) with 95% confidence intervals (CI).

Results: A total of 418,196 patients were transported to EDs, of which 214,612 were 60 years or older. Overall, mean TOC was 39.9 min (SD 54.2). Patients aged 0-17 years had the lowest proportion in longer TOC intervals (5% for 60-89 mins; 2% for ≥ 90 mins), while patients 75 years or older had the highest (9%; 9% respectively). A TOC of at least 60 min was independently associated with older age (60 to 74 years OR 1.19, 1.15-1.22; 75 years or greater OR 1.27, 1.23-1.30), medical complexity (seven to eight diagnoses OR 1.15, 1.10-1.20; nine or greater diagnoses OR 1.29, 1.23-1.36), polypharmacy and specific presenting complaints (altered level of consciousness, respiratory distress, general weakness, head trauma). Medical acuity and receiving a paramedic intervention were not associated with prolonged TOC. Similar findings were determined in the subgroup analysis of older adults.

Conclusions: Prolonged TOC times disproportionately affect older or clinically complex patients, regardless of their acuity or need for paramedic intervention. Our findings highlight the importance for paramedic services, hospitals, and stakeholders to develop targeted care models and collaborations to reduce prolonged TOC.

Objectives: To compare the effects of powered and manual stretchers on participants' perceived comfort and measured acceleration during lifting and loading operations.

Methods: This non-randomized, laboratory-based crossover study involved forty-one participants (thirty-one firefighters and ten third-year paramedic students) who served as simulated patients experiencing lifting, lowering, loading, and unloading maneuvers using manual and powered stretchers. Four stretcher types were evaluated: one powered stretcher (Power-PRO^™ XT) and three manual stretchers (Matsunaga GT, Exchange 4070, Scad Mate), with each group using the manual stretcher they routinely operated. Linear acceleration data were collected using a nine-axis inertial measurement unit placed at the participants' anterior waist. Root mean square (RMS) and peak accelerations along the X-, Y-, and Z-axes were calculated. Participants completed a twenty-three-item comfort questionnaire based on the Semantic Differential method. Due to non-normal data distribution, nonparametric statistical tests were employed for analysis.

Results: The lifting/lowering and loading/unloading movements showed that the powered stretcher significantly reduced the RMS values, maximum accelerations, and minimum accelerations in the vertical axis (Z-axis) compared to manual stretchers. Specifically, the powered stretcher demonstrated lower RMS acceleration (0.29 m/s² vs. 0.73 m/s², p < 0.001), maximum acceleration (1.60 m/s² vs. 2.90 m/s², p < 0.001), and minimum acceleration (-1.48 m/s² vs. -3.30 m/s², p < 0.001) in the vertical direction compared to other manual stretchers. Similar results were observed in the comparison of participant loading/unloading movements. However, no significant differences were observed between the powered and Exchange stretchers in X-axis minimum acceleration, Y-axis maximum and minimum accelerations, or Z-axis maximum acceleration. Similarly, Y-axis minimum accelerations did not significantly differ between the powered stretcher and Matsunaga GT or Scad Mate stretchers. After loading and unloading movements, the questionnaire results showed that the powered stretcher was rated significantly higher on comfort-related items including "comfortable," "secure," "like," "smooth," and "relaxing."

Conclusions: In a controlled, laboratory-based setting, simulated use of manual and powered stretchers showed that powered stretchers significantly minimize patient discomfort and vibrations. This study underscores the potential for enhancing patient safety and quality of care. In conclusion, the powered stretcher is a promising tool for improving the quality and safety of patient transportation in prehospital settings.

Objectives: Abusive head trauma (AHT) is a leading cause of death in young children. Analyses of patient characteristics presenting to Emergency Medical Services (EMS) are often limited to structured data fields. Artificial Intelligence (AI) and Large Language Models (LLM) may identify rare presentations like AHT through factors not found in structured data. Our goal was to apply AI and LLM to EMS narrative documentation of young children to detect AHT.

Methods: This is a retrospective cohort study of EMS transports of children <36 months of age with a diagnosis of head injury from the 2018-2019 ESO Research Data Collaborative. Non-abusive closed head injury (NA-CHI) was distinguished from AHT and child maltreatment (AHT-CAN) through 2 expert reviewers; kappa statistic (k) assessed inter-rater reliability. A Natural Language Processing (NLP) framework using an LLM augmented with expert derived n-grams was developed to identify AHT-CAN. We compared test characteristics (sensitivity, specificity, negative predictive value (NPV)) between this NLP framework to a Generative Pretrained Transformer (GPT) or n-grams only models to detect AHT-CAN. Association of specific word tokens with AHT-CAN was analyzed using Pearson's chi-square. Area Under the Receiver Operator Curve (AUROC) and Area Under the Precision-Recall Curve (AUPRC) are also reported.

Results: There were 1082 encounters in our cohort; 1030 (95.2%) NA-CHI and 52 (4.8%) AHT-CAN. Inter-rater agreement was substantial (k = 0.71). The augmented NLP framework had a specificity and sensitivity of 72.4% and 92.3%, respectively with a NPV of 99.5%. In comparison, the GPT model had a sensitivity of 69.2%, specificity of 97.1% and NPV of 98.4% and n-grams alone had a sensitivity of 53.8%, specificity of 62.0%, NPV of 96.4%. AUROC was 0.91 and AUPRC was 0.52. A total of 44 n-grams and bi-grams were positively associated with AHT-CAN including "domestic," "various," "bruise," "cheek," "multiple," "doa," "not respond," "see EMS."

