Emergency Medical Services Setting Research Articles

Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis.

Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

Can the MIRACLE2 Score Be Used in the Prehospital Environment and Is It Useful? An Observational Study

ObjectiveThe MIRACLE2 score has been developed for use in a primary percutaneous coronary intervention center. It is unclear if it is feasible in the helicopter emergency medical service (HEMS) setting. MethodsThe computerized system at 1 UK HEMS was interrogated between December 1, 2020, and May 1, 2022, for the components of the MIRACLE2 score (recorded contemporaneously) plus demographics and outcomes in all post–return of spontaneous circulation patients conveyed to the hospital. pH was excluded because of no point-of-care testing resulting in a modified MIRACLE2 score (maximum score of 9). Data were analyzed using the chi-square test; P < .05 was statistically significant. ResultsThree hundred thirty patients (240 males) with out-of-hospital cardiac arrests were reviewed. Ninety-two adult patients with nontraumatic out-of-hospital cardiac arrests had sustained return of spontaneous circulation and a median MIRACLE2 score of 4 (range, 0-7). Forty-seven patients died before hospital discharge; the median MIRACLE2 score was higher in those who died (4) than those who survived (1.5, P < .01); 90.3% of those with a score ≥ 5 were triaged to an emergency department rather than directly to a catheterization laboratory. ConclusionA modified MIRACLE2 score can be calculated in the HEMS setting. The benefit of point-of-care testing pH requires investigation. There may be a benefit in predicting outcomes in this nondifferentiated group, but additional research is required.

Comparison of Hyperangulated Versus Standard Geometry Video Laryngoscopy in a Simulated Helicopter Emergency Medical Service Setting: A Randomized Crossover Trial

Comparison of Hyperangulated Versus Standard Geometry Video Laryngoscopy in a Simulated Helicopter Emergency Medical Service Setting: A Randomized Crossover Trial

The Effect of Prehospital Blood Transfusion on Patient Body Temperature from the Time of Emergency Medical Services Transfusion to Arrival at the Emergency Department.

Transfusion of blood products is life-saving and time-sensitive in the setting of acute blood-loss anemia, and is increasingly common in the emergency medical services (EMS) setting. Prehospital blood products are generally "cold-stored" at 4°C, then warmed with a portable fluid-warming system for the purpose of preventing the "lethal triad" of hypothermia, acidosis, and coagulopathy. This study aims to evaluate body temperature changes of EMS patients receiving packed red blood cells (PRBC) and/or fresh frozen plasma (FFP) when using the LifeWarmer Quantum Blood & Fluid Warming System (LifeWarmer, https://www.lifewarmer.com/). From 1 January 2020 to 31 August 2021, patients who qualified for and received PRBC and/or FFP were retrospectively reviewed. Body-temperature homeostasis pre- and post-transfusion were evaluated with attention given to those who arrived to the emergency department (ED) hypothermic (<36°C). For all 69 patients analyzed, the mean initial prehospital temperature (°C) was 36.5 ± 1.0, and the mean initial ED temperature was 36.7 ± 0.6, demonstrating no statically significant change in value pre- or post-transfusion (0.2 ± 0.8, p = .09). Shock index showed a statistically significant decrease following transfusion: 1.5 ± 0.5 to 0.9 ± 0.4 (p < .001). Use of the Quantum prevents the previously identified risk of hypothermia with respect to unwarmed prehospital transfusions. The data is favorable in that body temperature did not decrease in critically ill patients receiving cold-stored blood warmed during administration with the Quantum.

Designing and implementing smart glass technology for emergency medical services: a sociotechnical perspective.

This study aims to investigate key considerations and critical factors that influence the implementation and adoption of smart glasses in fast-paced medical settings such as emergency medical services (EMS). We employed a sociotechnical theoretical framework and conducted a set of participatory design workshops with 15 EMS providers to elicit their opinions and concerns about using smart glasses in real practice. Smart glasses were recognized as a useful tool to improve EMS workflow given their hands-free nature and capability of processing and capturing various patient data. Out of the 8 dimensions of the sociotechnical model, we found that hardware and software, human-computer interface, workflow, and external rules and regulations were cited as the major factors that could influence the adoption of this novel technology. EMS participants highlighted several key requirements for the successful implementation of smart glasses in the EMS context, such as durable devices, easy-to-use and minimal interface design, seamless integration with existing systems and workflow, and secure data management. Applications of the sociotechnical model allowed us to identify a range of factors, including not only technical aspects, but also social, organizational, and human factors, that impact the implementation and uptake of smart glasses in EMS. Our work informs design implications for smart glass applications to fulfill EMS providers' needs. The successful implementation of smart glasses in EMS and other dynamic healthcare settings needs careful consideration of sociotechnical issues and close collaboration between different stakeholders.

