Prehospital Emergency Care最新文献

Objectives: Social determinants of health (SDOH) are the non-medical factors that affect people's health and quality of life. Emergency medical services (EMS) clinicians are in a unique position to recognize and respond to SDOH through their presence and responses in the communities they serve. The objective of this study was to generally explore the existing body of literature of SDOH within the context of EMS.

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guided the analysis of peer-reviewed literature from PubMed, CINAHL, and Web of Science databases published between January 1960 and June 2024. Using Covidence software, titles and abstracts then, separately, full texts, were reviewed by two distinct researchers to include studies published in English that referenced SDOH and EMS. We later excluded articles that were published before 2010, when the SDOH term was made more popular by its inclusion in the Healthy People 2020 project. Reviewers then performed data extraction for qualitative analysis using a grounded theory approach.

Results: Of the 1,503 records imported from the databases (PubMed n = 779, Web of Science n = 687, CINAHL n = 37), 1,164 unique manuscripts were screened, and 62 full texts were assessed for eligibility. Forty-two articles met inclusion criteria; 39 were EMS patient-centric and three were illustrative of EMS clinicians' SDOH, thus excluded from this analysis. Patient-related impact levels included individual characteristics, community characteristics, EMS clinicians' recognition of and response to SDOH, healthcare system factors, and social and cultural considerations. Articles were on the topic areas of medical conditions, EMS practice, trauma, pediatrics, and mental health. More than half (n = 24) of the manuscripts were from studies conducted in North America and a majority (n = 32) of the papers were published since 2020.

Conclusions: Research in SDOH and their association with EMS is rapidly growing. A deeper understanding of how the EMS system and EMS clinicians affect, recognize, and manage patients' SDOH insecurities can improve efforts toward health equity and improve patients' health outcomes.

Objective: Emergency department (ED) capabilities, such as trauma center or stroke center designation, are key to understanding the effects of emergency medical services (EMS) transport destination decisions on patient outcomes. In current EMS datasets, ED capabilities are self-reported by the EMS clinician or agency. The reliability and validity of the EMS-reported ED capabilities is unknown. Our objective was to link EMS transport destinations with verified ED capability data to develop a novel national dataset to better understand prehospital routing practices.

Methods: We linked two cross-sectional databases: the 2021 ESO Data Collaborative and the 2021 National Emergency Department Inventory (NEDI)-USA. The ESO Data Collaborative contains de-identified prehospital patient care records from nearly 2,000 participating EMS agencies across the United States. The NEDI-USA is a survey of all nonfederal, non-specialty U.S. EDs open 24/7/365 (including freestanding EDs), with verified stroke, trauma, and burn capability data. From EMS records, we obtained all unique destinations designated as "hospital" as of 2021. After verifying addresses were NEDI-eligible EDs (i.e., providing emergency services 24/7/365), we performed a 3-step linkage process to NEDI-USA: (1) name/address exact matches; (2) probabilistic matching on name/address based on bigrams, accepting adequate (>85%) match scores after review; and (3) hand-matching using Google Maps. We calculated descriptive statistics to describe the linkage process.

Results: Of the 9,420 unique "hospital" destinations in the EMS dataset, 2,714 (29%) were non-hospital facilities (e.g., nursing home) or were non-NEDI-eligible (e.g., specialty hospital such as a psychiatric facility). We linked 98% (n = 6,605/6,706) of NEDI-eligible EMS hospital transport destinations to EDs in NEDI-USA. Excluding duplicate addresses for a single hospital (e.g., ED address versus main entrance address), the linked addresses represented 3,877 unique EDs in 49 states, which included 68% (n = 3,821/5,580) of the EDs included in the 2021 NEDI-USA database.

Conclusions: We successfully linked 98% of EMS ED transport destinations to verified ED capability information. This novel linked dataset now includes rich destination capability information associated with each EMS transport that can be leveraged for describing and improving routing practices for specific patient conditions, such as patients with stroke-like symptoms to stroke centers or major traumas to verified trauma centers.