Conclusions: AI and LLMs have high sensitivity and specificity to detect AHT-CAN in EMS free-text narratives. Words associated with physical signs of trauma are strongly associated with AHT-CAN. LLMs augmented with a list of n-grams may help EMS identify signs of trauma that aid in the detection of AHT in young children.

Objectives: Opioid-associated fatal and non-fatal overdose rates continue to rise. Prehospital overdose education and naloxone distribution (OEND) programs are attractive harm-reduction strategies, as patients who are not transported by EMS after receiving naloxone have limited access to other interventions. This narrative summary describes our experiences with prehospital implementation of evidence-based OEND practices across Ohio as part of the HEALing Communities Study (HCS).

Methods: HCS was a parallel-group, cluster randomized, unblinded, wait-list controlled trial of 67 communities highly impacted by opioid-related overdose fatalities in four states, including Ohio. An EMS Intervention Design Team (IDT), consisting of EMS physicians, paramedics, and an EMS department Chief with an established OEND program, supported participating EMS agencies. Services of the IDT included protocol development, program training, and stigma-reduction education. HCS funding supported implementation costs and varied by county/agency.

Results: In 12 Ohio counties, 29 agencies implemented an OEND program; agencies served rural, suburban, and urban communities. While leaving naloxone kits with patients and/or families at an EMS call was universally adopted, additional OEND approaches were undertaken. Seven EMS agencies registered with the Ohio Department of Health's Project DAWN program, allowing hub-and-spoke distribution of state-provided naloxone to smaller OEND programs. An urban EMS agency targeted mass gatherings for OEND efforts; bicycle teams providing crowd medical response distributed leave-behind naloxone kits in a process mirroring traditional 9-1-1 calls while static first aid stations offered overdose educational materials, information on local resources, and take-home naloxone kits. A rural EMS agency allowed community members to request naloxone kits from agency headquarters. To address an overdose hotspot at an interstate rest area, a rural joint ambulance district partnered with the county health department to install and maintain a public-access naloxone station. Observed facilitators included Ohio's legal and regulatory environment, creating local definitions of success, identifying and empowering local champions, and operational solutions to ease OEND for practitioners. Stigma represents the biggest barrier, with ongoing education as the best solution. Incremental program implementation was most successful.

Conclusions: Our OEND implementation experiences across multiple Ohio EMS agencies identified several barriers, facilitators, and creative solutions that may inform future prehospital harm-reduction programs.

Objectives: This systematic review aims to determine the effectiveness of ambulance transportation versus helicopter transportation on mortality for trauma patients.

Methods: A systematic review of published and unpublished databases (to August 2023) was performed. Studies, reporting mortality, for people who experienced trauma and were transported to a trauma unit by ambulance or helicopter were eligible. The Newcastle-Ottawa scale was employed to evaluate study quality.

Results: Of the 7,323 studies screened, 63 met the inclusion criteria. Thirty-two percent of these studies included patients with diverse injury types, while nine studies included patients across all age groups. The majority (92%) of the included data were retrospective in nature. Eighteen studies (28.57%) achieved the highest score on the Newcastle-Ottawa scale suggesting high-quality evidence. Seven studies examining 24-h mortality reported variable findings. Eighteen studies reported mortality without exact time points through adjusted analyses, 17 favored air transport. Air transport showed an advantage across all subgroups in the adjusted data, while the unadjusted data presented relatively similar outcomes between the two modes of transport.

Conclusions: This systematic review found that adjusted analyses consistently favored air transport over ground transport. Unadjusted analyses showed no significant difference between the two modes of transport, except in specific subgroups. Further subgroup analyses revealed notable disparities between the two modalities, suggesting that these differences may be influenced by multiple factors. These findings highlight the need for further research to clarify the true impact of transport modality on trauma outcomes.

Objectives: Emergency Medical Services (EMS) agencies are beginning to provide low-barrier access to treatment for opioid use disorder (OUD) through the development of EMS buprenorphine (EMS-Bupe) programs. However, evidence-based practices for these programs are lacking. Our aim was to review the current literature on EMS and emergency department (ED) based buprenorphine treatment programs to provide consensus recommendations on the EMS-Bupe program development.

Methods: We performed a scoping review of EMS-Bupe programs and ED medication for OUD (MOUD) programs. We searched Ovid MEDLINE(R), Embase.com, Cochrane Central Register of Controlled Trials and Web of Science (Science Citation Index) for English language articles and abstracts. Additional articles/abstracts as identified independently by coauthors were added. Recommendations were generated through consensus based on the findings of the scoping review and other relevant literature.

Results: We identified a total of 9 EMS-Bupe articles/abstracts and 21 ED MOUD abstract, representing 5 EMS-Bupe programs in 4 states. There was significant variability between programs, from infrastructure, medication dosing, and retention rates. Results and recommendations were grouped into 8 categories: EMS program infrastructure, withdrawal classification thresholds, EMS protocol inclusion/exclusion criteria, buprenorphine dosing and adjunct medications, EMS disposition and scene times, EMS clinician training, referrals, and EMS data collection and quality management.

Conclusions: The EMS-Bupe program data are limited but show important variability. In general, we recommend that programs respond to community needs by establishing relationships with local resources. We also favor protocols that increase patient eligibility and treatment retention. Lastly, programs should consider low-barrier, patient-centered strategies aimed at preventing gaps in treatment.