Prehospital Patient Care Research Articles

Early treatment with GLP-1 after severe trauma preserves renal function in obese Zucker rats.

Early posttrauma hyperglycemia (EPTH) is correlated with later adverse outcomes, including acute kidney injury (AKI). Controlling EPTH in the prehospital setting is difficult because of the variability in the ideal insulin dosage and the potential risk of hypoglycemia, especially in those with confounding medical comorbidities of obesity and insulin resistance. Glucagon-like peptide-1 (GLP-1) controls glucose levels in a glucose-dependent manner and is a current target in antidiabetic therapy. We have shown that after orthopedic trauma, obese Zucker rats exhibit EPTH and a later development of AKI (within 24 h). We hypothesized that GLP-1 treatment after trauma decreases EPTH and protects renal function in obese Zucker rats. Obese Zucker rats (~12 wk old) were fasted for 4 h before trauma. Soft tissue injury, fibula fracture, and homogenized bone component injection were then performed in both hind limbs to induce severe extremity trauma. Plasma glucose levels were measured before and 15, 30, 60, 120, 180, 240, and 300 min after trauma. GLP-1 (3 μg·kg-1·h-1, 1.5 ml/kg total) or saline was continuously infused from 30 min to 5 h after trauma. Afterwards, rats were placed in metabolic cages overnight for urine collection. The following day, plasma interleukin (IL)-6 levels, renal blood flow (RBF), glomerular filtration rate (GFR), and renal oxygen delivery (Do2) and consumption (V̇o2) were measured. EPTH was evident within 15 min after trauma but was significantly ameliorated during the 5 h of GLP-1 infusion. One day after trauma, plasma IL-6 was markedly increased in the trauma group and decreased in GLP-1-treated animals. RBF, GFR, and Do2 all significantly decreased with trauma, but renal V̇o2 was unchanged. GLP-1 treatment normalized RBF, GFR, and Do2 without affecting V̇o2. These results suggest that GLP-1 decreases EPTH and protects against a later development of AKI. Early treatment with GLP-1 (or its analogs) to rapidly, effectively, and safely control EPTH may be beneficial in the prehospital care of obese patients after trauma.

317 Acute Respiratory Illness among a Prospective Cohort of Pediatric Patients Using Emergency Medical Services in India: Demographic, Environmental, and Out-of-Hospital Clinical Predictors of Mortality in a High-Risk Population

In India, acute respiratory illnesses (ARIs), including pneumonia, are the leading cause of early childhood death. Emergency medical services (EMS) in India have been shown to be a critical component in the public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries (LMICs) is severely limited. This study describes the demographic, environmental, and clinical characteristics associated with 30-day mortality among pediatric patients transported via EMS in India with an acute respiratory complaint. We conducted a prospective observational study of patients <18 years using EMS for “shortness of breath” or a primary chief complaint of “fever” with a secondary complaint of “difficulty breathing” or “cough” across 7 Indian states from June 20 to September 2, 2016. The primary outcome was 2, 7, and 30-day mortality. Baseline descriptive characteristics are provided as numbers and percents. Multivariate modeling, owing to predictors of increased mortality at 7 and 30 days, was constructed. A total of 1443 pediatric patients <18 years of age were enrolled during the study period: 981 (68.5%) were collected from the field, and 452 (31.5%) were interfacility transports (IFTs). Response rates were 87.0%, 85.8%, and 83.4% (N=1222) at 2, 7, and 30 days, respectively. The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N=1347) of patients lived on family incomes below the poverty level; and 54.1% (N=706) were male. The majority of calls were to rural or tribal areas (N=1122; 78.2%), with an average length of transport from initial call to health facility of 72 mins (IQR: 47-105). Overall cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively, with a total of 94 deaths by 30-days. Stratified by age, the largest burden of mortality fell to neonates (0-28 days) with a mortality of 17.0% at 30-days, while under-5 mortality (U5M) was 9.8% during the same follow-up period. IFT patients carried an almost 3-fold risk of death as compared to field transports (14% versus 5%, p value<0.0001). In multivariate modeling evidence of an oxygen saturation <95% in the prehospital setting (OR: 3.18 CI: 1.77-5.71), respiratory distress (OR: 3.72 CI: 2.17-6.36) and familial use of an open cook stove (OR: 2.61 CI: 1.59-4.29), were the strongest predictors of mortality at 30 days among all patients. This is the first known study to detail the out-of-hospital clinical predictors of death among pediatric patients with shortness of breath in a LMIC. EMS rapidly connects critically ill children to needed care in India. Despite this, U5M remains high. While national case fatality rates (CFRs) for India are not widely published, U5M from ARIs remains higher than various previously published hospital-based studies (CFR range: 3.8%-8.1%) and significantly more than published CFRs for developed countries (range: 0.4%-4.8%). The risk of death remains particularly acute for those patients transported as IFTs and among those with respiratory distress, or hypoxia. Early recognition of critically ill children, targeted out-of-hospital interventions, and diversion to higher level of care may help to mitigate the burden of mortality in this population.