220 Emergent Medicine: Impact of Out-of-Hospital Red Lights and Sirens (RLS) on Time to Antibiotic Administration in Sepsis Alert Patients

220 Emergent Medicine: Impact of Out-of-Hospital Red Lights and Sirens (RLS) on Time to Antibiotic Administration in Sepsis Alert Patients

Care experiences of older people with mental health needs and their families in emergency medical services settings.

There are challenges to person-centred care provision in Emergency Medical Services (EMS) settings. The environment is often busy and noisy which can influence the experience of older people and their carer/partners when they attend emergency departments. Older people with mental health needs are a vulnerable group of people who are at risk of not having their needs met in acute care settings. This is due to complex presentations and increased pressures on the EMS system. The aim of the paper was to explore the care experience of older people with mental health needs and their carer/partners in pre-hospital and in-hospital Emergency Medical Services settings. This study used an interpretive qualitative approach incorporating in-depth, individual interviews to gather information on the experience of the older person with mental health needs and carers/partners. Data were analysed using Braun and Clarke's (2006) thematic analysis. Fifteen individual interviews were carried out with older people with mental health needs (n= 10) and with carers/partners (n= 5). Six themes on 'Getting there, getting in and getting out', 'Seeing the person', 'Perceptions and experiences of the pre-hospital and Emergency Department (ED)', 'The effects of the experience on personal well-being', 'Older person/carer/partner perceptions and experiences of the EMS staff' and 'Making it better' emerged from the data. The results suggest that previous experiences with the emergency care system influence the way older people with mental health needs and their carers make decisions on current and future care needs. Negative experiences can be influenced by the layout and organisation of the ED. Participants remain reluctant to discuss or disclose their diagnosis in the Emergency Medical Services setting due to a perceived stigma. Health and social care systems and services need to undergo transformations to ensure that all people who access services are treated fairly and effectively.

Clinical Reasoning among Registered Nurses in Emergency Medical Services: A Case Study

In emergency medical services (EMS), the clinical reasoning (CR) of registered nurses (RNs) working in ambulance care plays an important role in providing care and treatment that is timely, accurate, appropriate and safe. However, limited existing knowledge about how CR is formed and influenced by the EMS mission hinders the development of service provision and decision support tools for RNs that would further enhance patient safety. To explore the nature of CR and influencing factors in this context, an inductive case study examined 34 observed patient–RN encounters in an EMS setting focusing on ambulance care. The results reveal a fragmented CR approach involving several parallel decision-making processes grounded in and led by patients’ narratives. The findings indicate that RNs are not always aware of their own CR and associated influences until they actively reflect on the process, and additional research is needed to clarify this complex phenomenon.

Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis.

