Prehospital Emergency Care最新文献

Objectives: While clinical judgment is vital for all clinicians, it is not clearly assessed in initial or continuing emergency medical services (EMS) education due to unclear definitions. Recently, clarity of this concept has been provided through the development of a theoretical framework for clinical judgment in EMS that considers the broad and evolving nature of prehospital care delivery. To facilitate standardization of clinical judgment assessments, in this educational practice review we present a template for item development leveraging the new framework.

Methods: We developed this template with input from EMS clinicians, educators, and subject matter experts from the nursing field with experience in clinical judgment item development. This template includes the basic cognitive steps of EMS clinical judgment, including recognizing cues, analyzing cues, defining a hypothesis, generating solutions, taking action, and evaluating the outcomes of those actions.

Results: We provide a transparent and reproducible template for item generation for clinical judgment assessments evaluating the six basic cognitive reasoning steps. Further, we provide a fully developed example of template application using a hypoglycemic patient case. This template can be used to support item generation for specific event phases (e.g., en route, scene, and post scene) in a clinical scenario.

Conclusions: This template allows for generation of items for each EMS event phase that can be repeated serially for any combination of prehospital clinical situations.

Objectives: Delays in reperfusion treatment in ST-elevation myocardial infarction (STEMI) patients leads to higher morbidity and mortality. Previous reports for Helicopter Emergency Medical Services (HEMS) suggests a 10-minute skid-to-skid (arrival to departure) time to achieve appropriate reperfusion times. However, there is no published data on whether this goal is achievable for a HEMS service. This study aims to see if a midwestern critical care service can consistently achieve a 10-minute helicopter skid-to-skid time or ground critical care service arrival to departure time. Further, comparing this metric between ground and helicopter transportations will help evaluate the ideal transportation method to optimize time to percutaneous intervention (PCI).

Methods: This was a retrospective chart review utilizing 10 years of data from our ground and HEMS program to assess whether a 10-minute arrival to departure time for STEMI patients could be achieved. Patients included were at least 18 years of age and were transported from the referring facility for further STEMI management. Wilcoxon rank sum test and Chi-square tests were used to evaluate data between helicopter and ground services.

Results: Included in the study were 686 patients, 608 by helicopter transport and 78 by ground transport. The median arrival to departure time was 14 min (IQR = 5) for helicopter patients and 13 min (IQR = 6) for ground patients. There was not a statistically significant difference in this metric for STEMI patients transported by helicopter versus ground. A statistically significant difference, though, existed between helicopter and ground transports among percent with times less than or equal to 10 min versus percent times greater than 10 min, X² = 5.46, df = 1, p = 0.02. Two referring facilities had statistically significant differences in median arrival to departure times.

Conclusions: Our study found that a median EMS arrival to departure time of 10 min to transport STEMI patients was not consistently achieved via either helicopter or ground transportation.

Objectives: Early identification and fluid resuscitation are recognized performance measures within sepsis care. Despite fluid resuscitation, fluid goals are often not achieved in the prehospital environment. Furthermore, description of implementation process and evaluation of implementation success are historically underreported in prehospital research. The objective of this study was to contextualize and evaluate the system-wide implementation of a novel fluid resuscitation device, the LifeFlow PLUS^®, in the treatment of prehospital sepsis patients.

Methods: A single urban emergency medical services (EMS) system internally decided to adopt a novel fluid resuscitation device. This EMS system added the device to the clinical care guidelines of suspected sepsis patients. Prior to and during implementation of the new guidelines, several strategies were undertaken to promote consistent, appropriate system-wide use of the device. A mixed methods study design was deployed. Surveys of EMS clinicians and leaders assessed perceptions of the device and sepsis education prior to field implementation of the device. Clinician and leader semi-structured interviews assessed implementation experience and device adoption. Document analysis evaluated deployment of implementation strategies. Data were triangulated to contextualize implementation and evaluate success.

Results: Clinician (88%) and leader (91%) confidence in appropriate clinician device use and device superiority for sepsis care (73 and 100%, respectively) were high. Clinicians (58%) were less likely to view the device as easy to implement compared to leaders (73%). Three themes were developed from semi-structured interviews, including "exposure" to the device, "reinforcing factors" to prompt device use, and "clinician buy-in." Twenty unique implementation strategies (e.g., dynamic trainings, mandating change) were used to promote successful system-wide device adoption.