Management of post-partum haemorrhage in the Timor Leste National Ambulance Service.

Timor Leste has one of the highest maternal death rates in the world at 215 per 100 000 live births.1 Post-partum haemorrhage (PPH) accounts for 27% of maternal deaths globally. Annually the Timor Leste National Ambulance Service (TLNAS) attends over 20 000 cases, of which 2% are diagnosed with PPH. The objective of this study was to evaluate prehospital care of PPH patients transported by the TLNAS. A retrospective audit of PPH patients transported between May 2015 and May 2017. The inclusion criteria were patients diagnosed with PPH and transported during the study period. Data from the patient care records of 214 TLNAS PPH patients were abstracted using the PPH care evaluation tool. Paramedics diagnosed 211 (97%) PPH patients, took observations on 181 (85%) and obtained a patient history from 193 (90%) patients. TLNAS paramedics did not regularly provide other treatment including oxygen 36 (17%), intravenous isotonic crystalloid fluid 117 (55%), uterine massage 0 (0%), external aortic compression 0 (0%) and non-pneumatic anti-shock garments 9 (4%). This research has shown that paramedics are not consistently using available clinical interventions.

Prehospital Care in Traumatic Brain Injury: Factors Affecting Patient's Outcome.

Background:Traumatic brain injury (TBI) is the leading cause of deaths worldwide. The morbidity and mortality due to TBI are related to both primary as well as secondary insults. The patients who survive from the primary insults, some may still have long-term disabilities. Most of these outcomes are related to the high incidence of prehospital secondary brain insults. Knowledge of these variables and timely management of the disease at the prehospital level can significantly improve the outcome and decrease the mortality.Aims:The present study is aimed to evaluate the current status of prehospital care, prehospital factors, epidemiological characteristics, and outcome of TBI patients at a Level 1 trauma center.Material and Methods:It is a prospective observational study of 830 cases of TBI, done from November 15, 2015, to March 15, 2016, in the Department of Neurosurgery, Institute of Traumatology, SMS Medical College, Jaipur, Rajasthan, India.Results:Analysis of data revealed that the incidence of TBI in males is four times higher than females. Most patients are in the age group of 21–30 years (30.24%) followed by 31–40 years (18.55%). Road traffic injury (69.52%) is the most common mode of injury in the age group of 21–30 years followed by injury due to fall (22.77%) which mostly affects the age group of 0–10 years (72.64%) and 61–70 years (38.6%). Analysis of different factors revealed that age is significantly correlated with the outcome having P = 0.016. Glasgow Coma Scale, saturation of peripheral oxygen, systolic blood pressure at admission are also significantly correlated with the outcome having P < 0.001, P < 0.001, and P < 0.001, respectively.Conclusion:It is evident from the study that the factors which affect the outcome of a TBI are influenced by prehospital care, and thus prehospital management of the TBIs can definitely improve the outcomes.

