Prehospital Emergency Care最新文献

Objectives: To systematically review the (1) incidence, prevalence, and severity of mental health issues and occupational stress issues among emergency telecommunicators, and (2) effectiveness and harms of interventions to promote resistance and resilience regarding these issues.

Methods: We searched Medline, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, journals, and websites from January 1, 2001, through June 30, 2024. We conducted duplicate screening of titles and abstracts followed by full texts of potentially relevant records. We included studies of telecommunicators in high-income countries that reported the incidence/prevalence/severity of mental health issues and occupational stress issues or evaluated interventions targeting resistance/resilience regarding these issues. We excluded studies of telecommunicators in training during the study. We assessed the risk of bias using study design-specific tools, conducted meta-analyses using random-effects models, and evaluated strength of evidence (SoE) per Agency for Healthcare Research and Quality methods. We registered the systematic review prospectively in PROSPERO (CRD42023465325).

Results: We included 31 studies (29 cross-sectional studies, 1 pre-post study, and 1 randomized controlled trial) that evaluated a total of 6,621 participants. Research Question 1 (30 studies): No study reported on incidence of any outcome. During routine practice, prevalence estimates were: any depression 15.5%, suicidal ideation 12.4%, suicide plans 5.7%, suicide attempts 0.7%, alcohol abuse 15.5%, high/extreme peri-traumatic distress 5%, high secondary traumatic stress 16.3%, and acute stress disorder 17% (low SoE for each). In terms of severity, on average, depressive symptoms and stress were mild/low to moderate, burnout was mild to severe (moderate SoE); peri-traumatic distress was moderate, and secondary traumatic stress was mild (low SoE). After critical incidents, the prevalence of high and medium general stress was 39.7% and 28.2%, respectively (low SoE). In terms of severity, on average, burnout and general stress were moderate (low SoE). Research Question 2 (2 studies): The evidence was insufficient regarding the impacts of interventions on anxiety, depression, posttraumatic stress disorder, and alcohol use.

Conclusions: The prevalence and severity of mental health and occupational stress issues in the emergency telecommunicator workforce merits greater attention. Much more research is needed regarding the effectiveness of interventions for strengthening the resistance and resilience of the workforce.

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: 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: To systematically review the effectiveness and harms of interventions to promote resistance and resilience regarding mental health and occupational stress issues among emergency medical service (EMS) clinicians.

Methods: We registered the systematic review prospectively on PROSPERO (CRD42023465325). We searched Medline, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, journals, and websites for studies published from January 1, 2001, through June 30, 2024. We conducted duplicate screening of titles and abstracts followed by full texts of potentially relevant abstracts. We included studies of EMS clinicians in high-income countries that evaluated interventions targeting resistance or resilience regarding mental health or occupational stress issues. We assessed the risk of bias and evaluated strength of evidence (SoE) using standard methods.

Results: We included seven studies (one randomized controlled trial, one controlled trial with a waitlist control, four pre-post studies, and one prospective cohort [single group] study) that evaluated a total of 425 EMS clinicians. We deemed five of the seven studies to have high risk of bias, one moderate risk, and one low risk. No meta-analysis was feasible because of heterogeneity in the interventions evaluated across studies. Mindfulness-building interventions targeting resistance and resilience among EMS clinicians were associated with reduced burnout at up to 6 months of follow-up (low SoE). The evidence was insufficient regarding the impacts of interventions targeting both resistance and resilience on anxiety and depression. No conclusions are possible for resistance-only or resilience-only interventions. No studies reported on the effectiveness of any interventions in reducing hospitalizations, post-traumatic stress disorder, substance use, suicidality, or withdrawals from the workforce. No studies reported on unintended harms of interventions.

Conclusions: Given the sparse evidence identified in this systematic review, evidence-based options to improve mental health outcomes for EMS clinicians are very limited. Future research is urgently needed to inform strategies to address the many mental health and occupational stress issues that face the EMS clinician workforce.

