Ground Emergency Medical Services Research Articles

Removing the barriers to prehospital blood: a roadmap to success.

This review describes the necessity, evolution, and current state of prehospital blood programs in the United States. Less than 1% of 9-1-1 Ground Emergency Medical Service agencies have been able to successfully implement prehospital blood transfusions as part of a resuscitation strategy for patients in hemorrhagic shock despite estimates that annually between 54,000 and 900,000 patients may benefit from its use. The use of prehospital blood transfusions as a tool for managing hemorrhagic shock has barriers to overcome to ensure it becomes widely available to patients throughout the United States. Barriers include 1) current state Emergency Medical Services clinicians' scope of practice limitations, 2) program costs and reimbursement of blood products, 3) no centralized data collection process for prehospital hemorrhagic shock and patient outcomes, 4) collaboration between prehospital agencies, blood suppliers, and hospital clinicians and transfusion service activities. The following paper identifies barriers and a proposed roadmap to reduce death due to prehospital hemorrhage.

Retrospective Matched Cohort Comparison of Prehospital Finger Thoracostomy and Needle Thoracostomy Performed by Ground Emergency Medical Services

Introduction: Tension pneumothorax related to chest trauma is a rapidly lethal condition that requires immediate treatment, often prior to arrival at definitive care. Recent concerns regarding the safety and efficacy of needle thoracostomy (NT) have led to alternatives. Finger thoracostomy (FT) is a potential life-saving treatment performed by prehospital providers as an alternative to NT. We hypothesize that FT has improved rates of prehospital thoracic decompression and is a safe alternative to NT.
 Materials and Methods: Retrospective cohort study of consecutive adult trauma patients presenting to a Level 1 trauma center who sustained chest trauma. A matched cohort of patients who underwent prehospital FT was compared to patients who underwent prehospital NT for thoracic decompression. Wilcoxon Rank Sum Test and Chi-Squared Analyses were performed for comparison of prehospital and in-hospital outcome variables.
 Results: 34 patients were compared, of which 15 underwent prehospital FT and 19 underwent prehospital needle thoracostomy NT. Groups were well matched in terms of demographics and injury characteristics. No difference in transport times were observed. All 15 patients in the FT group sustained cardiac arrest prior to arrival with 20% achieving return of spontaneous circulation (ROSC), while 6/19 NT patients arrived in cardiac arrest, with 66.7% achieving ROSC (p = 0.04). The rate of successful intrathoracic decompression was higher in the FT group (93.3% vs 47.4%, p<0.001). The NT group had a higher rate of chest tube placement (p=0.005). In-hospital mortality was not different between the two groups (p=0.213).
 Conclusions: FT is a viable alternative to NT for emergent thoracic decompression. The higher success rate of intrathoracic decompression supports the use of FT as an alternative to NT for prehospital tension pneumothorax, although future studies are needed establish superiority and further evaluate mortality and in-hospital outcomes.

Rural Emergency Medical Services Clinicians’ Perceptions and Preferences in Receiving Clinical Feedback From Hospitals: A Qualitative Needs Assessment

Objective Emergency medical services (EMS) clinicians experience dissatisfaction with the quality and quantity of clinical feedback from hospitals. Satisfaction is further diminished by the lack of a standardized systems approach. The purpose of this study was to identify rural clinicians’ perceptions and preferences regarding clinical feedback received from hospitals, the delivery mechanisms, and its impact on their relationships with health care organizations. Methods This was a qualitative study focused on EMS clinicians involved in rural prehospital care at a single Midwestern academic medical center. Using a phenomenological framework, semi-structured interviews were conducted with medical directors, service directors, fire captains, air medical personnel, emergency medical responders, emergency medical technicians, advanced emergency medical technicians, and paramedics, all of whom were selected through purposive sampling. Interviews were recorded, transcribed, and independently coded by two trained reviewers. Results Twenty participants (11 frontline clinicians and 9 administrative staff members) with a wide range of clinical experience from 14 air and ground EMS agencies were interviewed. Emerging themes included: (1) the value or usefulness of feedback; (2) desired feedback system characteristics; (3) barriers to receiving feedback; (4) utilization and application of feedback; and (5) the feedback’s impact on the relationship with health care organizations. Participants felt that clinical feedback from hospitals was especially important as a method of improving quality of care, though was rarely provided. Professional development was seen as a major benefit of receiving clinical feedback from hospitals. Conclusion Our results suggest that consistent clinical feedback provided by hospitals was valued. Establishing a culture of providing organized feedback to practicing rural EMS clinicians is important for professional development and can strengthen the relationships between EMS clinicians and hospitals. These study findings can assist in the development and implementation of a standardized feedback instrument to benefit rural EMS clinicians, patients, and the health care system as a whole.