A Different Spin to Emergency Nursing: Spain, Part 1

This article provides an overview of emergency nursing in Spain. It discusses the invaluable role of nurses in the prehospital and hospital emergency care of patients. As there is no paramedic-type role in Spain, emergency nurses are an integral part of emergency medical services. George W. Contreras is Associate Professor and Director of Allied Health Department of Nursing, Kingsborough Community College, The City University of New York, Brooklyn, NY. Ana Lopez is Emergency Nurse, Barcelona Emerge9ncy Medical Services 112, Barcelona, Spain. Marta Perez Garcia is Emergency Nurse, Vielha Hospital, Vielha, Spain.

Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States

Background: Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. Methods: This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. Results: Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. Conclusion: Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.

Evolution of a high-performance emergency health services system in Nova Scotia.

Since 1997, Emergency Health Services in Nova Scotia (NS) has evolved from a program providing prehospital care for patients in transport to a system providing integrated healthcare in both traditional (ie, ambulance) and non-traditional settings (eg, patient homes, hospital settings). This article highlights (1) the reorganization of the emergency medical service system design, (2) the strategies enabling efficient operation of this design, and (3) resultant innovations evolving from both system redesign and strategy application. Emergency Health Services has utilized a Public Utility Model (PUM) design providing prehospital healthcare, public safety, and public health responses to the population of NS. The success of the PUM has been complimented by three strategies: (1) co-leadership model operations, (2) common languages to translate evidence into practice, and (3) collaborative and integrated relationships with other regulated healthcare providers. This prehospital system design and application strategies could be applied in other sectors of community and hospital systems of care.

Association between Blood Glucose and cardiac Rhythms during pre-hospital care of Trauma Patients \u2013 a retrospective Analysis

BackgroundDeranged glucose metabolism is frequently observed in trauma patients after moderate to severe traumatic injury, but little data is available about pre-hospital blood glucose and its association with various cardiac rhythms and cardiac arrest following trauma.MethodsWe retrospectively investigated adult trauma patients treated by a nationwide helicopter emergency medical service (34 bases) between 2005 and 2013. All patients with recorded initial cardiac rhythms and blood glucose levels were enrolled. Blood glucose concentrations were categorised; descriptive and regression analyses were performed.ResultsIn total, 18,879 patients were included, of whom 185 (1.0%) patients died on scene. Patients with tachycardia (≥100/min, 7.0 ± 2.4 mmol/L p < 0.0001), pulseless ventricular tachycardia (9.8 ± 1.8, mmol/L, p = 0.008) and those with ventricular fibrillation (9.0 ± 3.2 mmol/L, p < 0.0001) had significantly higher blood glucose concentrations than did patients with normal sinus rhythm between 61 and 99/min (6.7 ± 2.1 mmol/L). In patients with low (≤2.8 mmol/L, 7/79; 8.9%, p < 0.0001) and high (> 10.0 mmol/L, 70/1271; 5.5%, p < 0.0001) blood glucose concentrations cardiac arrest was more common than in normoglycaemic patients (166/9433, 1.8%). ROSC was more frequently achieved in hyperglycaemic (> 10 mmol/L; 47/69; 68.1%) than in hypoglycaemic (≤4.2 mmol/L; 13/31; 41.9%) trauma patients (p = 0.01).ConclusionsIn adult trauma patients, pre-hospital higher blood glucose levels were related to tachycardic and shockable rhythms. Cardiac arrest was more frequently observed in hypoglycaemic and hyperglycaemic pre-hospital trauma patients. The rate of ROSC rose significantly with rising blood glucose concentration. Blood glucose measurements in addition to common vital parameters (GCS, heart rate, blood pressure, breathing frequency) may help identify patients at risk for cardiopulmonary arrest and dysrhythmias.

A novel rat model of extremity trauma for prehospital pain management research.