ObjectiveTo review, inventory and compare available diagnostic tools and investigate which tool has the best performance for prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome (NSTE-ACS).MethodsSystematic review and meta-analysis. Medline and Embase were searched up till 1 April 2021. Prospective studies with patients, suspected of NSTE-ACS, presenting in the primary care setting or by emergency medical services (EMS) were included. The most important exclusion criteria were studies including only patients with ST-elevation myocardial infarction and studies before 1995, the pretroponin era. The primary end point was the final hospital discharge diagnosis of NSTE-ACS or major adverse cardiac events (MACE) within 6 weeks. Risk of bias was evaluated by the Quality Assessment of Diagnostic Accuracy Studies Criteria.Main outcome and measuresSensitivity, specificity and likelihood ratio of findings for risk stratification in patients suspected of NSTE-ACS.ResultsIn total, 15 prospective studies were included; these studies reflected in total 26 083 patients. No specific variables related to symptoms, physical examination or risk factors were useful in risk stratification for NSTE-ACS diagnosis. The most useful electrocardiographic finding was ST-segment depression (LR+3.85 (95% CI 2.58 to 5.76)). Point-of-care troponin was found to be a strong predictor for NSTE-ACS in primary care (LR+14.16 (95% CI 4.28 to 46.90) and EMS setting (LR+6.16 (95% CI 5.02 to 7.57)). Combined risk scores were the best for risk assessment in an NSTE-ACS. From the combined risk scores that can be used immediately in a prehospital setting, the PreHEART score, a validated combined risk score for prehospital use, derived from the HEART score (History, ECG, Age, Risk factors, Troponin), was most useful for risk stratification in patients with NSTE-ACS (LR+8.19 (95% CI 5.47 to 12.26)) and for identifying patients without ACS (LR−0.05 (95% CI 0.02 to 0.15)).DiscussionImportant study limitations were verification bias and heterogeneity between studies. In the prehospital setting, several diagnostic tools have been reported which could improve risk stratification, triage and early treatment in patients suspected for NSTE-ACS. On-site assessment of troponin and combined risk scores derived from the HEART score are strong predictors. These results support further studies to investigate the impact of these new tools on logistics and clinical outcome.FundingThis study is funded by ZonMw, the Dutch Organisation for Health Research and Development.Trial registration numberThis meta-analysis was published for registration in PROSPERO prior to starting (CRD York, CRD42021254122).

Qatar Ambulance Service staff's perception on the Quality-of-Service delivery to patients

Background: Quality improvement has been well documented in various industries to improve safety and processes.1 However, limited research has taken place within the pre-hospital sector in this regard. Various factors can be attributed to the delivery of effective services. Studies often investigate customer/patient perception and often sideline the importance of employee perception.2 This study evaluates Qatar&apos;s Hamad Medical Corporation Ambulance Service (HMCAS) staffs’ perception on service delivery to patients they treat and transport. Methods: An online survey was designed and distributed to HMCAS staff working within the emergency section (N = 750). A 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) was used. The SERVQUAL model consisting of 5 dimensions (RATER): Reliability, Assurance, Tangibility, Empathy, and Responsiveness was used.3 Two variables with the highest perception score were regarded as the drivers of service quality. A negative gap score (perception minus expectation) was used as the basis for the study recommendations. Results: As per the required calculated sample size to achieve a 95% confidence interval, 255 questionnaires were completed. Respondents were 79% Ambulance Paramedics, 18% supervisors, and 3% managers. The weights of each dimension&apos;s variables were calculated to obtain perception and expectation scores. Descriptive statistics and gap scores of the survey responses are presented in Table 1 for the two variables of each dimension. None of the gap scores were found to be statistically significant. The proposed recommendations generated from this study are presented in Table 2. Conclusion: A standardized staff quality perception tool can assist in identifying potentially missed quality-related service issue(s). In this study, the SERVQUAL model was easily adapted and applied to the pre-hospital Emergency Medical Service setting in Qatar and proved useful in identifying service delivery proponents needing attention. Overall and reassuringly, the staff believes that they provide quality service to their patients.

Development of a prehospital prediction model for risk stratification of patients with chest pain.

Chest pain is one of the most common reasons for contacting the emergency medical services (EMS). About 15% of these chest pain patients have a high-risk condition, while many of them have a low-risk condition with no need for acute hospital care. It is challenging to at an early stage distinguish whether patients have a low- or high-risk condition. The objective of this study has been to develop prediction models for optimising the identification of patients with low- respectively high-risk conditions in acute chest pain early in the EMS work flow. This prospective observational cohort study included 2578 EMS missions concerning patients who contacted the EMS in a Swedish region due to chest pain in 2018. All the patients were assessed as having a low-, intermediate- or high-risk condition, i.e. occurrence of a time-sensitive diagnosis at discharge from hospital. Multivariate regression analyses using data on symptoms and symptom onset, clinical findings including ECG, previous medical history and Troponin T were carried out to develop models for identification of patients with low- respectively high-risk conditions. Developed models where then tested hold-out data set for internal validation and assessing their accuracy. Prediction models for risk-stratification based on variables mutual for both low- and high-risk prediction were developed. The variables included were: age, sex, previous medical history of kidney disease, atrial fibrillation or heart failure, Troponin T, ST-depression on ECG, paleness, pain debut during activity, constant pain, pain in right arm and pressuring pain quality. The high-risk model had an area under the receiving operating characteristic curve of 0.85 and the corresponding figure for the low-risk model was 0.78. Models based on readily available information in the EMS setting can identify high- and low-risk conditions with acceptable accuracy. A clinical decision support tool based on developed models may provide valuable clinical guidance and facilitate referral to less resource-intensive venues.