The Effect of Coronavirus Disease 2019 on Adverse Events in Health Care: A Retrospective Study in Ground and Helicopter Emergency Medical Services

ObjectiveThe coronavirus disease 2019 (COVID-19) pandemic has proven to be a significant hardship for the entire world. Health care systems and their workers have been stretched to their limits. Research regarding whether this increased strain has affected patient safety has not been sufficient, especially in emergency medical services. The aim of this study was to determine if there has been an increased rate of adverse events in ground and helicopter emergency medical services since the onset of the COVID-19 pandemic. MethodsA 2-year retrospective review was performed at a Midwest regional critical care transport service. The rate of adverse events for 1-year periods before and after March 13, 2020, was the primary outcome. All adverse events that generated a quality improvement incident report form (QIRF) were included, except those generated for non–clinical-related incidents. Additionally, a smaller time frame between May 1st and August 31st of both years was included containing all flagged adverse events from peer reviewers; not all of these generated a QIRF. ResultsIn the time period between March 13, 2019, and March 12, 2020, 5 of 3,154 (0.16%) calls generated a QIRF versus 21 of 3,185 (0.66%) calls between March 13, 2020, and March 12, 2021. There was a significant relationship showing an adverse event was more likely to happen after the onset of COVID-19 compared with before (χ21 [N = 6,339] = 8.643, P ≤ .001). Additionally, from May 1st to August 31st, the total adverse event rates were 16.86% (143/848 calls) and 24.46% (387/1,582 calls) for 2019 and 2020, respectively. Similarly, statistical significance existed for adverse events occurring after onset of the pandemic versus before (χ21 [N = 2,430] = 18.253, P ≤ .001). ConclusionA higher rate of adverse events for the year after the onset of COVID-19 existed. Additional studies looking at the causes of adverse events and patient outcomes should be undertaken to further understand this increase.

Seasonality and temporal variation of pediatric trauma in Southern California

IntroductionSeasonality of pediatric trauma has been previously described, although the association of season with hour of presentation is less understood. Both factors have potential implications for resource allocation and team preparedness. MethodsA multicenter retrospective study was conducted to analyze the records of injured children <18 years-old who presented to one of the 15 trauma centers within Los Angeles County. Data from the County Trauma and Emergency Medicine Information System Registry was abstracted from 1/1/10 to 12/31/21. Patient demographics, mechanism of injury (MOI) and time of presentation by season were analyzed using Kruskal Wallis tests and chi-square tests. ResultsA total of 30,444 pediatric trauma presentations were included. Both the time of presentation and the MOI differed significantly by season with p < 0.001. Autumn had a higher incidence of pedestrian injuries during hours of 08:00 and 15:0020:00, and sports injuries from 16:00 to 21:00. In the Summer there were more burns between 17:00 and 23:00 and falls from greater than 10 ft after 13:00. The mode of transport used was also different across seasons (p = 0.03), with the use of both air and ground EMS greatest during summer and least during winter. The hours of greatest utilization remained relatively constant for all seasons for air transport (18:00–19:00 h) and ground transport (19:00–20:00 h). ConclusionThese data demonstrate the significant seasonal and temporal variation within pediatric trauma. These findings could be used to inform improvements in emergency response, and resource allocation in particular.