Pain management is important in prehospital care of patients with extremity trauma (ET). The goal of this study was to establish a rat model of ET for prehospital pain research and validate it using pain behaviors and analgesics. Rats were anesthetized using isoflurane, and ET was induced in one hindlimb via clamping retrofemoral tissues for 30 seconds, followed by closed fibula fracture. Rats regained consciousness after ET. Pain responses in the injured hindlimb to thermal hyperalgesia (paw withdrawal latency [PWL]), mechanical allodynia (paw withdrawal pressure [PWP]), and weight bearing (WB) were determined before and 90 minutes after ET. Morphine (2 mg/kg), fentanyl (10 μg/kg), sufentanil (1 μg/kg), ketamine (5 mg/kg), or vehicle (saline) were then administered via intravenous (i.v.) injection, followed by PWL, PWP, and WB assessments at 10 minutes, 40 minutes, 80 minutes, and 120 minutes after analgesia. After ET, PWL, PWP, and WB were significantly decreased by 61 ± 4%, 64 ± 8%, and 65 ± 4%, respectively, compared with pre-ET values. These pain behaviors were maintained for 3 hours to 4 hours. Compared with the saline group, opioid analgesics significantly increased PWL for at least 80 minutes, with sufentanil exhibiting the highest analgesic effect. An increase in PWL was only observed at 10 minutes after ketamine. The PWP was transiently increased with opioid analgesics for 10 minutes to 40 minutes, but was not changed with ketamine. Weight bearing was improved with opioid analgesics for at least 2 hours, but only for up to 80 minutes with ketamine. Our ET model includes long bone fracture and soft tissue injury, but no fixation surgery, mimicking prehospital ET. Our model produces acute, steady, and reproducible trauma-related pain behaviors, and is clinically relevant regarding the pain behaviors and established responses to common analgesics. This model of acute pain due to ET is ideal for prehospital pain management research.

Update in the Early Management and Reperfusion Strategies of Patients with Acute Ischemic Stroke.

Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.

Care pathways for low-risk transient ischaemic attack

Background: In secondary care, the urgency of review for transient ischaemic attack (TIA) has relied upon the use of the ABCD2 score, but this tool is not validated for use by emergency ambulance crews. There is a need to evaluate alternative care pathways for patients who might be eligible for direct referral to TIA clinics without prior conveyance to the emergency department (ED). Aim: The aim of this national survey was to describe current service provision across the UK for pre-hospital emergency care of patients with TIA. Methods: The authors approached all UK Ambulance trusts (n=13) by email, asking them to provide details of TIA patient referral pathways. Findings: Twelve ambulance services responded to the survey and nine reported that they had no current pathway; one had discontinued a pathway because of service reconfiguration; and three were currently using one. All pathways used the ABCD2 tool to screen patients and classified patients as low-risk if the ABCD2 score was 3 or below. Non-conveyance exclusion criteria varied. Although compliance with referral pathways was audited in an initial pilot in one service, no other evaluations of the effectiveness of pathways were reported. Conclusion: A minority of UK ambulance services report introducing referral pathways for low-risk TIA patients, avoiding initial assessment in the ED. Safety, effectiveness and acceptability of such pathways have not been evaluated to date.

Analysis of prehospital care of patients with acute myocardial infarction in Bulgaria

Introduction: Acute myocardial infarction is one of the most devastating cardiovascular diseases and about 50% of all deaths due to it occur prior to hospitalization. Our study aimed to evaluate the prehospital delay in patients with acute myocardial infarction. Methods: We enrolled 682 consecutive patients with acute myocardial infarction from May 2008 to December 2014, with a mean age of 66.6 ± 12.9 years. Detailed information was collected about the symptoms, first medical contact, concomitant clinical conditions, and the socioeconomic data. We analyzed the following prehospital times: (1) onset of symptoms to emergency call, (2) onset of symptoms to first medical contact, (3) first medical contact to hospital admission, and (4) onset of symptoms to hospital admission. Results: The first medical contact was with the National Emergency Medical Service in 266 (39.0%) patients, another emergency unit 106 (15.6%), cardiologist 41 (6%), general practitioner 36 (5.3%), and others 233 (34.1%). The median time from the onset of symptoms till emergency call was 190 min, from the first contact with a team of the National Emergency Medical Service till hospital admission 60 min, and from the onset of symptoms till hospital admission 4.8 h. Conclusion: The total prehospital delay in our study was unacceptably prolonged, with patient’s decision time as the major contributor. The delay could be substantially shortened by (1) increased awareness of the general population, particularly of individuals at high cardiovascular risk and (2) continuous medical education and regular practical training of the primary care providers about coping with medical emergencies.