Direct Versus Video Laryngoscopy in a Helicopter Emergency Medical Services Setting: A Retrospective Comparison

ObjectiveSince the introduction of video laryngoscopy (VL) as a technique for orotracheal intubation, its use has become widespread among prehospital providers. However, little information is available about the efficacy and success of VL compared with direct laryngoscopy (DL) in the helicopter emergency medical services (HEMS) setting. The objective of this study was to investigate whether VL or DL increased successful first-pass orotracheal intubations and overall intubation success by HEMS providers. DesignA retrospective chart review was performed on adults intubated by a HEMS program from January 2015 to July 2017. All orotracheal intubations with at least 1 attempt were included. Excluded were emergent cricothyrotomies, nonintubated patients, and those intubated before HEMS care. ResultsDL accounted for 21 intubations, whereas VL was used for 150 intubations. Nineteen of 21 (90.5%) DL intubations were successful on first pass, whereas 127 of 150 (84.7%) VL intubations were successful on first pass. The overall success rate was 90.5% for DL and 92.7% for VL. For both first-pass and overall success rates, the differences between modalities were not statistically significant. DL and VL had nearly identical complication rates, with hypoxia being the primary complication in both groups. ConclusionNo statistically significant difference was found in the first-pass rate, the overall success rate, or complications between DL and VL.

Clinical Characteristics of Patients Undergoing Needle Thoracostomy in a Canadian Helicopter Emergency Medical Service

Objective: Needle thoracostomy (NT) can be a life-saving procedure when used to treat tension pneumothorax. However, there is some question regarding the efficacy of NT in the prehospital setting. Failure to treat tension pneumothorax in a helicopter emergency medical service (HEMS) setting may prove especially deleterious to the patient due to gas expansion with increasing altitude. This study's objective was to identify the characteristics of patients treated with NT in a Canadian HEMS setting and the factors that may influence outcomes following NT use. Methods: This was a retrospective chart review of prehospital records from a Canadian HEMS service. Patients aged 18 years and older who underwent at least one NT attempt using a 14-gauge 8.3 cm needle from 2012 to 2018 were identified. Charts were reviewed to collect demographic data, NT procedural characteristics, vital signs, and clinical response metrics. Descriptive statistics were used to characterize the study sample and overall event characteristics. Binary logistic regression was performed to identify variables associated with a clinical response to the initial NT treatment. Results: 163 patients (1.3%) of 12,407 patients attended received NT. A positive clinical response to NT was recorded in 37% (n = 77) of the total events (n = 208), the most common of which was an improvement in blood pressure (BP) (18.8%, n = 39). Initial NT was associated with a low likelihood of clinical improvement in patients presenting with blunt trauma (OR = 0.18; p = .021; 95% CI [.04, .77]), CPR prior to NT (OR = 0.14; p = .02; 95% CI [.03, .73]), or in those who received bilateral NT treatment (OR = 0.13; p < .01; 95% CI [.05, .37]). A pretreatment BP < 90 mmHg was predictive of a positive clinical response to initial NT (OR = 3.33; p = .04; 95% CI [1.09, 10.20]). Conclusions: Only a small portion of patients in the setting of a Canadian HEMS service were treated with NT. Patients most likely to receive NT were males who had suffered blunt trauma. NT may have questionable benefit for patients presenting with blunt trauma, in cardiac arrest, or requiring bilateral NT.

