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A pinboard by
Matt Holland

This board is owned by Matt Holland, LKS ASE, Librarian. Contact Matt.Holland@nwas.nhs.uk.

PINBOARD SUMMARY

Hosts recent articles from research based journals. Pinboard started in September 2016.

Coverage

This board collates published research on the prehospital and paramedic Practice.

Audience

The board is aimed at those working in Ambulance Services and Prehospital Care. Anyone can look.

Updates

The board is updated regularly. Somewhere between daily and weekly depending on the volume of publication.

Who is responsible

This board is maintained and run by Matt Holland, Librarian LKS ASE Matt.Holland@nwas.nhs.uk.

More about LKS ASE

Check the LKS ASE website to find out more about us. Follow us on Twitter, our Twitter handle is @NWASLibrary.

1516 ITEMS PINNED

Tracheal intubation in a simulated cervical spine immobilisation: the Macintosh laryngoscope versus supraglottic airway devices - a manikin study

Abstract: Publication date: Available online 9 May 2018 Source:Trends in Anaesthesia and Critical Care Author(s): Dawid Aleksandrowicz, Tomasz Gaszyński Background Airway management is performed with simultaneous cervical spine immobilisation in trauma patients and is regarded as the gold standard. Application of spinal stabilisation may significantly worsen direct laryngoscopy and make intubation more difficult. Supraglottic airway devices may also be used for intubation. The aim of this study was to evaluate the Macintosh laryngoscope, the Classic Laryngeal Mask Airway and the I-gel used for blind intubation by experienced paramedics. Cervical collar was used to simulate reduced cervical spine mobility. Materials and methods Fifty-five experienced and active paramedics participated in the study (F=25, M=30). The intubation-to-successful-ventilation time was recorded. Efficacy of intubation and the ease of use by the operator were also assessed. All devices under study were used by each participant and they were randomly chosen. All participants were trained in supraglottic airway devices insertion and intubation although they were not experts in the latter as each of the paramedics performed less than 20 intubations. Results The mean intubation-to-ventilation time was the shortest when the I-gel device was used 28.2 s (±2.09). This was statistically significant when compared to both the Classic Laryngeal Mask Airway (p=0.0344) and the Macintosh laryngoscope (p<0.0001). Both of the studied supraglottic airway devices achieved an overall 100% successful intubation rate and required maximum 2 attempts out of 3 allowed. Conclusion The I-gel and the Classic Laryngeal Mask Airway were superior to the Macintosh laryngoscope as they shortened the time required to intubate and successfully ventilate the patient. They also improved the rate of successful intubation.

Pub.: 28 May '18, Pinned: 18 Jun '18

Disaster preparedness in French paediatric hospitals 2 years after terrorist attacks of 2015.

Abstract: We aimed to determine paediatric hospital preparedness for a mass casualty disaster involving children in both prehospital and hospital settings. The study findings will serve to generate recommendations, guidelines and training objectives. The AMAVI-PED study is a cross-sectional survey. An electronic questionnaire was sent to French physicians with key roles in specialised paediatric acute care. In total, 81% (26 of 32) of French University Hospitals were represented in the study. A disaster plan AMAVI with a specific paediatric emphasis was established in all the paediatric centres. In case of a mass casualty event, paediatric victims would be initially admitted to the paediatric emergency department for most centres (n=21; 75%). Paediatric anaesthesiologists, paediatric surgeons and paediatric radiologists were in-house in 20 (71%), 5 (18%) and 12 (43%) centres, respectively. Twenty-three (82%) hospitals had a paediatric specialised mobile intensive care unit and seven (25%) of these could provide a prehospital emergency response. Didactic teaching and simulation exercises were implemented in 20 (71%) and 22 (79%) centres, respectively. Overall, physician participants rated the level of readiness of their hospital as 6 (IQR: 5-7) on a 10-point readiness scale. Paediatric preparedness is very heterogeneous between the centres. Based on the study findings, we suggest that a national programme must be defined and guidelines generated. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pub.: 04 Jun '18, Pinned: 18 Jun '18

The utility of point-of-care ultrasound in targeted automobile ramming mass casualty (TARMAC) attacks.