Natural Experiment Outcomes Studies in Rotor Wing Air Medical Transport: Systematic Review and Meta-Analysis of Before-and-After and Helicopter-Unavailable Publications From 1970 to 2022

ObjectiveHelicopter emergency medical services (HEMS) is widely used for prehospital and interfacility transport, but there is a paucity of HEMS outcomes data from studies using randomized controlled trial designs. In the absence of robust randomized controlled trial evidence, judgments regarding HEMS potential benefit must be informed by observational data. Within the study design set of observational analyses, the natural experiment (NE) is notable for its high potential methodologic quality; NE designs are occasionally denoted “quasi-experimental.” The aim of this study is to examine all NE outcomes studies in the HEMS literature and to discern what lessons can be learned from these potentially high-quality observational data. MethodsHEMS NE studies were identified during the development of a new HEMS Outcomes Assessment Research Database (HOARD). HOARD was constructed using a broad-ranging search of published and gray literature resources (eg, PubMed, Embase, and Google Scholar) that used variations of the terms “helicopter EMS,” “air ambulance,” and “air medical transport.” Among the 221 studies ultimately included in HOARD, 16 NE publications describing 13 sets of observational data comprising myriad diagnostic groups were identified. Of these 16 HEMS NEs, 4 HEMS NE studies assessing trauma outcomes were used in a meta-analysis. A meta-analysis was also performed of 4 HEMS NE studies. ResultsAlthough the disparity of studies (in terms of both case mix and end points) precluded the generation of a pooled effect estimate of an adjusted mortality benefit of HEMs versus ground emergency medical services, HEMS was found to be associated with outcomes improvement in 8 of the 13 cohorts. ConclusionThe weight of the NE evidence supports a conclusion of some form of HEMS-mediated outcomes improvement in a variety of patient types. Meta-analysis of 4 HEMS NE studies assessing trauma outcomes generated a model with acceptable heterogeneity (I2 = 43%, Q test: P = .16), which significantly (P < .01) favored HEMS use with a pooled HEMS survival odd ratio estimate of 1.66 (95% confidence interval, 1.23-2.22).

Prehospital Time Following Traumatic Injury Is Independently Associated With the Need for In-Hospital Blood and Early Mortality for Specific Injury Types

ObjectiveTreating traumatic hemorrhage is time sensitive. Prehospital care and transport modes (eg, helicopter and ground) may influence in-hospital events. We hypothesized that prehospital time (on-scene time [OST] and total prehospital time [TPT]) and transport mode are associated with same-day transfusion and mortality. Furthermore, we sought to identify regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. MethodsWe obtained prehospital, in-hospital, and trauma registry data from an 8-center cohort of adult nonburn trauma patients from 2017 to 2022 directly transported from the scene to the hospital and having an Injury Severity Score (ISS) > 9 for the Task Order 1 project of the Linking Investigators in Trauma and Emergency Services research network. We excluded patients missing prehospital times, patients < 18 years of age, patients from interfacility transfers, and recipients of prehospital blood. Our same-day outcomes were in-hospital transfusions within 4 hours and 24-hour mortality. Each outcome was adjusted using multivariable logistic regression for covariates of prehospital phases (OST and TPT), mode of transport (helicopter and ground), age, sex, ISS, Glasgow Coma Scale motor subscale score < 6, and field hypotension (systolic blood pressure < 90 mm Hg). We evaluated the association of prehospital time on outcomes for scene missions by transport mode across severe injury patterns defined by Abbreviated Injury Scale > 2 body regions. ResultsOf 78,198 subjects, 34,504 were eligible for the study with a mean age of 47.6 ± 20.3 years, ISS of 18 ± 11, OST of 15.9 ± 9.5 minutes, and TPT of 48.7 ± 20.3 minutes. Adjusted for injury severity and demographic factors, transport type significantly modified the relationship between prehospital time and outcomes. The association of OST and TPT with the odds of 4-hour transfusion was absent for the ground emergency medical services (GEMS) cohort and present for the helicopter emergency medical services (HEMS) ambulance cohort, whereas these times were associated with decreased 24-hour mortality for both transport types. When stratifying by injury to most anatomic regions, OST and TPT were associated with a decreased need for 4-hour transfusions in the GEMS cohort. However, OST was associated with increased early transfusion only among patients with severe injuries of the thorax, and this association persisted after adjusting additionally for injury type (odds ratio [OR] = 1.03; 95% confidence interval [CI], 1.00-1.05; P = .02). The presence of polytrauma supported an association between prehospital time and decreased 24-hour mortality for the GEMS cohort (OST: OR = 0.97; 95% CI, 0.95-0.99; P < .01; TPT: OR = 0.99; 95% CI, 0.98-0.99; P = .02), whereas no injuries showed significant association of helicopter prehospital time on mortality after adjustment. ConclusionWe determined that transport type affects the relationship between prehospital time and hospital outcomes (4-hour transfusion: positive relationship for HEMS and negative for GEMS, 24-hour mortality: negative for both transport types). Furthermore, we identified regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. Of these regions, most notable were severe isolated injuries to the thorax that supported a positive relationship between HEMS OST and 4-hour transfusions and polytrauma that showed a negative relationship between GEMS OST or TPT and 24-hour mortality after adjustment.

Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study

ObjectiveInterhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA. MethodsThis was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions. Nonfederal referring hospitals located in the home state of the associated critical care transport medicine program and within 100 miles of the primary receiving facility in the region were included if complete data were available. We fit a Poisson principal component regression model incorporating geographic distance, the number of emergency department visits, the number of hospital discharges, case mix index, the number of intensive care unit beds, and the number of general beds and tested the association of the variables with helicopter emergency medical services utilization. ResultsA total of 106 referring hospitals were analyzed, 21 of which were hospitals identified as having a consistent request pattern. Using the hospitals with a consistent referral pattern, geographic distance had a significant positive association with flight request volume. Other variables, including emergency department visit volume, were not associated. Overall, the included variables offered poor explanatory power for the observed variation between referring facilities in the use of IHTA (r2 = 0.09). Predicted flights based on the principal component regression model for all referring hospitals suggested the majority of referring hospitals used multiple flight programs. ConclusionGeographic distance is associated with the use of IHTA. Unexpectedly, most basic hospital characteristics are not associated with the use of IHTA, and the degree of variation between referring facilities that is explained by patient volume is limited. The evaluation of nonhospital factors, such as the density and availability of critical care or advanced life support ground emergency medical services resources, is needed.

Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan

PurposeIn Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a “doctor car”. Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan.MethodsA nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations.ResultsThis study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065–1.415]).ConclusionUsing nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Abstract 300: An Opportunity for Awareness: The International Academy of Emergency Medical Dispatch's Stroke Diagnostic Tool is Predictive, but Underutilized, for Hospital Confirmed Large Vessel Occlusion Strokes

Background: Accurate identification of ischemic stroke from large vessel occlusion (LVO) by 9-1-1 professionals can facilitate prompt patient transfer to stroke centers that perform endovascular thrombectomy. We sought to determine the proportion of LVO stroke patients that were evaluated using the Medical Priority Dispatch System's (MPDS) Stroke Diagnostic Tool (SDxT). Methods: Structured, retrospective review of our institution’s stroke registry, EMS Records, and dispatch codes between January 1, 2019 and November 30, 2022. Inclusion: Adult (age &gt;17), accessed the 9-1-1 system and transported by a ground EMS agency for an acute stroke. Exclusion: age &lt;18, pregnant, incarcerated, cases with missing 9-1-1 data, and intracranial hemorrhage. Two trained/monitored abstractors, blinded to the study purpose, used a standardized data collection tool/dictionary to extract data. Data included MPDS codes, SDxT outcome, EMS care, demographics, hospital NIHSS score, advanced imaging, tPA administration, and mechanical thrombectomy. Primary outcome: the proportion of LVO cases that had an acute stroke (28 protocol) dispatch code. Secondary outcome: the proportion of LVO cases that that a SDxT score indicating “strong or clear evidence of a stroke”. We report proportions and 95% CI's as appropriate. Results: 60 patients met inclusion/exclusion criteria. 11/60, 18.3 % (95%CI= 10.4, 30) of the patients had complete data and a LVO. 54% were male, the median (IQR) age was 69.5 (61.3-77.5), and the median (IQR) NIHSS was 16 (5-19.75). Primary outcome: 45.5 % (95% CI= 21.3.72.0) of the LVO’s were coded as an Acute Stroke by the 9-1-1 center. Of those, 3/5 utilized the stroke diagnostic tool, all 3 of these were determined to have "Clear Evidence of Stroke". Limitations: Retrospective, unlinked data, small number of LVO's. Conclusion: When utilized, the SDxT correctly identified all LVO’s. There is an opportunity to increase awareness and utilization of the SDxT by 9-1-1 centers. Future research should focus on identifying barriers to stroke recognition and provide additional tools to address the real-life challenges our 9-1-1 communications specialists face when rapidly assessing for an acute stroke over the phone.