Objectives: Major trauma is a leading cause of morbidity and mortality worldwide. It is unclear if the addition of a critical care response unit (CCRU) with capabilities comparable to hospital emergency departments might improve outcomes following major trauma, when added to Basic or Advanced Life Support (BLS/ALS) prehospital care. This systematic review describes the evidence for a CCRU scene response model for major trauma.

Methods: We searched Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), CINAHL (EBSCOhost), Science Citation Index Expanded (Web of Science), Conference Proceedings Citation Index - Science (Web of Science), LILACS (Latin American and Caribbean Health Sciences Literature) for relevant publications from 2003 to 2024. We included any study that compared CCRU and BLS/ALS care at the scene of major trauma, reported patient-focused outcomes, and utilized statistical methods to reduce bias and confounding. The risk of bias was assessed by two independent reviewers, using the ROBINS-I tool. Based on our a priori knowledge of the literature, a narrative analysis was chosen. The review was prospectively registered (PROSPERO ID CRD42023490668).

Results: The search yielded 5243 unique records, of which 26 retrospective cohort studies and one randomized controlled trial met inclusion criteria. Sample sizes ranged from 308 to 153,729 patients. Eighteen of the 27 included studies showed associations between CCRUs and improved survival following trauma, which appear to be more consistently found in more critically injured and adult patients, as well as those suffering traumatic cardiac arrest. The remaining nine studies showed no significant difference in outcomes between CCRU and BLS/ALS care. Most studies demonstrated critical or severe risks of bias.

Conclusions: Current evidence examining CCRU scene response for major trauma suggests potential benefits in severely injury patients but is limited by overall low quality. Further high-quality research is required to confirm the benefits from CCRU scene response for major trauma.

Objectives: The medical utilization rates (MUR) can be applied to anticipate necessary medical resources at mass gatherings. The MUR describes the number of patients per thousand attendees. The aim of this observational study was to evaluate whether the type of music festival, Electronic Dance Music Festivals (EDMF) versus Mainstream, is related to the MUR and to drug-related incidents.

Methods: We conducted a retrospective analysis of patient data from Event Medical Service B.V., a Dutch company, providing emergency care at many festivals in the Netherlands. Data were collected in an online database between February 2022 and August 2023. The number of patient contacts per festival type was recorded and patients requiring advanced medical care (unable to sit, potentially hemodynamically unstable, and/or requiring advanced medical care), were analyzed for drug-related causes.

Results: A total of 20,829 patients presented at 518 events with a total attendance of almost 7.5 million visitors. There were 253 EDMF events with a median attendance of 12,000 and 265 mainstream events with a median attendance of 10,000 per event. The average MUR for the EDMF group was higher compared to the Mainstream group (28.8 vs. 17.8, p < 0.001). A total of 1,732 patients needed advanced medical care. The proportion of drug-related cases among the patients needing advanced medical care, mainly stimulants and combined drug use, was 74% for the EDMF group compared to 52% in the mainstream group (p < 0.001).

Conclusions: In this observational study we found a clear difference in MUR in Electronic Dance Music events compared to Mainstream events with a higher percentage of drug-related cases in patients with more severe conditions at EDMF events. Our findings may help to better plan scarce medical resources at mass gatherings in the music scene and suggest that EDMF need a targeted approach for more drug-related pathology.

Objectives: Care home residents often experience medical emergencies requiring ambulance attendance that may lead to potentially avoidable hospitalization. We aimed to explore ambulance staff experiences of medical emergencies in care homes.

Methods: We used a qualitative design and purposive sampling to recruit frontline ambulance staff who had attended medical emergencies in care homes in England, United Kingdom. Data were collected using semi-structured interviews (conducted by telephone or online) and were analyzed using thematic analysis.