Abstract: As terrorist actors revise their tactics to outmaneuver increasing counter-terrorism security measures, a recent trend toward less-sophisticated attack methods has emerged. Most notable of these "low tech" trends are the Targeted Automobile Ramming MAss Casualty (TARMAC) attacks. Between 2014 and November 2017, 18 TARMAC attacks were reported worldwide, resulting in 181 deaths and 679 injuries. TARMAC attack-related injuries are unique compared to accidental pedestrian trauma and other causes of mass casualty incidents (MCI), and therefore they require special consideration. No other intentional mass casualty scenario is the result of a blunt, non-penetrating trauma mechanism. Direct vehicle impact results in high-power injuries including blunt trauma to the central nervous system (CNS), and thoracoabdominal organs with crush injuries if the victims are run over. Adopting new strategies and using existing technology to diagnose and treat MCI victims with these injury patterns will save lives and limit morbidity. Point-of-care ultrasound (POCUS) is one such technology, and its efficacy during MCI response is receiving an increasing amount of attention. Ultrasound machines are becoming increasingly available to emergency care providers and can be critically important during a MCI when access to other imaging modalities is limited by patient volume. By taking ultrasound diagnostic techniques validated for the detection of life-threatening cardiothoracic and abdominal injuries in individuals and applying them in a TARMAC mass casualty situation, physicians can improve triage and allocate resources more effectively. Here, we revisit the high-yield applications of POCUS as a means of enhanced prehospital and hospital-based triage, improved resource utilization, and identify their potential effectiveness during a TARMAC incident. Copyright © 2018 Elsevier Inc. All rights reserved.

Pub.: 05 Jun '18, Pinned: 18 Jun '18

Preventing EMS workplace violence: A mixed-methods analysis of insights from assaulted medics.

Abstract: To describe measures that assaulted EMS personnel believe will help prevent violence against EMS personnel. This mixed- methods study includes a thematic analysis and directed content analysis of one survey question that asked the victims of workplace violence how the incident might have been prevented. Of 1778 survey respondents, 633 reported being assaulted in the previous 12 months; 203 of them believed the incident could have been prevented and 193 of them (95%) answered this question. Six themes were identified using Haddon's Matrix as a framework. The themes included: Human factors, including specialized training related to specific populations and de-escalation techniques as well as improved situational awareness; Equipment factors, such as restraint equipment and resources; and, Operational and environment factors, including advanced warning systems. Persons who could have prevented the violence were identified as police, self, other professionals, partners and dispatchers. Restraints and training were suggested as violence-prevention tools and methods CONCLUSIONS: This is the first international study from the perspective of victimized EMS personnel, to report on ways that violence could be prevented. Ambulance agencies should consider these suggestions and work with researchers to evaluate risks at the agency level and to develop, implement and test interventions to reduce the risks of violence against EMS personnel. These teams should work together to both form an evidence-base for prevention and to publish findings so that EMS medical directors, administrators and professionals around the world can learn from each experience. Copyright © 2018 Elsevier Ltd. All rights reserved.

Pub.: 05 Jun '18, Pinned: 18 Jun '18

Preliminary Report: Comparing Aspiration Rates between Prehospital Patients Managed with Extraglottic Airway Devices and Endotracheal Intubation

Abstract: Publication date: Available online 9 May 2018 Source:Air Medical Journal Author(s): Michael T. Steuerwald, Darren A. Braude, Timothy R. Petersen, Kari Peterson, Michael A. Torres Introduction There has been a shift from endotracheal intubation (ETI) toward extraglottic devices (EGDs) for prehospital airway management. A concern exists that this may lead to more frequent cases of aspiration. Methods This was a retrospective study using a prehospital quality assurance database. Patients were assigned to groups based on the method that ultimately managed their airways (EGD or ETI). Cases with documented blood/emesis obscuring the airway were considered inevitable aspiration cases and excluded. Aspiration was defined by the radiology report within 48 hours. Results A total of 104 EGD and 152 ETI patients were identified. Aspiration data were available for 67 EGD and 94 ETI cases. Of those, 8 EGD and 3 ETI cases had blood/emesis obscuring the airway and were excluded as planned. After exclusions, there were 5 EGD and 11 ETI cases in which aspiration was later diagnosed (EGD aspiration rate = 8%, ETI aspiration rate = 12%; χ2: P = .359; relative risk = .841; 95% confidence interval, .329-2.152). Conclusion In this small quality assurance database, aspiration rates were not significantly different for prehospital patients managed with an EGD versus ETI.