Comparing strategies for prehospital transport to specialty care after cardiac arrest

Outcomes are better when patients resuscitated from out-of-hospital cardiac arrest (OHCA) are treated at specialty centers. The best strategy to transport patients from the scene of resuscitation to specialty care is unknown. MethodsWe performed a retrospective cohort study. We identified patients treated at a single specialty center after OHCA from 2010 to 2021 and used OHCA geolocations to develop a catchment area using a convex hull. Within this area, we identified short term acute care hospitals, OHCA receiving centers, adult population by census block group, and helicopter landing zones. We determined population-level times to specialty care via: (1) direct ground transport; (2) transport to the nearest hospital followed by air interfacility transfer; and (3) ground transport to air ambulance. We used an instrumental variable (IV) adjusted probit regression to estimate the causal effect of transport strategy on functionally favorable survival to hospital discharge. ResultsDirect transport to specialty care by ground to air ambulance had the shortest population-level times from OHCA to specialty care (median 56 [IQR 47–66] minutes). There were 1,861 patients included in IV regression of whom 395 (21%) had functionally favorable survival. Most (n = 1,221, 66%) were transported to the nearest hospital by ground EMS then to specialty care by air. Patient outcomes did not differ across transport strategies in our IV analysis. DiscussionWe did not find strong evidence in favor of a particular strategy for transport to specialty care after OHCA. Population level time to specialty care was shortest with ground ambulance transport to the nearest helicopter landing zone.

A Retrospective Geospatial Simulation Study of Helicopter Emergency Medical Services’ Potential Time Benefit Over Ground Ambulance Transport in Northern South Africa

ObjectiveOne of the most important benefits of helicopter emergency medical services (HEMS) is a time benefit, either through expedited access to the casualty or a reduction in the transport time to definitive care. However, HEMS utilization does not come without risk to the public and crew or at an insignificant cost. Cost is an essential consideration for health policy decisions, especially in low- to middle-income countries, such as South Africa. The aim of this study was to determine whether there is a time benefit of HEMS dispatch in South Africa compared with simulated driving time. A secondary aim was to determine the distance from the incident site to the hospital at which a time benefit can be guaranteed. MethodsA retrospective study was undertaken by comparing the prehospital times of patients who underwent HEMS transportation with simulated ground emergency medical services (GEMS) transportation times. Handwritten patient records of actual flights were reviewed and analyzed. The actual flight times recorded were used to calculate the helicopter transport time, activation to scene time, scene time, and scene to hospital time. Times were assigned based on a nonsimultaneous dispatch model, as is used in South Africa. For each helicopter mission, Google Maps (Google Inc, Mountain View, CA) was used to simulate the fastest ground route from the same location of the incident to the same receiving hospital corrected for typical traffic trends. The actual HEMS and simulated GEMS times were compared using the paired t-test. Linear regression analysis was performed to determine a minimum driving distance at which HEMS provides a time benefit. ResultsA total of 118 HEMS transports were analyzed, the majority of which were trauma related (n = 115, 97%). HEMS transport resulted in a mean time deficit of −15 minutes (95% confidence interval, −18 to −11; P < .05) compared with simulated GEMS drive times. After regression, HEMS transport provides a time benefit at a driving distance greater than 119 km. ConclusionThe current study demonstrated that there was rarely a time benefit for actual primary emergency responses when HEMS was used compared with simulated driving time of GEMS transport. Using a nonsimultaneous dispatch model, a time benefit only occurs when the driving distance from the incident site to the hospital is greater than 119 km. There is an urgent need to critically evaluate HEMS utilization in the South African context.