Conclusions: The overall implementation success of this novel fluid resuscitation device was moderate. Barriers to adoption included complexity of clinical decision-making and ease of device use. Facilitators to adoption included the use of multiple modes of education, clinical reminders, presenting evidence of device benefit, and prehospital culture. Prior to future prehospital implementation programs, EMS systems should focus on identifying and addressing key barriers and facilitators to improve adoption.

Objectives: Clinical judgment (CJ) encompasses clinical reasoning (process of evaluating a problem) and clinical decision-making (choice made). A theoretical model to better define emergency medical services (EMS) CJ has been developed but its use has not been evaluated in EMS training and assessments. Our objective was to evaluate the performance of this EMS CJ model to assess clinical reasoning and decision-making in a simulated environment.

Methods: In this evaluation, EMS clinician teams (2-3 members) were directed to care for a simulated older adult patient in their home following a fall. Simulations were video recorded, clinician team actions coded, and evaluated for whether proper CJ reasoning and decisions were made. We evaluated CJ in two ways: 1) EMS medical directors' (MD) determination of whether the CJ questions were addressed (MD score) and 2) objective rubric evaluation of CJ questions using the EMS CJ model focused on recognition of appropriate cues, performance of actions, and revaluation after action (rubric score). The CJ questions addressed in this simulation included: 1) Is the patient stable/unstable?, 2) Are interventions necessary before movement?, 3) How should the patient be transferred from the floor?, and 4) Does the cause of the fall require hospital evaluation? Descriptive statistics were calculated, and concordance between the two assessments was evaluated (mean, 95% CI). Percent concordance was calculated with a validity threshold set at 70%.

Results: Four EMS MDs reviewed 20 videos addressing 80 clinical judgment decisions. Overall concordance between MD score and rubric score for CJ decisions was above the threshold at 88.1% (85.0, 91.2). Concordance between MD score and rubric score for each CJ decision was 92.0% (87.3, 96.7) for question 1, 79.9% (71.5, 88.3) for question 2, 95.0% (90.4, 99.6) for question 3, and 85.4% (79.5, 91.2) for question 4.

Conclusion: An objective evaluation of CJ decisions using a rubric derived from an EMS CJ theoretical framework demonstrated high concordance to subjective evaluations of CJ made by EMS MDs. This approach may allow for reproducible and objective CJ evaluations that could be used for competency assessment in EMS.

Objectives: The aim of this study was to describe the incidence of and modifiable risk factors for post intubation hemodynamic collapse in prehospital and interfacility critical care transport.

Methods: Single center retrospective chart review of adult patients (≥18 years) intubated by a critical care transport team between January 2017 and May 2023. The primary outcome was incidence of hemodynamic collapse (systolic blood pressure <90 mmHg for greater than 30 min, new vasopressor requirement, vasopressor dose increase, fluid bolus of >15 mL/kg, systolic blood pressure <65 mmHg at least once, or cardiac arrest). Secondary outcomes included post intubation hypoxia, as well as association of hemodynamic collapse with potentially modifiable risk factors including pre intubation shock index, pre intubation heart rate, pre intubation systolic blood pressure, and induction agent.

Results: Three hundred and thirty-three patients were included. Ninety-seven (29.1%) patients experienced hemodynamic collapse and 36 (10.8%) of patients experienced life threatening hemodynamic collapse. Pre intubation shock index >1 (OR 3.18, 95% CI 1.15-8.74) was associated with post intubation hemodynamic collapse. Choice of induction agent, fluid bolus prior to intubation, location of intubation, presence of traumatic injury, and age were not correlated with risk of hemodynamic collapse. The number of intubation attempts and methods of intubation were similar between groups.

Conclusions: Hemodynamic collapse and life-threatening hemodynamic collapse after intubation occurred frequently in this critical care transport cohort. Shock index greater than one was associated with significantly higher risk of hemodynamic collapse and life-threatening hemodynamic collapse.

Objectives: Elder mistreatment (EM), encompassing abuse and neglect, is a significant public health issue, affecting up to 10% of community-dwelling older adults annually. Elder mistreatment is a growing concern with a higher prevalence in institutional settings and substantial associated healthcare costs. Prehospital clinicians (PHCs) such as emergency medical technicians and paramedics are uniquely positioned to detect and report EM during their interactions with older adults in their homes. The objective of the study is to describe the rate and characteristics of EM documented by PHCs using the National Emergency Medical Services Information System (NEMSIS) database.