Pub.: 01 Jun '18, Pinned: 18 Jun '18

Validation of the cincinnati prehospital stroke scale

Abstract: Aditya Maddali, Farook Abdul Razack, Srihari Cattamanchi, Trichur V Ramakrishnan Journal of Emergencies, Trauma, and Shock 2018 11(2):111-114 Background: Early recognition of Stroke is one of the key concepts in the ≤Chain of Survival≥ as described by the American Heart Association/American Stroke Association Stroke guidelines. The most commonly used tools for prehospital assessment of stroke are ≤The Cincinnati Prehospital Stroke Scale,≥ (CPSS) the ≤Face, Arm, Speech Test,≥ and ≤The Los Angeles Prehospital Stroke Screen.≥ The former two are used to identify stroke using physical findings while the latter is used to rule out other causes of altered consciousness. Aim: The aim of this study is to validate the CPSS in the prehospital setting by correlating with computed tomography scan findings. (1) To determine if these scores can be implemented in the Indian prehospital setting. (2) To determine if it is feasible for new emergency departments (EDs) to use these protocols for early detection of stroke. Methodology: A prospective, observational study from December, 2015 to March, 2016. Patients with suspected stroke were enrolled. Data were collected prehospital in patients that arrived to the ED in an ambulance. Sensitivity, specificity, positive predictive value, and negative predictive value of the score were calculated using standard formulae. Results: CPSS showed good sensitivity of 81% (confidence interval [CI] – 68.5%–97%) when combined and a positive predictive value (PPV) of 100% (CI: 91.9%–100%). Individually, they showed a sensitivity of 75.8%, 79%, and 74.1%, respectively, with a PPV of 100% and specificity of 95%–100%. Conclusion: As a prehospital screening tool, CPSS can be extremely useful as any diagnosis is only provisional until confirmed by an appropriate investigation in a hospital.

Pub.: 29 May '18, Pinned: 18 Jun '18

World's First 24/7 Mobile Stroke Unit: Initial 6-Month Experience at Mercy Health in Toledo, Ohio.

Abstract: As the fourth mobile stroke unit (MSU) in the nation, and the first 24/7 unit worldwide, we review our initial experience with the Mercy Health MSU and institutional protocols implemented to facilitate rapid treatment of acute stroke patients and field triage for patients suffering other time-sensitive, acute neurologic emergencies in Lucas County, Ohio, and the greater Toledo metropolitan area. Data was prospectively collected for all patients transported and treated by the MSU during the first 6 months of service. Data was abstracted from documentation of on-scene emergency medical services (EMS) personnel, critical care nurses, and onboard physicians, who participated through telemedicine. The MSU was dispatched 248 times and transported 105 patients after on-scene examination with imaging. Intravenous (IV) tissue plasminogen activator (tPA) was administered to 10 patients; 8 patients underwent successful endovascular therapy after a large vessel occlusion was identified using CT performed within the MSU without post treatment symptomatic hemorrhage. Moreover, 14 patients were treated with IV anti-epileptics for status epilepticus, and 19 patients received IV anti-hypertensive agents for malignant hypertension. MSU alarm to on-scene times and treatment times were 34.7 min (25-49) and 50.6 min (44.4-56.8), respectively. The world's first 24/7 MSU has been successfully implemented with IV-tPA administration rates and times comparable to other MSUs nation-wide, while demonstrating rapid triage and treatment in the field for neurologic emergencies, including status epilepticus. With the rising number of MSUs worldwide, further data will drive standardized protocols that can be adopted nationwide by EMS.

Pub.: 06 Jun '18, Pinned: 18 Jun '18

Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis

Abstract: There is increasing concern regarding the mental health impact of first responder work, with some reports suggesting ambulance personnel may be at particularly high risk. Through this systematic review and meta-analysis we aimed to determine the prevalence of mental health conditions among ambulance personnel worldwide.A systematic search and screening process was conducted to identify studies for inclusion in the review. To be eligible, studies had to report original quantitative data on the prevalence of at least one of the following mental health outcome(s) of interest (PTSD, depression, anxiety, general psychological distress) for ambulance personnel samples. Quality of the studies was assessed using a validated methodological rating tool. Random effects modelling was used to estimate pooled prevalence, as well as subgroup analyses and meta-regressions for five variables implicated in heterogeneity.In total, 941 articles were identified across all sources, with 95 full-text articles screened to confirm eligibility. Of these, 27 studies were included in the systematic review, reporting on a total of 30,878 ambulance personnel. A total of 18 studies provided necessary quantitative information and were retained for entry in the meta-analysis. The results demonstrated estimated prevalence rates of 11% for PTSD, 15% for depression, 15% for anxiety, and 27% for general psychological distress amongst ambulance personnel, with date of data collection a significant influence upon observed heterogeneity.Ambulance personnel worldwide have a prevalence of PTSD considerably higher than rates seen in the general population, although there is some evidence that rates of PTSD may have decreased over recent decades.