Which Method of Transportation Is Associated With Better Outcomes for Patients With Firearm Injuries to the Head and Neck?

In firearm injuries (FI), rapid transportation is important for survival. Information regarding different methods of transportation for head and neck FI is limited. The purpose of the study was to measure the association between method of transportation and the need for tracheostomy and/or intensive care unit (ICU). This retrospective cross-sectional study reviewed patients in Trauma Registry at Grady Memorial Hospital (GMH) in Atlanta, Georgia, from January 2016 to June 2021. Patients ≥18years old who sustained FI to the head and neck and were transported via ground emergency medical services (GEMS) or helicopter emergency medical services (HEMS) were included. Patients who arrived at the hospital by foot, private vehicle, or transported from a different hospital were excluded. The primary predictor variable was method of transportation (GEMS: ambulance transportation to GMH vs HEMS: helicopter transportation to GMH helipad). The primary outcome variables were tracheostomy (yes/no) and ICU admission (yes/no). Patient, injury, and hospital-related covariates were collected. Univariate analysis, χ2 test for categorical variables, and independent t test for continuous variables were calculated. Statistical significance was P<.05. Of total, 609 patients met the inclusion criteria. There were 560 patients (483 males) with a mean age of 33.6years old (range, 18 to 90) transported by GEMS. There were 49 patients (40 males) with a mean age of 44years old (range, 18 to 82) transported by HEMS. Patients transported by HEMS were statistically more likely to have longer transportation time in minutes [13.2 (range, 5 to 132) versus 24.2 (range, 9 to 46), P= <.001], lower Glasgow Coma Scale score [9.9 (range, 3 to 15) versus 6.3 (range, 3 to 15); P= <.001], higher Injury Severity Score [19.3 (range, 3.7 to 98) versus 24.2 (range, 10.3 to 98); P=.007], require transfusion [195 (34.8%); versus 26 (53.1%); P=.013], tracheostomy [46(8.2%) versus 13 (26.5%); P= <.001], and/or admitted to ICU [169, 30.2% versus 24 (49%); P=.007]. HEMS was positively associated with more tracheostomy and/or ICU admission. Additionally, patients transported by HEMS experienced longer transportation time and severe injuries. HEMS triage criteria specific for FI to the head and neck should be developed.

Access to trauma center care: A statewide system-based approach.

Timely access to specialized trauma care is a vital element in patient outcome after severe and critical injury requiring the skills of trauma teams in levels I and II trauma centers to avoid preventable mortality. We used system-based models to estimate timely access to care. Trauma system models consisted of ground emergency medical services, helicopter emergency medical services, and designated levels I to V trauma centers were constructed for five states. These models incorporated geographic information systems along with traffic data and census block group data to estimate population access to trauma care within the "golden hour." Trauma systems were further analyzed to identify the optimal location for an additional level I or II trauma center that would provide the greatest increase in access. The population of the states studied totaled 23 million people, of which 20 million (87%) had access to a level I or II trauma center within 60 minutes. Statewide-specific access ranged from 60% to 100%. Including levels III to V trauma centers, access within 60 minutes increased to 22 million (96%), ranging from 95% to 100%. The addition of a levels I and II trauma center in an optimized location in each state would provide timely access to a higher trauma capability for an additional 1.1 million, increasing total access to approximately 21.1 million people (92%). This analysis demonstrates that nearly universal access to trauma care is present in these states when including levels I to V trauma centers. However, concerning gaps remain in timely access to levels I and II trauma centers. This study provides an approach to determine more robust statewide estimates of access to care. It highlights the need for a national trauma system, one in which all components of state-managed trauma systems are assembled in a national data set to accurately identify gaps in care. Therapeutic/Care Management; Level IV.