High-Fidelity Simulation Training for Helicopter Emergency Medical Services Flight Nurses: A Report From the First Italian Experience

ObjectiveSimulation-based training has a significant effect in enhancing professionals’ skills in the helicopter emergency medical service (HEMS) setting and is reported to be more effective than other learning strategies. The main objective of this study was to assess the efficacy of a specific high-fidelity simulation (HFS) training course for HEMS nurses before entering into operational service. MethodsThis report describes the first Italian experience of a specifically designed HFS training program for HEMS nurses held in Bologna, Italy, in a dedicated scenario with a mock-up helicopter and an advanced mannequin. ResultsA total of 14 nurses participated in the SAFE2019 (Simulazione ad Alta Fedeltà per l'Elisoccorso–High-Fidelity Simulation for HEMS) courses. The aspects considered most useful and effective were related to team working, communication issues, and nontechnical skills (NTS) development. Moreover, participants suggested implementing a series of scheduled HFS retraining sessions. ConclusionHFS in a dedicated HEMS scenario during the orientation period has contributed to enhanced technical competencies and NTS, increasing comfort and situational awareness for new entrant flight nurses. Simulation may represent a valuable resource to assess and maintain competencies through periodic retraining sessions for full HEMS teams or when new devices are adopted.

Knowledge, attitude, and practice toward COVID-19 among paramedics in Saudi Arabia: Implications for educational program

Coronavirus disease-2019 (COVID-19) is an ongoing public health issue, which threatens the lives of more than 2.4 million people worldwide. This study's purpose is to establish paramedics’ knowledge, attitude, and practices (KAP) towards COVID-19 in Saudi Arabia. An online cross-sectional, descriptive study was conducted among paramedics in four hospitals via WhatsApp Messenger. The study population was composed of paramedics aged 18 years and above. A pre-validated questionnaire was used to evaluate KAP towards COVID-19. Bloom’s cut-off of 80% was used to assess sufficient knowledge (≥80%), positive attitude (≥4), and good practice (≥2.4). All analyses were performed using SPSS version 26 of the approaching 300 paramedics, 71 (24%) responded. The majority of participants were male (n=61, n=85.9%), with an average age of 33 (range: 18–57) years. Overall, 4.2% (n=3) had sufficient knowledge, 42% (n=30) had a positive attitude, and 4% (n=4) had good practice regarding to COVID-19. There was a statistically significant difference between paramedics’ KAP according to their socio-demographic characteristics. Younger paramedics (≥ 18) have sufficient knowledge and a good practice toward COVID-19 than older paramedics (≥37) (p=0.000, p=0.005), respectively. Older paramedics (≥37) have a positive attitude towards COVID-19 relative to younger paramedics (≥ 18) (p=0.000). A statistically significant difference between the total KAP and the level of education (p=0.000) at which the diploma (p=0.000) had sufficient knowledge of COVID-19 than the bachelors and the postgraduate level. Bachelor's and graduates have a positive attitude (p=0.000) towards COVID-19 than the diploma. Saudi paramedics have poor knowledge of COVID-19. In addition, the results of this study have shown that there are statistically significant differences in KAPs’ paramedics according to their demographic characteristics. The author suggests follow-up studies concerning emergency medical services (EMS) settings around the country. Relevance to clinical practice: Ongoing professional education program for Saudi paramedics is encouraged to improve knowledge of paramedics, thus preventing negative attitudes and encouraging constructive preventive and therapeutic practices.

Analgesia in adult trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis

BackgroundSufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed.MethodsObservational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe.ResultsOverall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids (n=20,051; 76.9%), esketamine (n=9082; 34.9%), metamizole (n=798; 3.1%) and NSAIDs (n=483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen (n=21,743; 83.4%), while opioids together with esketamine (n= 3591; 13.8%) or metamizole (n=369; 1.4%) were the most common combinations. Females received opioids less frequently than did males (n=6038; 74.5% vs. n=14,013; 78.1%; p< 0.001). Pain relief was often sufficient (> 95%), but females more often had moderate to severe pain on arrival in hospital (n=34; 5.0% vs. n=59; 3.2%; p=0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO2 and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared.ConclusionsOpioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS.

Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting

The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.