Pub.: 05 Jun '18, Pinned: 18 Jun '18

[Successful prehospital emergency thoracotomy after blunt thoracic trauma : Case report and lessons learned].

Abstract: The European Resuscitation Council guidelines for resuscitation in patients with traumatic cardiac arrest recommend the immediate treatment of all reversible causes, if necessary even prior to continuous chest compression. In the case of cardiac tamponade immediate emergency thoracotomy should also be considered. The authors report the case of a 23-year-old male patient with multiple injuries including blunt thoracic trauma, which caused a witnessed cardiac arrest. He successfully underwent prehospital emergency resuscitative thoracotomy. The lessons learned from this case on internal and external quality measures are discussed in detail. After 60 min of technical rescue, extensive trauma life support including intubation, chest decompression and bleeding control was carried out. The cardiovascular insufficiency progressively deteriorated and under the suspicion of a cardiac tamponade a prehospital emergency thoracotomy was carried out. After successful resuscitative thoracotomy and return of spontaneous circulation (ROSC) the patient was airlifted to the next level 1 trauma center for damage control surgery (DCS). The patient could be discharged 59 days after the accident and now 2 years later is living a normal life without neurological or cardiopulmonary limitations. Airway management, chest decompression including resuscitative thoracotomy, fluid resuscitation and blood products were the key components to ensure that the patient achieved ROSC. Advanced Trauma Life Support® as well as structural prerequisites made these measures and good results for the patient possible.

Pub.: 07 Jun '18, Pinned: 18 Jun '18

Effect of Detection Time Interval for Out-of-Hospital Cardiac Arrest on Outcomes in Dispatcher-Assisted Cardiopulmonary Resuscitation: A Nationwide Observational Study.

Abstract: The association between the detection time interval (DTI) from the call for ambulance to the detection of out-of-hospital cardiac arrest (OHCA) by the dispatcher and the neurological outcome in dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is unclear. Adults who sustained OHCA with cardiac etiology received DA-CPR between 2013 and 2016 were analyzed. The main predictor was DTI defined as the time interval from the beginning of the emergency call to identification of OHCA by the dispatcher. The primary outcomes were the good cerebral performance category (CPC) 1 or 2. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for outcomes, adjusting for potential confounders, by the 10- and 30-seconds DTI delay and three DTI groups; Short (0-90 seconds), Middle (91-180 seconds), and Long (181-1,200 seconds) groups. Interaction analysis for DTI and urbanization level (megacity with 10 million or more population in urban region, metropolis with 1 to 5 million population in urban region, and Rural province with less than 2 million population in urban, suburban, and rural region) was performed to compare the effect size of DTI group according to urbanization level. Of 116374 adults with an OHCA, 11833 were finally analyzed. Overall, the number (%) of survival to discharge was 1380 (11.4%), and the good CPC was 945 (8.0%). For good cerebral performance category, the AOR (95% CIs) for good CPC was 0.99 (0.98-1.00) by 10-seconds DTI delay and 0.97 (0.95-0.99) by 30-seconds DTI delay. The AORs (95% CIs) for good CPC were 0.84 (0.71-1.00) for the Middle and 0.79 (0.66-0.96) for the Long DTI groups compared with Short DTI. The AORs (95% Cl) for good CPC compared with Short DTI group were 0.93 (0.68-1.27) by Middle DTI and 0.84 (0.59-1.20) by Long DTI in megacity, 0.60 (0.44-0.81) by Middle DTI and 0.60 (0.44-0.82) by Long DTI in metropolis, and 0.43 (0.31-0.60) by Middle DTI and 0.38 (0.26-0.56) by Long DTI in Rural province, respectively. A longer DTI in DA-CPR showed significantly lower good neurological recovery in adult patients with witnessed OHCA. A 30 second delay in DTI was associated with a 3% decrease of a good CPC score (can abbreviate CPC since it was abbreviated earlier. The DTI effect on good CPC was significant in metropolis and Rural province while not in megacity region. Copyright © 2018. Published by Elsevier B.V.

