Prehospital Emergency Care最新文献

Objectives: Antiarrhythmic administration is an important treatment for out-of-hospital cardiac arrest (OHCA) with a shockable rhythm, but a minimal amount is known about disparities in such antiarrhythmic practices. We sought to investigate the association between community race/ethnicity and prehospital antiarrhythmic administration for OHCA.

Methods: We conducted a retrospective study of a national prehospital database, National Emergency Medical Services Information System (NEMSIS), linked to Census data. We included OHCAs with a shockable rhythm from 2018 to 2021. We stratified patients based on majority (>50%) ZIP code race/ethnicity (non-Hispanic White (White), non-Hispanic Black (Black), and Hispanic/Latino). We then created two cohorts: (1) patients with a shockable rhythm at any point to study differences in antiarrhythmic administration rates, and (2) patients with an initial shockable rhythm to analyze differences in time to antiarrhythmic administration. For patients with a shockable rhythm at any point, we used logistic regressions to evaluate the association of community race to antiarrhythmic administration. For patients with an initial shockable rhythm, we compared the time from emergency medical services (EMS) dispatch to the first antiarrhythmic administration.

Results: Of 763,944 cardiac arrests, 311,499 had a shockable rhythm during the OHCA, and 237,838 had an initial shockable rhythm. For patients with a shockable rhythm at any point, majority White (33.0%) received antiarrhythmics at a higher rate than majority Black (28.9%; aOR 0.9, 95%CI 0.8-0.9) and majority Hispanic/Latino (27.8%; aOR 0.8 95%CI 0.7-0.8). For patients with an initial shockable rhythm, the time to antiarrhythmic for White (median 19.6 min, IQR 15.00-26.28 min) was lower than for Black (median 20.5 min, IQR 16.33-26.35 min, p < 0.01) but higher than Hispanic/Latino (median 18.0 min, IQR 14.33-23.42 min, p < 0.01).

Conclusions: While antiarrhythmic administration rate was lower for minority communities and time to antiarrhythmic was higher for Black OHCAs, time to antiarrhythmic administration was lower for Hispanic/Latino OHCAs.

Objectives: Out-of-hospital cardiac arrest (OHCA) victims receiving defibrillation from an automated external defibrillator (AED) placed early in the chain of survival are more likely to survive. We sought to explore the accuracy of AED pad placement for lay rescuers (LR) and first responders (FR).

Methods: We conducted a secondary analysis of data collected during randomized OHCA simulation trials involving LRs and FRs. The LRs received hands-only CPR and AED guidance from a simulated 9-1-1 telecommunicator. The FRs did not receive telecommunicator instruction. Participants were surveyed about medical training and experience. Correct AED pad placements (anterior: AP, lateral: LP) were individually determined from video abstraction based on manufacturer's recommendations and distance to anatomical landmarks. Incorrect AP placement was defined as the upper edge of the pad past the crest of the trapezius, the medial edge past midline, or the lower edge beyond the nipple line. Incorrect LP placement was defined as the upper edge of the pad past the nipple line, the medial edge past midline, or the lower edge beyond the navel line. We examined the association between correct pad placement and previous CPR training (current, expired, or never) for LR and correct pad placement and self-reported recent field experience (<1 year) with AED application for FR using Fisher's exact.

Results: Lay rescuers correctly placed the AP in 30/38 (78.9%) and the LP 30/38 (78.9%) simulations. Application did not differ significantly based on previous CPR training (AP p = .236, LP p = .621). The most common incorrect placement was too low for both AP (5/8, 62.5%) and LP (4/8, 50.0%). First responders applied the AP correctly in 16/18 (88.9%) and the LP in 14/18 (77.8%) simulations. Among FRs, correct pad application did not differ significantly based on recent field experience (AP p = .497, LP p = .119). The most common incorrect placement was too low for both AP (2/2, 100.0%) and LP (3/4, 75.0%).

Conclusions: There is an opportunity for improvement for both LRs and FRs to apply AEDs per manufacturer's recommendations. Further research is needed to improve instructions and follow-up training to ensure accurate AED pad placement.

Objectives: In 2021, the opioid overdose crisis led to 1441 fatalities in Chicago, the highest number ever recorded. Interdisciplinary post-overdose follow-up teams provide care at a critical window to mitigate opioid-related risk and associated fatalities. Our objective was to describe a pilot follow-up program in Chicago including eligible overdose incidents, provision of response team services, and program barriers and successes.