Results: We interviewed 15 ambulance staff members and developed four analytical themes, capturing what ambulance staff perceived facilitated or impeded high-quality care being provided during emergencies in care homes. Participants felt that effective communication was important to ensure a good care experience and discussed barriers to communications, such as language difficulties or disagreements during decision-making. They highlighted the need for better ongoing care in care homes, further training for ambulance and care staff, and that the current service pressures were a barrier to providing high-quality emergency care.

Conclusions: This study highlights the main challenges and facilitators that ambulance staff are faced with when dealing with emergencies in care homes. The findings will help inform the development and evaluation of interventions to improve outcomes and experiences of emergencies in care homes.

Objectives: The objective of this study was to evaluate the feasibility of point-of-care testing (POCT) devices for N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement in prehospital settings, with the aim of improving the speed and accuracy of stroke diagnosis, thereby facilitating quicker and more effective patient care.

Methods: Prehospital blood samples were collected from suspected stroke patients, and NT-proBNP levels were measured using a POCT device in ambulances and hospitals. Results from the NT-proBNP POCT and smartphone images were analyzed. Plasma samples underwent Elecsys proBNP II immunoassay after storage at -80ºC.

Results: A total of 121 suspected stroke patients were included in the study. The correlation between POCT measured by the POCT and immunoassay for NT-proBNP was strong (R = 0.926). Smartphone images also strongly correlated with POCT values at 10 min (R²=0.9716) and 15 min (R²=0.9405). Stability analysis of samples showed consistent NT-proBNP results and a high correlation (R = 0.907) was observed between plasma and whole blood samples for NT-proBNP POCT.

Conclusions: This study highlights the potential of NT-proBNP POCT devices in ambulances to expedite stroke diagnosis and management within 10 min. Smartphone integration further enhances efficiency, adding advancement in prehospital stroke management.

Objectives: While epinephrine is widely used for medical cardiac arrests, there is a knowledge gap regarding its utility for traumatic arrests. Traumatic arrests result from hypovolemia, hypoxia, or anatomic impairment of cardiac function such that the inotropic and vasoconstrictive effects of epinephrine may be ineffective or harmful. We hypothesized that epinephrine does not improve survival among patients with traumatic cardiac arrest.

Methods: This was a multicenter retrospective cohort study of trauma patients sustaining prehospital cardiac arrest who were treated at seven level I and II trauma centers over 6 years (2011-2017), ascertained via trauma registry data and chart abstraction. The primary outcome was survival to hospital discharge; patients treated with or without epinephrine were compared. Multivariable analyses were performed using Poisson regression. Time to event analyses were conducted using Cox proportional hazard models.

Results: We included 1631 adult and pediatric trauma patients with prehospital cardiac arrest. Prehospital epinephrine was administered to 844 (52%). The median age was 35 years, 335 (21%) were female, 712 (44%) sustained blunt trauma, and 58 (4%) had a shockable initial rhythm. Survival to hospital discharge was significantly lower in the prehospital epinephrine cohort compared to the no epinephrine cohort in univariable analysis [43/844 (5%) vs. 125/787 (16%), p < 0.001]. Among patients with blunt mechanism, survival was significantly lower in the prehospital epinephrine cohort [12/382 (3%) vs. 54/330 (16%), p < 0.001]. Among patients with penetrating mechanism, survival was not statistically different [10/276 (4%) with epinephrine vs. 22/374 (6%) without, p = 0.19]. In multivariable analyses adjusting for age, sex, mechanism, and initial rhythm, epinephrine was associated with lower likelihood of survival in the overall and blunt cohorts; there was no significant difference in the penetrating cohort (overall aRR 0.33, 95% CI 0.23-0.46; blunt aRR 0.20, 95% CI 0.11-0.37; penetrating aRR 0.62, 95% CI 0.30-1.28). Adjusted and unadjusted time to event analyses across each of these cohorts showed that epinephrine was associated with either statistically inferior or indistinct hazard ratios.

Conclusions: Epinephrine was not associated with improved survival following traumatic cardiac arrest, and in multiple subanalyses, it was associated with inferior outcomes. These results may inform prehospital traumatic arrest protocols.

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.