Pub.: 07 Jun '18, Pinned: 18 Jun '18

Does the prehospital National Early Warning Score predict the short-term mortality of unselected emergency patients?

Abstract: The prehospital research field has focused on studying patient survival in cardiac arrest, as well as acute coronary syndrome, stroke, and trauma. There is little known about the overall short-term mortality and its predictability in unselected prehospital patients. This study examines whether a prehospital National Early Warning Score (NEWS) predicts 1-day and 30-day mortalities.Data from all emergency medical service (EMS) situations were coupled to the mortality data obtained from the Causes of Death Registry during a six-month period in Northern Finland. NEWS values were calculated from first clinical parameters obtained on the scene and patients were categorized to the low, medium and high-risk groups accordingly. Sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs), and likelihood ratios (PLRs and NLRs) were calculated for 1-day and 30-day mortalities at the cut-off risks.A total of 12,426 EMS calls were included in the study. The overall 1-day and 30-day mortalities were 1.5 and 4.3%, respectively. The 1-day mortality rate for NEWS values ≤12 was lower than 7% and for values ≥13 higher than 20%. The high-risk NEWS group had sensitivities for 1-day and 30-day mortalities 0.801 (CI 0.74–0.86) and 0.42 (CI 0.38–0.47), respectively.In prehospital environment, the high risk NEWS category was associated with 1-day mortality well above that of the medium and low risk NEWS categories. This effect was not as noticeable for 30-day mortality. The prehospital NEWS may be useful tool for recognising patients at early risk of death, allowing earlier interventions and responds to these patients.

Pub.: 07 Jun '18, Pinned: 18 Jun '18

Comparison of the performance of battery-operated fluid warmers.

Abstract: Warming intravenous fluids is essential to prevent hypothermia in patients with trauma, especially when large volumes are administered. Prehospital and transport settings require fluid warmers to be small, energy efficient and independent of external power supply. We compared the warming properties and resistance to flow of currently available battery-operated fluid warmers. Fluid warming was evaluated at 50, 100 and 200 mL/min at a constant input temperature of 20°C and 10°C using a cardiopulmonary bypass roller pump and cooler. Output temperature was continuously recorded. Performance of fluid warmers varied with flows and input temperatures. At an input temperature of 20°C and flow of 50 mL/min, the Buddy Lite, enFlow, Thermal Angel and Warrior warmed 3.4, 2.4, 1 and 3.6 L to over 35°C, respectively. However, at an input temperature of 10°C and flow of 200 mL/min, the Buddy Lite failed to warm, the enFlow warmed 3.3 L to 25.7°C, the Thermal Angel warmed 1.5 L to 20.9°C and the Warrior warmed 3.4 L to 34.4°C (p<0.0001). We found significant differences between the fluid warmers: the use of the Buddy Lite should be limited to moderate input temperature and low flow rates. The use of the Thermal Angel is limited to low volumes due to battery capacity and low output temperature at extreme conditions. The Warrior provides the best warming performance at high infusion rates, as well as low input temperatures, and was able to warm the largest volumes in these conditions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pub.: 09 Jun '18, Pinned: 18 Jun '18

Closure simulation for reduction of emergency patient diversion: a discrete agent-based simulation approach to minimizing ambulance diversion.

Abstract: The city of Munich uses web-based information system IVENA to promote exchange of information regarding hospital offerings and closures between the integrated dispatch center and hospitals to support coordination of the emergency medical services. Hospital crowding resulting in closures and thus prolonged transportation time poses a major problem. An innovative discrete agent model simulates the effects of novel policies to reduce closure times and avoid crowding. For this analysis, between 2013 and 2017, IVENA data consisting of injury/disease, condition, age, estimated arrival time and assigned hospital or hospital-closure statistics as well as underlying reasons were examined. Two simulation experiments with three policy variations are performed to gain insights on the influence of diversion policies onto the outcome variables. A total of 530,000+ patients were assigned via the IVENA system and 200,000+ closures were requested during this time period. Some hospital units request a closure on more than 50% of days. The majority of hospital closures are not triggered by the absolute number of patient arrivals, but by a sudden increase within a short time period. Four of the simulations yielded a specific potential for shortening of overall closure time in comparison to the current status quo. Effective solutions against crowding require common policies to limit closure status periods based on quantitative thresholds. A new policy in combination with a quantitative arrival sensor system may reduce closing hours and optimize patient flow.