Methods: Chicago's Crisis Assistance Response and Engagement Overdose Response Team (CARE ORT) was piloted starting February 1, 2023 across three neighborhoods that collectively responded to an average of 6-7 opioid-related Emergency Medical Services (EMS) incidents each day, among the highest in Chicago. The program involved a two-member field response team consisting of a community paramedic and a peer recovery coach that followed-up with individuals who experienced an opioid overdose in the previous 24-72 h to offer connections to treatment, overdose education and harm reduction kits including naloxone.

Results: During its 14-month pilot, there were 2875 eligible overdose events within the pilot area. A total of 723 (25.2%) individuals received an outreach attempt, of which 65 individuals (9.0%) were reached and accepted services. Most overdose incident locations were in public locations (78.4%), but most of the patients that CARE ORT served had overdosed in a private residence (76.9%) and reported being stably housed (71.0%). Among the 65 individuals reached and served, 31 (47.7%) had a prior overdose event in the past 12 months and 32 (49.2%) accessed naloxone in the past three months. Twenty-nine out of 65 CARE ORT patients (44.6%) were referred to outpatient, inpatient or residential treatment and 19 of those (65.5%) for medication assisted recovery with buprenorphine, methadone, or naltrexone.

Conclusions: The CARE ORT model proved successful in engaging predominantly older, non-Hispanic Black men in post-overdose outreach who were stably housed. While the number of individuals reached compared to the total eligible individuals was low, the program successfully navigated multiple barriers of limited EMS referral information, limited accuracy of data management, and urban realities of public overdose locations to reach a marginalized patient population with a high risk of mortality.

Objectives: Survival from out-of-hospital cardiac arrests (OHCA) remains lower in rural areas. Longer Emergency Medical Services (EMS) response times suggests that rural OHCA survival may need to rely more on early bystander intervention. This study compares the rates of bystander Cardiopulmonary Resuscitation (CPR) between rural and urban areas and examines societal factors associated with bystander CPR.

Methods: This study was a retrospective cohort study using merged county-level data from the National Emergency Medical Services Information System (NEMSIS) sample from 2019 and 2020, the 2019 American Community Survey, and the Bureau of Health Care Workforce data. We included all adults (age ≥ 18) with OHCA who were treated by an EMS clinician reporting data to NEMSIS, with the primary exposure of OHCA rurality, and the primary outcome of bystander CPR by a member of the public. Rurality was assigned using the Rural Urban Commuting Area code associated with the OHCA location. Cases were excluded if there was an indication for witnesses identified as health care personnel, the incident occurred at a health care site, or geographical data were not available. The association between patient- and community-level covariates and bystander CPR were measured using generalized estimating equations to model the adjusted odds ratios (aOR) and 95% confidence intervals (CI), clustering on county.

Results: A total of 99,171 OHCA patients were identified and 60.9% (n = 60,380) received bystander CPR. Patients with OHCA living in isolated small rural towns (aOR: 1.57, 95%CI: 1.28-1.91) were more likely to have bystander CPR when compared to those living in urban cities. The odds of bystander CPR was lower in counties with larger populations of those without high school diplomas (e.g. >15% vs ≤6%, aOR: 0.56; 95%CI: 0.51-0.61), non-Caucasian populations (e.g. >40% vs ≤10%, aOR: 0.83; 95%CI: 0.76-0.91), and older populations (e.g. >14% vs ≤9%, aOR: 0.82; 95%CI: 0.74-0.91).

Conclusions: We observed lower rates of bystander CPR in communities with lower education, higher rates of non-Caucasian populations, and older populations. Our findings emphasize the need for public interventions in bystander CPR training to meet the needs of diverse community characteristics, and particularly in areas where EMS response times may be longer.

While several studies have focused on preliminary data and outcomes associated with prehospital buprenorphine administration interventions, to date there has been little discussion of the challenges experienced during the initial implementation of a prehospital buprenorphine protocol. In this case series we examine 3 separate patient encounters with different crews, patients, and receiving emergency medicine (EM) physicians, which highlight initial challenges experienced with implementing the first prehospital buprenorphine program in a rural Appalachian County within South Carolina. In 2 cases we highlight conflicts that may require collegial intervention and education of local receiving EM physicians regarding the new prehospital protocol. In 1 case we describe a patient who was eligible but not enrolled due to a misunderstanding among an Emergency Medical Services (EMS) clinician of how to correctly apply protocol criteria. We discuss the management of each implementation issue and outcomes after follow-up with members of the study team. As these novel programs emerge, understanding the potential challenges and personal biases that may be encountered when implementing a prehospital buprenorphine administration protocol is essential to inform organizations planning to implement similar programs.