Objectives: Although disparities exist in aspirin administration for chest pain and ST elevation myocardial infarctions (STEMI), little is known about community-based disparities in aspirin administration for prehospital patients. We evaluated disparities in prehospital aspirin using a national prehospital database.

Methods: We conducted a retrospective analysis of the 2018-2021 NEMSIS database linked to census data, including adult prehospital encounters. We created two cohorts: dispatch reason of chest pain and identified STEMI on prehospital EKG. We stratified patients based on majority ZIP Code race/ethnicity (>50% White, Black, and Hispanic) and into quartiles based on household income. Using multivariable logistic regression, we evaluated the association between incident community characteristics and aspirin administration.

Results: We included 4,881,663 chest pain encounters and 184,610 STEMIs. Chest pain encounters in majority White communities (32.3%) received aspirin more often for chest pain than Black (22.1%; aOR 0.59, [0.59-0.60]) or Hispanic (24.8%; aOR 0.66, [0.66-0.67]) communities. Compared to the top income quartile (29.0%), the lowest income quartile had lower odds of aspirin administration (4th-27.6%; aOR 0.93, [0.92-0.94]). For STEMIs, adjusted odds of aspirin administration were higher for White (53.4%) than Black (52.5%; aOR 0.81, [0.78-0.84]) or Hispanic (53.6%; aOR 0.93, [0.89-0.96]) patients. Compared to the highest income quartile (55.0%), lower quartiles had lower odds of aspirin administration (2nd-54.2%; aOR 0.95, [0.92-0.97]; 3rd-52.9%; aOR 0.93, [0.91-0.96]; 4th-52.0%; aOR 0.86, [0.84-0.89]).

Conclusions: Patients from Black, Hispanic/Latino, and lowest-income communities received aspirin for chest pain at a lower rate than white or high-income patients.

Objectives: Early hospital transport may benefit out-of-hospital cardiac arrest (OHCA) patients with shockable rhythms who are refractory to defibrillation, particularly in settings with limited advanced on-scene interventions. However, its impact in emergency medical service (EMS) systems with limited advanced cardiac life support (ACLS) capabilities remain unclear. This study aimed to assess the association between intra-arrest transport and survival outcomes in OHCA patients with initial shockable rhythms who remained in refractory shockable rhythms despite the first defibrillation attempt.

Methods: Using a nationwide OHCA registry from a country with an intermediate prehospital service level where interventions such as prehospital anti-arrhythmic drugs or double sequential defibrillation are not feasible, adult medical OHCA patients with initial shockable rhythms who failed the first defibrillation between January 1, 2015, and December 31, 2022 were analyzed. The primary outcome was good neurological recovery. Time-dependent propensity score matching was performed to assess the association between intra-arrest transport and survival outcomes. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated, and stratified analyses were performed based on matched time intervals after the first defibrillation.

Results: Of 10 246 eligible patients, 8131 underwent intra-arrest transport. After 1:1 time-dependent propensity score matching, 2332 patients each in the intra-arrest transport and on-scene resuscitation groups were included. In the matched cohort, intra-arrest transport was not associated with good neurological recovery (11.7% and 11.5% in the intra-arrest transport and on-scene resuscitation groups, respectively; RR [95% CI] 0.97 [0.91-1.07]). In the stratified analyses based on matched time intervals after the first defibrillation, intra-arrest transport within 5 min after the first defibrillation was associated with poorer neurological outcomes (RR [95% CI] 0.86 [0.77-0.97]).

Conclusions: In an EMS setting with a limited-service level, intra-arrest transport showed no benefit for OHCA patients with an initial shockable rhythm who remained in refractory shockable rhythms despite the first defibrillation attempt. High-quality on-scene management is crucial before the initiation of hospital transport. Further research is needed to develop integrated systems ensuring effective prehospital and hospital care.