Pub.: 10 Jun '18, Pinned: 18 Jun '18

The Aftermath of the Kuwait Mosque Bombing: A retrospective cohort analysis and lessons learned.

Abstract: The occurrence of terrorist attacks are still recurrent incidents plaguing the middle east region. However, Kuwait has been mostly spared from these attacks over the years. Therefore, when the bombing of the mosque in 2015 happened, it shocked a country that is not prepared for such disasters. Our aim was to present the incident that occurred on that day and on the lessons learned from it. A collaborative effort among the hospitals in Kuwait examined the details and outcomes of the initial response to the bombing. The centers reported their retrospective data, which was analyzed to determine prehospital and intra-hospital management and assess the medical response to the terrorist bombing. A total of 239 victims were involved in the explosion, of which 18 were pronounced dead on site. 147 (67%) were transferred to the hospital for care 22 min after the explosion occurred. The injuries seen were not localized to one region of the body, but afflicted various organ systems. 86 patients were admitted to the hospital, for which five required urgent surgical intervention. Total mortality (on-site and in-hospital) reported after the bombing was 11.2%. Rapid response after a mass casualty is of utmost importance for the adequate management of the victims of such tragedies, and could ensure excellent outcomes if performed precisely. However, many lessons can be learned from this shocking event, especially that it exposed the gaps currently present in our disaster plan systems and the importance of looking into addressing them. Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Pub.: 11 Jun '18, Pinned: 18 Jun '18

Ambulance staff and end-of-life hospital admissions: A qualitative interview study.

Abstract: Hospital admissions for end-of-life patients, particularly those who die shortly after being admitted, are recognised to be an international policy problem. How patients come to be transferred to hospital for care, and the central role of decisions made by ambulance staff in facilitating transfer, are under-explored. To understand the role of ambulance staff in the admission to hospital of patients close to the end of life. Qualitative interviews, using particular patient cases as a basis for discussion, analysed thematically. Ambulance staff ( n = 6) and other healthcare staff (total staff n = 30), involved in the transfer of patients (the case-patients) aged more than 65 years to a large English hospital who died within 3 days of admission with either cancer, chronic obstructive pulmonary disease or dementia. Ambulance interviewees were broadly positive about enabling people to die at home, provided they could be sure that they would not benefit from treatment available in hospital. Barriers for non-conveyance included difficulties arranging care particularly out-of-hours, limited available patient information and service emphasis on emergency care. Ambulance interviewees fulfilled an important role in the admission of end-of-life patients to hospital, frequently having to decide whether to leave a patient at home or to instigate transfer to hospital. Their difficulty in facilitating non-hospital care at the end of life challenges the negative view of near end-of-life hospital admissions as failures. Hospital provision was sought for dying patients in need of care which was inaccessible in the community.

Pub.: 12 Jun '18, Pinned: 18 Jun '18

Intubation Success after Introduction of a Quality Assurance Program Using Video Laryngoscopy

Abstract: Publication date: Available online 7 June 2018 Source:Air Medical Journal Author(s): Amir Louka, Christopher Stevenson, Gregory Jones, Jeffrey Ferguson Objective The deployment of video laryngoscopy devices that include recording capability presents a new and unique opportunity for medical directors to review prehospital patient encounters. We sought to evaluate the effect of introducing a video laryngoscope and video quality assurance program to an air medical program on measures of intubation success including overall success, first-pass success, success within 2 attempts, and the total number of attempts. Methods This was a retrospective review of data collected on intubations by nurses and paramedics of the Virginia State Police Med-Flight 1 air medical program. Results After introduction of the video laryngoscope and quality assurance program, the overall intubation success improved to 100% but did not reach statistical significance (95% confidence interval [CI], −4.40 to 12.57; P = .25). First-pass success improved from 76.19% to 92.86% (CI, 1.14-33.14; P = .02), whereas the average attempts declined from 1.31 to 1.09 per patient encounter (CI, −.41 to −.03; P = .02). Success within 2 attempts was 92.86% before the intervention and 98.21% after (CI, 4.25-17.82; P = .19). Conclusion Video laryngoscopy and a robust means for medical director oversight are important components of a high-performance airway management program and demonstrably improve intubation first-pass success.

Pub.: 10 Jun '18, Pinned: 18 Jun '18

Psychometric Analysis of a Survey on Patient Safety Culture-Based Tool for Emergency Medical Services.