Objectives: Clinical management of traumatic brain injury (TBI) focuses on preventing secondary injury from cerebral edema and ongoing anoxic injury. Consensus guidelines recommend maintaining systolic blood pressure (SBP) ≥ 110 mmHg. A recent prehospital study suggested lowest adjusted mortality from 130 mmHg to 180 mmHg, suggesting the ideal pressure may be higher. This study aims to explore and externally validate the association between lowest out-of-hospital SBP and mortality in a nationwide database.

Methods: Retrospective observational study of nationwide data from the ESO© (Austin, TX) prehospital electronic health record. Inclusion criteria were an ICD-10 code for TBI, age >10 years, admission to the hospital, abbreviated injury severity head/neck sub-score ≥ 3. Data were split into 70% training and 30% test sets. Unadjusted and adjusted generalized additive models with splines for the continuous variables of SBP and age were created to assess the relationship between lowest SBP and mortality. Adjusted model covariates included age, sex, injury severity score, mechanism, polytrauma, trauma center transport (level 1, 2, or 3), hypoxia and airway management. To evaluate the independent association of lowest SBP with mortality, the adjusted marginal means for predicted probability of death at any fixed value of SBP were estimated and an optimized SBP range was identified. Age and injury severity were evaluated as possibly relevant interaction terms with SBP.

Results: From 2018 to 2022, 44,360 encounters with ICD-10 codes for TBI were screened and 9,449 met final inclusion criteria, with 2,005 meeting the primary outcome (21.2%). Both unadjusted and adjusted analysis identified lowest prehospital SBP as a significant predictor (p < 0.001). Based on adjusted marginal means, the optimized SBP for mortality was 132 mmHg (range 110-158 mmHg). The interaction between SBP and age was significant with a higher optimized SBP of 133 mmHg (range 125-145 mmHg) for patients aged 65 and older.

Conclusions: Out-of-hospital SBP is a significant predictor of mortality in subjects with severe TBI. These results suggest an optimized SBP range 110-158 mmHg, consistent with current consensus guidelines of SBP > 110 mmHg but may suggest benefit for higher SBP targets in older patients.

Objectives: Despite early evidence of effectiveness, cost-savings, and resource optimization, mobile integrated health (MIH) programs have not been widely implemented in the United States. System, community, and organizational-level barriers often hinder evidence-based public health interventions, such as MIH programs, from being broadly adopted into real-world clinical practice. The objective of this study is to identify solutions to the barriers impeding the implementation of MIH through interviews with multilevel stakeholders.

Methods: Using the CENTERing multi-level partner voices in Implementation Theory methodology, the study team recruited stakeholders to participate in semi-structured interviews that were recorded, transcribed, and open-coded. Stakeholders were asked to explore and propose solutions to established barriers to the implementation of MIH programs including poor understanding of the role of MIH, the absence of sustainable reimbursement for MIH programs, and its disruption of existing clinical workflows. The study team used the Consolidated Framework for Implementation Research to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes related to pragmatic solutions for overcoming barriers to the adoption of MIH.

Results: Interviews with Department of Public Health officials, medical directors of MIH programs, non-physician MIH program leaders, community paramedics, health insurance officials, ambulatory physicians, hospital administrators, and hospital contract specialists (n = 18) elicited solutions to address barriers including (1) Developing a consistent identity for the MIH paradigm, (2) adopting an interdisciplinary approach to the development of efficient MIH workflows that utilize informatics to mimic existing clinical work, and (3) implementing capitated fee schedules that are cost-effective by targeting high-risk populations that are already a priority for payors.

Conclusions: An investigation of solutions to barriers that impede the translation of MIH models into sustainable practice elicited several unifying themes including the establishment of a cohesive identity for MIH to improve engagement and dissemination, the use of a strategic approach to program design that aligns with existing healthcare delivery workflows and collaboration with payors to promote a robust reimbursement structure. These findings may help accelerate the implementation of MIH programs into real clinical practice.