Point-of-Care Testing Practices, Failure Modes, and Risk-Mitigation Strategies in Emergency Medical Services Programs in the Canadian Province of Alberta

Emergency medical services (EMS) programs have been using point-of-care testing (POCT) for more than 20 years. However, only a handful of reports have been published in all of that time on POCT practices in field settings. To provide an overview of POCT practices and failure modes in 3 of Alberta's EMS programs, and to propose risk-mitigation strategies for reducing or eliminating these failure modes. Details about POCT practices, failure modes, and risk-mitigation strategies were gathered through (1) conversations with personnel, (2) in-person tours of EMS bases, (3) accompaniment of EMS personnel on missions, (4) internet searches for publicly available information, and (5) a review of laboratory documents. Practices were most standardized and robust in the community paramedicine program (single service provider, full laboratory oversight), and least standardized and robust in the air ambulance program (4 service providers, limited laboratory oversight). Common failure modes across all 3 programs included device inoperability due to cold weather, analytical validation procedures that failed to consider the unique challenges of EMS settings, and a lack of real-time electronic transmission of results into the health care record. A provincial framework for POCT in EMS programs is desirable. Such a framework should include appropriate funding models, laboratory oversight of POCT, and relevant expertise on POCT in EMS settings. The framework should also incorporate specific guidance on quality standards that are needed to address the unique challenges of performing POCT in field settings.

Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from NAEMSP

Background Millions of patients receive medications in the Emergency Medical Services (EMS) setting annually, and dosing safety is critically important. The need for weight-based dosing in pediatric patients and variability in medication concentrations available in the EMS setting may require EMS providers to perform complex calculations to derive the appropriate dose to deliver. These factors can significantly increase the risk for harm when dose calculations are inaccurate or incorrect. Methods We conducted a scoping review of the EMS, interfacility transport and emergency medicine literature regarding pediatric medication dosing safety. A priori, the authors identified four research topics: (1) what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients, (2) what practices or technologies are known to enhance dosing safety, (3) can data from other settings be extrapolated to the EMS environment to inform dosing safety, and (4) what impact could standardization of medication formularies have on enhancing dosing safety. To address these topics, 17 PICO (Patient, Intervention, Comparison, Outcome) questions were developed and a literature search was performed. Results After applying exclusion criteria, 70 articles were reviewed. The methods for the investigation, findings from these articles and how they inform EMS medication dosing safety are summarized here. This review yielded 11 recommendations to improve safety of medication delivery in the EMS setting. Conclusion These recommendations are summarized in the National Association of EMS Physicians® position statement: Medication Dosing Safety for Pediatric Patients in Emergency Medical Services.

A systematic review of stability of medicines used in emergency medical service settings

Background: Temperature, among several environment conditions like humidity, is known to impact medicine stability1,2. In emergency medical service (EMS) settings, it is often challenging to control these conditions. In the GCC region including Qatar, temperature and relative humidity values may rise over 50°C and 80%, respectively, according to climate data from the Qatar Civil Aviation Authority3. The aim of this systematic review is to collate and analyze data on the stability of EMS medicines exposed to temperature excursions beyond recommended limits (20-25°C with excursions up to 15-30°C) and provide evidence-based best practice recommendations on storage of medicines in EMS settings. Method: Literature on stability studies in EMS settings were obtained from PubMed, Embase, Web of Science and grey literature. Data from articles that met inclusion and exclusion criteria were collected using developed data collection forms then analyzed following PRISMA statement. The quality of articles were assessed using the Health Evidence Tool. Results: Thirteen studies were included (Table 1). Results were variable depending on the region and whether the study was done in an EMS setting or simulated in laboratory. Studies affirmed that medicines were exposed to temperatures beyond limits in EMS settings (Table 2). Medicines recommended to be refrigerated were not stable in a temperature-dependent manner. Although many medicines were stable, temperature-sensitive medicines degraded faster, while extreme cold produced various effects. No study has explored the biological effects of degradation and degradation products. Conclusion: EMS medicines are exposed to temperature extremes which may affect their stability and decrease their shelf-life. Therefore, routine stability testing during storage, replacement of exposed medicines and inclusion of temperature monitoring devices are paramount to validate the content of EMS medicines administered to end-users. We aim to collaborate with Hamad Medical Corporation Ambulance Service in Qatar to study the stability of EMS medicines in several settings including ambulances and paramedic bags of indoor and outdoor bike units.