Abstract: Evaluating organizational safety culture is critical for high-stress, high-risk professions such as prehospital emergency medical services (EMS). The aim of the study was to evaluate the psychometric properties of a safety culture instrument for EMS, based on the Agency for Healthcare Research and Quality's widely used Surveys on Patient Safety Culture (SOPS). The final EMS-adapted instrument consisted of 37 items covering 11 safety culture domains including 10 domains from existing SOPS instruments and one new domain for communication while en route to an emergency call. The analysis sample included 23,029 nationally certified EMS providers. Domain structure was evaluated on two separate halves of the data set through confirmatory factor analysis using a polychoric correlation matrix for ordinal data. The reliability and validity of each domain were evaluated using Cronbach α and Pearson correlation coefficients. The confirmatory factor analysis supported the 11-domain model. All items loaded above the 0.4 threshold (range = 0.508-0.984). Three composite domains exhibited factor variance below the 0.5 threshold: staffing (0.32), communication about incidents (0.26), and handoffs (0.26). Floor and ceiling effects were not detected. Inter-item consistency exceeded 0.6 for all subscales (α = 0.65-0.88). Predictive validity was supported as all domain composites were correlated with the outcome variables of overall safety rating (r = 0.44-0.72) and frequency of event reporting (r = 0.31-0.48). Overall, the EMS-adapted tool demonstrated adequate psychometric properties consistent with those of existing SOPS instruments. Additional research is needed to evaluate the instrument's performance at the agency level and its correlation with safety outcomes in the prehospital setting.

Pub.: 13 Jun '18, Pinned: 18 Jun '18

High acuity rural transport: findings from a qualitative investigation.

Abstract: The High Acuity Response Team (HART) was introduced in British Columbia (BC), Canada, to fill a gap in transport for rural patients that was previously being met by nurses and physicians leaving their communities to escort patients in need of critical care. The HART team consists of a critical care registered nurse (CCRN) and registered respiratory therapist (RRT) and attends acute care patients in rural sites by either stabilizing them in their community or transporting them. HART services are deployed in partnership with provincial ambulance services, which provide vehicles and coordination of all requests in the province for patient transport. This article presents the qualitative findings from a research evaluation of the efficacy of the HART model, including staffing and inter-organizational functioning. Open-ended qualitative research interviewing was done with key stakeholders from 21 sites. Research participants included HART CCRNs, RRTs, administrative leads, as well as local emergency department (ED) physicians and nurses. Thematic analysis was done of the transcripts. A total of 107 interviews in 21 study sites were completed. Participants described characteristics of the model, perceptions of efficacy and areas for improvement. Rural sites reported a decrease in physician- and nurse-accompanied transports for high-acuity patients due to the HART team, but also noted challenges in delayed deployment, sometimes leading to adverse patient outcomes. The salient issues for the HART model were grounded in a somewhat artificial distinction between pre-hospital and interfacility transport for rural patients, which leads to a lack of service coordination and potentially avoidable delays. A beneficial systems change would be to move towards dedicated integration of high-acuity transport services into hospital organizational structures and community health services in rural areas.

Pub.: 13 Jun '18, Pinned: 18 Jun '18

Prehospital Notification Procedure Improves Stroke Outcome by Shortening Onset to Needle Time in Chinese Urban Area.

Abstract: Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) can improve clinical outcome in eligible patients with acute ischemic stroke (AIS). However, its efficacy is strongly time-dependent. This study was aimed to examine whether prehospital notification by emergency medical service (EMS) providers could reduce onset to needle time (ONT) and improve neurological outcome in AIS patients who received IVT. We prospectively collected the consecutive clinical and time data of AIS patients who received IVT during one year after the initiation of prehospital notification procedure (PNP). Patients were divided into three groups, including patients that transferred by EMS with and without PNP and other means of transportation (non-EMS). We then compared the effect of EMS with PNP and EMS use only on ONT, and the subsequent neurological outcome. Good outcome was defined as modified Rankin Scale score of 0-2 at 3-months. In 182 patients included in this study, 77 (42.3%) patients were transferred by EMS, of whom 41 (53.2%) patients entered PNP. Compared with non-EMS group, EMS without PNP group greatly shortened the onset to door time (ODT), but EMS with PNP group showed both a significantly shorter DNT (41.3 ± 10.7 min vs 51.9±23.8 min, t=2.583, p=0.012) and ODT (133.2 ± 90.2 min vs 174.8 ± 105.1 min, t=2.228, p=0.027) than non-EMS group. Multivariate analysis showed that the use of EMS with PNP (OR=2.613, p=0.036), but not EMS (OR=1.865, p=0.103), was independently associated with good outcome after adjusting for age and baseline NIHSS score. When adding ONT into the regression model, ONT (OR=0.994, p=0.001), but not EMS with PNP (OR=1.785, p=0.236), was independently associated with good outcome. EMS with PNP, rather than EMS only, improved stroke outcome by shortening ONT. PNP could be a feasible strategy for better stroke care in Chinese urban area.

