Prehospital Emergency Care最新文献

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: 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: 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: There are well-described racial, ethnic, and gender-based inequities following out-of-hospital cardiac arrest (OHCA). Few studies have analyzed disparities in emergency medical services (EMS) termination of resuscitation (TOR) practices. This purpose of this study was to identify inequities in duration of prehospital resuscitation prior to TOR.

Methods: A retrospective cohort of adult (≥18 years-old), non-traumatic OHCA events in a single metropolitan, fire-based EMS system was evaluated. Duration of resuscitation prior to prehospital TOR was separately evaluated among racial/ethnic (Black, Hispanic, and White) and gender (female and male) groups using a multivariable linear regression model. Variables in the model included bystander cardiopulmonary resuscitation (CPR) provision, arrest witnessed status, initial rhythm (shockable versus non-shockable), and patient age. Multiple imputation was used to account for missing data entries where duration of resuscitation was not documented. Incidence of hospital transport between racial/ethnic and gender groups was also assessed.

Results: Between February 1, 2020 and February 28, 2023, 3700 patients met inclusion criteria, of which 1,895 (51.2%) had field TOR and 1,328/1,895 had a documented time of TOR. When controlling for arrest witnessed status, bystander CPR provision, initial shockable rhythm, and subject age, Black race [24.1 min (95% confidence interval 21.2-27.0, p < 0.001)] and Hispanic ethnicity [23.7 min (95% CI 20.0-27.5, p = 0.03)] were associated with shorter duration of resuscitation compared to White race [25.8 min (95% CI 23.9-27.7)]. These racial inequities persisted when using multiple imputation modeling. There was no difference in duration of resuscitation between female [24.3 min (95% CI 22.4-26.2)] and male gender [24.7 min (95% CI 21.8-27.5), p = 0.46]. There were no differences in incidence of hospital transport.

Conclusions: This study identified inequities in prehospital termination of resuscitation practices following OHCA. Black and Hispanic patients, as compared to White patients, received approximately 2-min-shorter prehospital resuscitative efforts prior to TOR despite controlling for bystander CPR, witnessed status, initial rhythm, and patient age. There were no gender-based differences in prehospital duration of resuscitation.

Objectives: This case series highlights the utility of Point of Care Ultrasound (POCUS) during cardiac arrest pulse checks, and how this tool can be used to identify Pulseless Rhythm with Echocardiographic Motion (PREM), also known as pseudo-pulseless electrical activity (PEA), and the potential changes in prehospital resuscitation management based on that finding.

Methods: We've documented four cases of PREM identification in the prehospital field to draw attention to this phenomenon and ideally serve as a blueprint for other agencies to adopt PREM-specific protocols.

Results: This case series demonstrates how cardiac visualization alters patient management in the setting of cardiac arrest. Each of the cases presented is unique in presentation and treatment. The use of POCUS has opened a door to the possibility of adopting prehospital guidelines for the management of PREM in prehospital cardiac arrest and subsequently more tailored treatment of patients.

Conclusions: Use of portable ultrasound in prehospital cardiac arrest highlights a large gap in our understanding and treatment of PREM. While these patients all ultimately died, their cases highlight the opportunity for more appropriate care, both prehospital and in-hospital. Because literature has posited that PEA is a more complex cardiac rhythm than previously thought, we are suggesting that pre-hospital cardiac arrest care guidelines reflect our current body of understanding. These cases emphasize the importance of emergency medical service (EMS) POCUS use and supports a transition to hands-free, or ultrasound-guided, pulse checks during cardiac arrest. More research is needed regarding the etiology of Pulseless Rhythm with Echocardiographic Standstill (PRES) versus PREM, what treatment guidelines would be best in cases of PREM, and how we can implement PREM recognition to health care personnel of all levels on a national scale.

Objectives: Detailed job satisfaction evaluations are often used to build strategies for employee retention. Despite recognizing that emergency medical services (EMS) dissatisfaction drives turnover, validated tools rigorously evaluating satisfaction have not been employed. We aim to assess the association between EMS clinician satisfaction and their likelihood of leaving the profession using the validated Spector Job Satisfaction Survey (JSS).

Methods: We conducted a cross-sectional survey of nationally certified EMS clinicians in the United States recertifying between October 2022 and April 2023. Our primary outcome was the self-reported likelihood of leaving EMS within 12 months (likely or not likely to leave). The primary exposure was job satisfaction, assessed using the 36-item JSS, scored from 36 to 216, and analyzed in two models: total satisfaction (dissatisfied [scores 36-108], ambivalent [108-144], satisfied [144-216]), and satisfaction subscales (e.g., pay, promotion, supervision). We applied Least Absolute Shrinkage and Selection Operator (LASSO) regression to identify key predictors of intent to leave EMS, adjusting for demographic and agency characteristics. Post-LASSO Bayesian logistic regression estimated odds ratios (OR) and 95% credible intervals (CrI).

Results: Among 33,414 EMS clinicians (response rate: 26.3%), the median age was 36 years (IQR: 29,46), 74.2% were male, and 83.0% were White, non-Hispanic. Most respondents worked full-time (77.6%), primarily as EMTs (48.5%), in urban settings (89.9%). Mean satisfaction scores were higher among those not likely to leave EMS (146.7 [standard deviation: 29.0]) than those likely to leave (121.2 [28.4]). Odds of leaving decreased for more satisfied clinicians: ambivalent clinicians [0.35 (0.32-0.38)]; satisfied clinicians [0.11 (0.10-0.13)]; referent dissatisfied. Additionally, specific satisfaction subscales were associated with lower odds of leaving for those satisfied compared to those dissatisfied, including nature of work [0.32 (0.28-0.37)], pay [0.46 (0.40-0.52)], promotion opportunities [0.53 (0.47-0.61)], supervision [0.65 (0.57-0.73)] and contingent rewards [0.77 (0.67-0.88)].

Conclusions: The EMS clinicians with higher satisfaction with their nature of work, pay, and promotion opportunities were less likely to report intent to leave. These findings highlight key factors that may inform workforce retention efforts.