Methods: This study analyzed data from NEMSIS, which includes standardized information about PHC emergency response encounters across the United States. In 2018, 22,532,890 activations were included from 9,599 agencies in 43 states and US territories. Elder mistreatment was identified using specific International Classification of Diseases (ICD) codes related to EM. Demographic data, injury location, and associated physical findings were also examined.

Results: Out of 9,605,522 EMS encounters for patients aged ≥60, EM was coded in 1,765 encounters (0.02%). Most EM cases were listed as the cause of injury (64%), followed by the clinician's first impression (25.4%). Physical abuse was the most common type of mistreatment reported (20.8%), followed by sexual abuse (18.2%), neglect (9.7%), and psychological/emotional abuse (0.34%). The median age of patients with documented EM was 72, and 62.3% were female. The most common anatomic locations of injuries were the lower extremities, head, and upper extremities.

Conclusions: Despite the high prevalence of EM, PHCs infrequently document EM in their encounters with older adults. Additional training and comprehensive protocols are needed to improve the identification and reporting of EM, mainly elder neglect. Empowering PHCs through education and protocol development can significantly impact the detection and intervention of EM.

Objectives: Emergency Medical Services patients who survive overdose are at high risk for subsequent overdose and death. Programs that seek to link overdose survivors to harm reduction and treatment services are increasingly common, though they vary in design and measured effect. Public Health - Seattle & King County (PHSKC) used a continuous quality improvement (CQI) process to assess and improve a phone-based model for post-overdose outreach in King County, Washington.

Methods: King County Emergency Medical Services (KC-EMS) health records are queried weekly to identify suspected opioid overdose and other drug-related encounters. Patients treated by KC-EMS that met outreach eligibility criteria were contacted by phone and offered referrals to local services. Three Plan-Do-Study-Act (PDSA) cycles were sequentially implemented to iteratively assess program indicators and implement program adaptations. The PDSA cycles varied in terms of eligibility criteria, outreach modality, and level of resources devoted to phone number searches. Program indicators and corresponding costs were measured for each phase and calculated per month, per eligible patient, and per patient referred to services.

Results: During the initial call-based outreach pilot, the fewest number of patients met eligibility criteria (monthly average =39) and were referred to services (monthly average =2). In Phase Two, outreach shifted to automated texting and eligibility criteria expanded, resulting in an increase in the monthly average number of eligible patients (monthly average =137) and patients referred to services (monthly average =3). Phase Three adaptations expanded eligibility criteria further but limited outreach to patients with a phone number documented in their KC-EMS record, resulting in an average of 405 eligible patients per month and four patients that were referred to services. The costs per patient referred to services changed from $454 in Phase one to $589 in Phase Two to $279 in Phase Three.

Conclusions: The PDSA process helped PHSKC's post-overdose outreach team identify adaptations to improve the efficiency of the post-overdose outreach program. The number of people referred to services was modest, reflecting the challenges of post-incident phone-based outreach. Our experience highlights the value of incorporating CQI processes in ongoing program operations and the need for a multi-pronged overdose prevention strategy.

A growing number of individuals with unmet mental health needs in the United States rely on emergency medical services during mental health crises, and 9-1-1 emergency medical dispatchers (EMD) are often a critical lifeline to help. Unfortunately, current industry-standard dispatching protocols and training required for EMD certification largely lack specificity for managing 9-1-1 calls related to mental health emergencies. The purpose of this report is to illustrate the value of additional targeted training for EMDs that enables them to more effectively assist callers struggling with mental illness or suicidal thoughts. We review a 9-1-1 call in which an EMD utilized specific strategies and language learned during a 3-day emergency mental health dispatch (EMHD) training course to assist a middle-aged male who was expressing suicidal intent with a firearm. Key principles and phrasing from the training were used successfully by the EMD to dissuade the caller from self-harm, and he was ultimately safely met by first responders on scene and transported for care. We also share post-call recollections and reactions from the EMD to demonstrate how in addition to reducing risks for callers and their families, EMHD training has the potential to reduce on-scene risks for field responders and may increase confidence and mitigate negative stress responses in EMDs. Emergency medical services systems in the United States should continue to explore enhanced training and protocols to improve care for 9-1-1 callers experiencing mental health crises.