Explainable Prediction Model of the Need for Emergency Hemostasis Using Field Information During Physician-Staffed Helicopter Emergency Medical Service Interventions: A Single-Center, Retrospective, Observational Pilot Study

ObjectiveEarly recognition of hemostasis is important to prevent trauma-related deaths. We conducted a pilot study of a predictive model of hemostatic need using factors that can be collected during helicopter emergency medical service (HEMS) interventions until transport hospital selection using cases from our institution. MethodsThis single-center, retrospective, observational pilot study included 251 trauma patients aged ≥ 18 years treated with HEMS between April 2017 and March 2022, in Nara Medical University. Cardiac arrest and pre-HEMS treatment patients were excluded. Emergency hemostatic surgery prediction models were constructed using the light gradient boosting machine cross-validation method using objective data that could be collected before hospital determination. The accuracy of this model was compared with that of the ground emergency medical service–based model, and factors influencing outcome were visualized using Shapley additive explanations. ResultsThe predictive accuracy of the model with HEMS intervention factors was an area under the receiver operating characteristic curve of 0.80, superior to the 0.73 accuracy area under the receiver operating characteristic curve for ground emergency medical services constructed with contact information. Clinically important factors, such as shock index, blood pressure changes, and ultrasound findings, had a significant impact on outcomes, with nonmonotonic effects observed across factors. ConclusionThis pilot study suggests that predictive models of emergency hemostasis can be built using limited prehospital information. To validate this model, a larger, multicenter study is recommended.

A Video-Based Study of Emergency Medical Services Handoffs to a Pediatric Emergency Department

BackgroundEmergency medical services (EMS) to emergency department (ED) handoffs are important moments in patient care, but patient information is communicated inconsistently. ObjectiveThe aim of this study was to describe the duration, completeness, and communication patterns of patient handoffs from EMS to pediatric ED clinicians. MethodsWe conducted a video-based, prospective study in the resuscitation suite of an academic pediatric ED. All patients 25 years and younger transported via ground EMS from the scene were eligible. We completed a structured video review to assess frequency of transmission of handoff elements, handoff duration, and communication patterns. We compared outcomes between medical and trauma activations. ResultsWe included 156 of 164 eligible patient encounters from January to June 2022. Mean (SD) handoff duration was 76 (39) seconds. Chief symptom and mechanism of injury were included in 96% of handoffs. Most EMS clinicians communicated prehospital interventions (73%) and physical examination findings (85%). However, vital signs were reported for fewer than one-third of patients. EMS clinicians were more likely to communicate prehospital interventions and vital signs for medical compared with trauma activations (p < 0.05). Communication challenges between EMS clinicians and the ED were common; ED clinicians interrupted EMS or requested information already communicated by EMS in nearly one-half of handoffs. ConclusionsEMS to pediatric ED handoffs take longer than recommended and frequently lack important patient information. ED clinicians engage in communication patterns that may hinder organized, efficient, and complete handoff. This study highlights the need for standardizing EMS handoff and ED clinician education regarding communication strategies to ensure active listening during EMS handoff.

Prehospital Active and Passive Warming in Trauma Patients

ObjectiveHypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients. MethodsIn a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated. ResultsA total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05). ConclusionFor adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.

Matched Cohort Study of Open Thoracostomies Performed by Ground Medics

Background: Tension pneumothorax resulting from chest trauma is a rapidly fatal condition that requires prompt treatment. Prehospital open thoracostomy (POT) is a potentially lifesaving intervention that can be performed in the field to treat tension pneumothorax. However, the results from POT performed by ground EMS providers have not been well-studied. The objective of this study was to compare outcomes for patients with chest trauma who underwent POT performed by ground EMS providers with a matched cohort who did not undergo this procedure in the field.&#x0D; Methods: A retrospective chart review of consecutive adult patients presenting to a Level I trauma center with chest trauma were analyzed from 2017-2020. Outcomes were compared to a patient cohort who did not undergo POT matched by severity of injury and prehospital CPR.&#x0D; Results: A total of 14 POT patients were identified. Majority of POT were bilateral (n=11/14, 78.6%) and all of these patients (n=14/14) had prehospital cardiac arrest. Return of spontaneous circulation was obtained in 2 patients with penetrating injuries (14.3%). There was no difference in total and scene EMS time compared to the matched cohort without POT (p&gt;0.05).&#x0D; Conclusions: This study demonstrated that open thoracostomies could be performed by ground EMS units without increasing prehospital time for severely injured trauma patients and greater achievement of ROSC. Larger, prospective, multi-institutional analyses are needed to further evaluate outcomes.