Objectives: Fatal and nonfatal pediatric opioid poisonings have increased in recent years. Emergency medical services (EMS) clinicians are often the first to respond to an opioid poisoning and administer opioid reversal therapy. Currently, the epidemiology of prehospital naloxone use among children and adolescents is incompletely characterized. Thus, our study objective was to describe naloxone administrations reported by EMS clinicians during pediatric activations in the United States. Methods: We performed a cross-sectional study using the National Emergency Medical Services Information System (NEMSIS). Within NEMSIS, we identified emergency responses where children 1 day through 17 years old were documented by EMS to have received ≥1 dose of naloxone in 2022. We analyzed demographic and EMS characteristics and age-specific prevalence rates of activations where naloxone was reported. Results: In 2022, 6,215 activations involved naloxone administration to children. Most activations involved males (55.4%, 3,435 of 6,201) and occurred in urban settings (85.7%, 5,214 of 6,083). Naloxone administration prevalence per 10,000 activations was highest among the 13-17 year age group (57.5), followed by the 1 day to <1 year (17.9) age group. A dispatch complaint of an overdose or poisoning was documented in 28.9% (1,797 of 6,215) of activations and was more common among activations involving adolescents aged 13-17 years (31.5%, 1,555 of 4,937) than infants 1 day to <1 year (12.8%, 48 of 375). The first naloxone dose was documented to improve clinical status in 54.1% (3,136 of 5,793) of activations. Naloxone was documented to worsen clinical status in only 0.2% (11 of 5,793) of activations. Conclusions: In pediatric activations involving naloxone, less than one-third were dispatched as an overdose or poisoning but over half were documented to clinically improve after the first dose of naloxone. Naloxone was rarely documented to worsen clinical status. Our findings highlight the safety of prehospital naloxone use, as well as the importance of a high index of suspicion for opioid poisoning in the pediatric population. Opportunities exist to leverage linked data sources to develop interventions to improve prehospital opioid poisoning recognition and management.

Objectives: International Prehospital Emergency Care (PEC) standards have been primarily developed by and for high resource settings. Most PEC systems in Asia, which are still in the early stages of development, struggle to achieve these standards. There is a need for an evaluation tool which can define achievable basic building blocks for PEC systems in low resource settings to improve quality of PEC. We aimed to identify the core, basic elements (building blocks of a PEC system) for a Prehospital Emergency Care Systems Evaluation Tool (PECSET) for low resource settings in Asia.

Methods: A 4-stage modified Delphi consensus method was used to engage 32 PEC experts from 12 Asian countries. Participants voted on 32 elements identified from a prior scoping review, focus group discussions, and survey. Each round of voting was conducted through an anonymous, web-based application and followed by face-to-face group discussions. The first two rounds aimed to answer, "Is the element important and feasible in a low resource setting?" The last two stages aimed to answer "Should this element be prioritized as core in the tool?" A thematic analysis of the recorded and transcribed discussions was used to identify participants' rationale for prioritization.

Results: After four rounds of voting, 12 elements were identified as core elements: (1) dispatch assisted instructions, (2) protocols for screening, triage and destination, (3) medical direction, (4) standardized training programs, (5) minimum ambulance standards, (6) operational metrics, (7) quality assurance, (8) operational safety protools, (9) essential patient care documentation, (10) medical records management, (11) layperson awareness and education and (12) universal access emergency number. However, the participants decided to include all 32 elements in the tool grouped into broader categories by percent agreement for a tiered approach for early, intermediate, and advanced PEC systems. Rationales for prioritization included a need for focus on basic infrastructure and building resilience in resource-stretched systems.

Conclusions: Through a Delphi consensus process, stakeholders identified core elements for PEC systems in low resource settings. These findings will inform the development of a tool for quality assurance and monitoring in low resource settings in South and Southeast Asian countries.

Objectives: Take home naloxone kits can reduce mortality, but we know little about how they are perceived by people with lived experience of opioid use. Provision of naloxone in the community has been shown to significantly reduce mortality from opioid overdose. Currently, this is predominantly through drug treatment support services but expanding provision through other services might be effective in increasing kit take-up and mortality reduction. This study aimed to examine participants' experiences of opiate overdose and acceptability of provision of naloxone kits through ambulance/paramedic emergency services (EMS) and hospital Emergency Departments (ED).

Methods: Qualitative interviews were conducted with 26 people who had direct experience of opioid use. Participants were recruited at two substance-use treatment centers and a third sector support organization in three large cities in the United Kingdom. Interviews examined respondents' experiences of opioid use and opioid overdose, access and personal use of naloxone kits, and opinions about kit provision from EMS and hospital ED staff. Interview data were thematically analyzed using a constant comparative method.

Results: Four key themes were identified during analysis: (1) High levels of overdose experience and knowledge of naloxone and naloxone kits; (2) naloxone kits were perceived as effective and easy to use; (3) There were some concerns around the risks of administering naloxone, such as peer aggression during withdrawal. (4) Participants supported much wider personal, family and peer provision of naloxone kits from community support organizations as well as from EMS.

Conclusions: Participants felt naloxone kits were an important resource and they wanted increased provision across a range of services including EMS and hospital ED staff as well as community pharmacies and needle exchange centers. Participants wanted naloxone kit provision to be extended to peers, family and friends.