Objectives: Motorcycle helmets save lives and reduce serious injury after motorcycle collisions (MCC). In 2022, 18 states had laws requiring helmet use by motorcyclists aged ≥21 years. Our objective was to compare helmet use and head trauma in emergency medical services (EMS) patients involved in MCC in states with and without helmet use laws.

Methods: We conducted an analysis of the 2022 ImageTrend Collaborate national EMS dataset. We included 9-1-1 responses where the patient was a motorcyclist in a transport accident (ICD-10 V20-V29) and aged ≥21 years. Patient demographics, incident urbanicity, helmet use, presence of state helmet use law, patient disposition, Glasgow Coma Scale (GCS) score, and trauma team activations were examined. Our primary outcome of interest was EMS documentation of helmet use (yes/no). Our secondary outcome was the presence of a head injury. We examined EMS-documented head injury, defined using clinician impressions and chief complaint anatomical location. Chi-square tests were used to assess differences in proportions, and a multivariable logistic regression model was used to estimate odds of moderate/severe head injury adjusted for covariates of interest.

Results: A total of 15,891 patient encounters were included, 10,738 (67.6%) occurred in states without helmet use laws. States without helmet use laws had higher proportions of unhelmeted patients (56.8% vs 24.2%, p < 0.001), encounters in non-metro/rural areas (19.7% vs 13.3%, p < 0.001), and GCS-defined moderate/severe head injuries (4.6% vs 2.3%, p < 0.001). In a multivariable model that included 10-yr age groups, sex, race, urbanicity, and documented helmet use, the adjusted odds of moderate/severe head injury were lower for females (0.47, 95%CI, 0.35-0.65) and Black patients (0.47, 95%CI 0.32-0.70), and were higher for incidents in nonmetro/rural areas (1.58, 95%CI 1.28-1.95) and when EMS had not documented helmet use (3.17, 95%CI 2.56-3.92).

Conclusions: In this retrospective cross-sectional study, a higher proportion of patients involved in MCCs in states without helmet laws were not wearing helmets at the time of injury, and unhelemted patients had increased likelihood of sustaining a head injury. EMS agencies in states without helmet laws should prepare their systems and clinicians for an increased incidence of head injuries after MCCs.

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: Emergency medical services (EMS) personnel, including EMS physicians, should reflect the diversity of the patient populations they serve to ensure equitable healthcare outcomes. The historical predominance of White male EMS medical directors may contribute to disparities in patient care. Recruiting and training a diverse cadre of EMS fellows is a key step toward fostering equity in EMS leadership and improving outcomes for diverse communities. This study examines demographic trends among EMS fellows and explores their implications for advancing equity in EMS care delivery.

Methods: Publicly available data were extracted from the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books for the academic years 2012-2013 through 2022-2023. Data regarding residents' and fellows' self-identified gender and race/ethnicity were analyzed for EMS fellowships, emergency medicine (EM) residencies, and all residencies/fellowships. The investigation utilized chi-square tests to analyze associations between categorical variables, such as gender and race, and the Cochran-Armitage Trend Test to evaluate trends in proportions across years.

Results: Data for 680 EMS fellows during the 11-year period were reviewed. Overall, 66% (range 55-78%) of EMS fellows were male and 34% (range 22-45%) were female. There was a smaller proportion of female EMS fellows than female EM residents (37%), female toxicology fellows (39%), female pediatric emergency medicine (PEM) fellows (65%), and female residents overall (45%). The majority of EMS fellows identified as White (75%, range 69-100%). The next most commonly reported race/ethnicity by EMS fellows was Asian (8%, range 0-13%). There was a larger proportion of White EMS fellows than White toxicology fellows (68%), White EM residents (60%), White PEM fellows (49%), and White residents overall (45%). There were no significant trends in gender or race/ethnicity of EMS fellows over time.

Conclusions: Over the first 11 years since fellowship accreditation, one third of EMS fellows were female and more than three quarters of EMS fellows were White. EMS leaders, including fellowship directors, should strengthen the recruitment of women and underrepresented racial and ethnic minority groups in EMS medical direction.