Pub.: 14 Jun '18, Pinned: 18 Jun '18

Accuracy of Prehospital Care Providers in Determining Total Body Surface Area Burned in Severe Pediatric Thermal Injury.

Abstract: Accurate measurement of total body surface area (TBSA) burned is a key factor in the care of pediatric patients with burn, especially those with large thermal injuries. There is a paucity of data on the accuracy of these measurements by prehospital, nonburn center, and emergency department (ED) providers, which can have drastic implications for patient management and outcomes. We sought to determine the accuracy of these estimates for large pediatric burns. A retrospective chart review was conducted of patients with TBSA ≥10% admitted to an American Burn Association (ABA)-verified pediatric burn center from 2007 to 2015. Final TBSA was determined by pediatric burn surgeons and compared with prehospital emergency medical service providers, outside hospital physicians for transferred patients, and burn center ED physicians. Statistical significance was determined using a paired t-test with P < 0.05. A total of 139 patients ≤18 years of age met inclusion criteria, with an average TBSA of 18.9 ± 1.1%, weight 23.7 ± 1.6 kg and age of 5.4 ± 0.41 years. When compared in a pairwise fashion to the TBSA values determined by pediatric burn surgeons, estimates of TBSA were higher by: prehospital emergency medical service providers, 40.0% (n = 67, P < 0.0001); outside hospital physicians, 18.7% (n = 46, P = 0.0009), and burn center ED physicians, 7.2% (n = 120, P = 0.0117). TBSA burn estimates for pediatric patients by prehospital, nonburn center, and ED providers are significantly higher than those recorded by burn surgeons at an ABA-verified pediatric burn center. These inaccuracies in TBSA measurement may have profound clinical implications.

Pub.: 15 Jun '18, Pinned: 18 Jun '18

Overuse of Air Ambulance Services at a Regional Burn Center.

Abstract: Air ambulances rapidly transport burn patients to regional centers, expediting treatment. However, limited guidelines on transport introduce the risk for inappropriate triage and overuse. Given the additional costs of air vs ground transport, evaluation of transportation use is prudent. A retrospective review of all burn patients transported by helicopter to a single burn center from May 2013 to January 2016 was performed. Data gathered included patient demographics, transfer origin, burn characteristics, and inpatient hospital stay. The primary outcome was appropriate triage based on literature-derived severity criteria. Secondary outcomes included independent predictors of emergent treatments and the cost of overuse. Sixty-eight patients were examined, of which 66% met air ambulance criteria. Inappropriately triaged patients sustained smaller burns (% TBSA 4.8 vs 25.3, P < .001), had fewer flame burns (48 vs 82%, P = .007), had decreased lengths of stay (mean days 8.2 vs 21.2, P = .002), underwent fewer inpatient surgeries (mean 0.69 vs 2.57, P = .006), received no emergent procedures (0 vs 56%, P < .001), and suffered no deaths (0 vs 9%, P < .001). Independent predictors of emergent procedures included transport for airway concern (odds ratio = 45.29, confidence interval = 2.49-825.21, P = .010) and % TBSA (odds ratio = 1.13, confidence interval = 1.02-1.27, P = .019). If the 23 inappropriately triaged patients had been transported by ground, a cost savings of $106,370 could have been realized using 2016 California Medicare reimbursements (per-patient savings of $4624). While appropriate in most circumstances, the cost of air ambulances should be weighed in light of their utility, as a significant proportion of patients did not benefit from air transport.

Pub.: 15 Jun '18, Pinned: 18 Jun '18

Different defibrillation strategies in survivors after out-of-hospital cardiac arrest.

Abstract: In the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival. We performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded. A total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm. Survivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pub.: 16 Jun '18, Pinned: 18 Jun '18