Abstract TP5: Helicopter Emergency Medical Services (HEMS) Transportation Utilization For Acute Ischemic Strokes At A Community Based Hospital In South Florida

Background: Efficiency in the transfer of patients with ischemic stroke is a vital factor for patient prognosis. A comprehensive stroke center servicing remote areas in south Florida became HEMS direct-from-field capable on October 15, 2020. In some remote areas, the transfer of patients is via ground or air; the severity of the clinical presentation determines the mode. Concern about HEMS overutilization for lower stroke acuities prompted this study. Purpose: The purpose of this project was to evaluate the current HEMS stroke triage process, assess the accuracy of stroke diagnosis, and use this information to improve EMS education to prevent over-triage for stroke. Methods: A retrospective cohort study from October 15, 2020, to July 31, 2021, collected HEMS adult stroke alert data and compared it to the prior year's summary ground EMS (GEMS) stroke alert data. Using HEMS transportation logs, presenting stroke symptoms and pre-hospital assessment were abstracted. In addition, we evaluated initial NIHSS, downgrade rate, stroke diagnosis percentage, treatment rate, and times. Results: The analysis included a total of 52 HEMS stroke alerts. Assessment tools utilized by HEMS included the Cincinnati stroke scale (4%) and the FAST-ED (37%); the majority of cases (59%) did not document a stroke assessment tool. The median NIHSS was 10, with 37% presenting with a score &lt;6. Respectively, 6% and 15 % of cases were downgraded upon arrival and after CT imaging. Significantly (p&lt;.001), more HEMS cases were diagnosed as a stroke (69%) compared to GEMS (57%). Stroke treatment rates remained similar (HEMS=23%; GEMS=23%). Median door-to-needle times were significantly faster for HEMS (15min) than GEMS (25min) (p&lt;.05). Median door-to puncture times were significantly faster for HEMS (61mins) than GEMS (72mins) (p&lt;.05). Conclusion: With low downgrade rates and high diagnosis accuracy, the current HEMS triage process, although not consistently documented, accurately detects stroke, even for low acuity cases. Patients arriving via HEMS receive equal access to stroke treatment with significantly faster treatment times, ensuring the best possible prognosis. EMS educational efforts should focus on improving documentation compliance.

Ground Versus Air: Which Mode of Emergency Medical Service Transportation Is More Likely to Crash?

ObjectiveWe analyzed helicopter emergency medical services (HEMS) and ground emergency medical services (GEMS) crash data in the United States during 1983 to 2020 to compare incidences of total, fatal, and injury crashes. MethodsHEMS and GEMS total, fatal, and injury crashes during 1983 to 2020 and 1988 to 2020, respectively, were analyzed in this retrospective study. Data were obtained from the National Transportation Safety Board and the National Highway Traffic Safety Administration. Additional data from the Federal Aviation Administration, the National Emergency Medical Services Information System, and prior literature were used for rate calculations. A Poisson regression model was used to determine rate ratios with 95% confidence intervals comparing total, fatal, and injury crash rates from 2016 to 2020. ResultsHEMS crash rates decreased since 1983. Total GEMS crashes have increased since 1988. Of the total crashes, 33% (HEMS) and 1% (GEMS) were fatal, and 20% (HEMS) and 31% (GEMS) resulted in injury. During 2016 to 2020, GEMS crash rates were 11.0 times higher than HEMS crash rates (95% confidence interval, 5.2-23.3; P < .0001). ConclusionHEMS has a lower crash probability than GEMS. The availability of data is a limitation of this study. National GEMS transportation data could be useful in studying this topic further.