Objectives: The use of methoxyflurane is becoming increasingly popular in the treatment of pain in an emergency setting, in part due to its ease of administration. However, little is known about the risk of serious adverse events in children and adolescents. The aim of this study was to examine the safety of methoxyflurane in a pediatric population.

Methods: The study was a retrospective cohort study of pediatric prehospital events using probabilistic linked health data. All ambulance transfers in Western Australia between 1990 and 2016 involving children and adolescent patients were identified. Patients were categorized based on administered analgesia: methoxyflurane, an opioid analgesic, both methoxyflurane and an opioid analgesic, or no analgesic. Hospital and mortality data were linked to transferred patients to identify deaths, adverse drug reactions, liver and kidney toxicity, and re-admissions to hospital following ambulance transfer. Generalized linear models, adjusting for sociodemographic and ambulance transfer characteristics, were used to compare outcomes between children exposed to methoxyflurane and the other three groups.

Results: The study cohort consisted of 37,211 children, including 9,472 patients (25.5%) treated with methoxyflurane alone, 2,764 (7.4%) treated with an opioid analgesic, 1,235 (3.3%) treated with both methoxyflurane and an opioid analgesic, and 23,740 (63.8%) treated with no analgesic. Death in children and adolescents was uncommon, with less than five deaths (<0.1%) observed in the 12 months following treatment with methoxyflurane and no deaths in those treated with both methoxyflurane and an opioid analgesic. Adverse drug reaction was rare (<0.1%) in patients treated with methoxyflurane, as was liver and kidney toxicity with no case observed. At 90-days follow-up, there was no significant difference in hospitalization in patients treated with methoxyflurane and those treated with methoxyflurane and an opioid analgesic (adjusted OR:1.01, 95%CI:0.85-1.21). Compared with methoxyflurane treated patients, patients treated with an opioid analgesic were more likely to be hospitalized (aOR:1.23, 95%CI:1.09-1.39), while patients treated with no analgesic were less likely to be hospitalized (aOR:0.85, 95%CI:0.79-0.92).

Conclusions: In children and adolescents transported by ambulance, the use of methoxyflurane was not associated with an increased risk of hospitalization, death, serious adverse drug reactions or liver and kidney toxicity.

Objectives: Disparities remain in survival after out-of-hospital cardiac arrest (OHCA) for women compared to men. Our objective was to evaluate differences in automated external defibrillator (AED) use before Emergency Medical Services (EMS) arrival and time from arrival to initial EMS defibrillation by EMS-assessed gender (women or men).

Methods: This was a secondary analysis of adult non-traumatic, EMS-treated OHCA cases in the Portland Cardiac Arrest Epidemiologic Registry from 2018 to 2021. Emergency Medical Services-witnessed cardiac arrests were excluded and the primary outcomes were pre-EMS AED application and the time from EMS arrival to first defibrillation among patients in a shockable rhythm at first rhythm assessment without pre-EMS AED application. We examined pre-EMS AED application rates overall and separately for law enforcement, in cases where they were on-scene before EMS without a lay bystander AED applied, and lay responders, in cases where law enforcement had not applied an AED. We used multivariable logistic and linear regressions to adjust for potential confounders, including age, arrest location, witness status, bystander CPR, year, and time from dispatch to EMS arrival. We accounted for clustering by county of arrest using a mixed-effects approach.

Results: Of the 3,135 adult, EMS-treated non-traumatic OHCAs that were not witnessed by EMS, 3,049 had all variables for analysis, of which 1,011 (33.2%) were women. The adjusted odds (adjusted odds ratio [95% CI]) for any pre-EMS placement of an AED was significantly higher for men compared to women (1.40 [1.05-1.86]). These odds favoring men remained when examining law enforcement AED application (1.89 [1.16-3.07]), but not lay bystander AED application (1.19 [0.83-1.71]). Among patients still in arrest on EMS arrival, with a shockable initial EMS rhythm, and without pre-EMS AED application, the time from EMS arrival on-scene to initial defibrillation was significantly longer for women compared to men (+0.81 min [0.22-1.41 min]).

Conclusions: Women with OHCA received lower rates of pre-EMS AED application and delays in initial EMS defibrillation compared to men.