Objectives: Neonates, infants 30 days of age or younger are understudied in prehospital emergencies. Our objective was to describe prehospital assessment and care for patients <30 days of age at the San Diego-Tijuana Point of Entry (POE). Additional objectives included describing assessments, care, frequency, and level of care for newborns brought to the border by Mexican ambulances.

Methods: This was a retrospective analysis from January 1, 2014, to January 01, 2020, of all 9-1-1 calls involving patients <30 days of age at the San Diego POEs. The 9-1-1 responses to newly delivered patients were "newborns". Patients who were not immediately post-delivery were "neonates." Patient demographics, response intervals, clinician interventions, and dispositional data were collected from electronic patient records. Descriptive statistics were applied.

Results: A total of 57 patients <30 days of age were included. With 27 newborn patients, 15 were delivered by emergency medical services (EMS) personnel (27, 55.6%). Initial appearance, pulse, grimace, activity, and respiration (APGAR) scores were 8-10 in 44.4% and 5-7 in 29.6%. Procedures included newborn care (88.9%), advanced life support (ALS) assessment (63.0%), and warming (59.3%). There were five patients that had stimulation, 7 received oxygen, and 3 received Bag-Valve-Mask (BVM) ventilation. No serial heart rates were documented. Regarding 30 neonates, the predominant method of transport to the POE was Mexican ambulance (n 16, 53.3%). Medications administered included oxygen (n 16, 53.3%) and albuterol/ipratropium (n 1, 3.3%). Procedures included ALS assessment (n 19, 63.3%), pulse oximetry (n 22, 73.3%), and 3-lead electrocardiogram (n 8, 26.7%). Three patients (10%) received BVM. Mexican Ambulances brought 16 neonates. A physician or nurse was present in 37.5% of transfers, 50% were incubated, 25% intubated, 37.5% on supplemental oxygen, and 71% had preexisting intravenous access. These were not interfacility transfers but were 9-1-1 activations by U.S. border agents; and 14 neonates did not arrive via Mexican ambulance. Their complaints were respiratory distress (n 7, 50%) and Brief Resolved Unexplained Episode (n 4, 28.6%).

Conclusions: We found that 9-1-1 transports at the San Diego-Tijuana POE for patients <30 days were few and involved resuscitation, neonates in Mexican ambulances with specialized equipment, physicians, and unfamiliar medications. Neonates arriving via private transport had respiratory distress and BRUE.

Objectives: The impact of emergency medical services (EMS) response times when integrating bystanders' automated external defibrillator (AED) use into established response systems remains unclear. This study aims to investigate 30-day survival probabilities for different EMS response times for bystander and non-bystander defibrillated patients and identify for which EMS response times bystander defibrillation improves 30-day survival probability.

Methods: Data on patients with bystander witnessed out-of-hospital-cardiac arrest (OHCAs) with initial shockable rhythm who received bystander cardiopulmonary resuscitation were retrieved from Danish Cardiac Arrest Registry for years 2016-2022. Proportions of 30-day survival were calculated for five intervals of EMS response time for patients who received bystander defibrillation and those who did not. The causal inference framework utilizing targeted maximum likelihood estimation was used to estimate 30-day survival probability for each interval of EMS response time and when comparing cases where bystander defibrillation was performed with those where it was not. This analysis was adjusted for relevant confounding factors and conducted separately for residential and public OHCAs.

Results: The study included 3,924 patients with OHCA. Bystander defibrillation was more frequent in public than in residential OHCAs (64.1% vs. 35.9%). Short EMS response times had higher 30-day survival probability. Bystander defibrillation resulted in higher probability of 30-day survival for EMS response times of 7-9 min (survival ratio 1.24 [95% CI: 1.03; 1.49]) in public OHCAs in the adjusted model, when compared to non-bystander defibrillated patients.

Conclusions: With EMS response times of 7-9 min, we detected a clear 30-day survival benefit for bystander defibrillated patients in public locations. No 30-day survival benefits were seen for other EMS response time intervals or in residential locations.