Pre-hospital ambulance care of patients following a suspected seizure: A cross sectional study

PurposeWe aimed to investigate the characteristics of patients presenting to the ambulance service with suspected seizures, the costs of managing these patients and the factors which predicted transport to hospital. MethodsWe employed a cross-sectional design using routine clinical data from a UK regional ambulance service. Logistic regression was used to identify predictors of transport to hospital from ambulance response times, demographics, clinical (physiological) findings and treatments. ResultsThere were 177,715 emergency incidents recorded in 2011/12 of which 2.9% (5139/177,715) were classified as seizures by ambulance call handlers and 2.7% (4884/177,715) by paramedics on the scene. Suspected seizures were the seventh most common call type. The annual cost of managing these incidents was £890,148. Clinical and physiological variables were normal for most patients. 59.3% (2894/4884) of patients were transported to hospital. 1/4884 (0.02%) patient died. Administration of diazepam, insertion of an airway and pyrexia perfectly predicted transport to hospital, tachycardia had a modest association, but other variables were only weak predictors of transport to hospital. ConclusionsThis study shows that most patients after a suspected seizure are not acutely unwell but nevertheless most patients are transported to hospital. Further research is required to determine which factors are important in decisions to transport to hospital and to create evidence-based tools to help paramedics identify patients who could be safely managed without transport to hospital.

Effect of quality control circle on improving the quality of pre-hospital care in patients with ST-segment elevation myocardial infarction

Objective To improve the quality of pre-hospital care in patients with ST-segment elevation myocardial infarction (STEMI) by quality control circle (QCC) . Methods From August 2016 to February 2017, the QCC activity on the theme of the quality of pre-hospital care for patients with acute was carried out in Zhengzhou Central Hospital. The factors influencing the pre-hospital treatment of 79 patients with acute STEMI were investigated. In addition, the reasons were analyzed, so as to formulate and implement the corresponding countermeasures. The rate of bypass and the change of site disposal time in patients with acute STEMI were observed. Results After the QCC activity, the bypass rate of the pre-hospital patients with STEMI increased from 58.2% to 91.7%, and the site disposal time was shortened from 42.1 min to 29.3 min, and the differences were statistically significant (P<0.05) . Conclusions QCC activity has an obvious effect on improving the quality of pre-hospital care in patients with STEMI, which significantly increases the bypass rate and greatly shortens the site disposal time. At the same time, it improves the comprehensive quality of QCC activity team members. Key words: Quality control circle; ST-segment elevation myocardial infarction; Primary percutaneous coronary intervention; First medical contact

Prehospital Interventions Performed on Pediatric Trauma Patients in Iraq and Afghanistan

Background: United States (US) and coalition military medical units deployed to combat zones frequently encounter pediatric trauma patients. Pediatric patients may present unique challenges due to their anatomical and physiological characteristics and most military prehospital providers lack pediatric-specific training. A minimal amount of data exists to illuminate the prehospital care of pediatric patients in this environment. We describe the prehospital care of pediatric trauma patients in Iraq and Afghanistan. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. Subjects were grouped by age: <1, 1–4, 5–9, 10–14, and 15–17 years. We focused our analysis on interventions related to trauma resuscitation. Results: Of 42,790 encounters in the DODTR during the study period, 3,439 (8.0%) were aged <18 years. Most subjects were in the 5–9 age group (33.1%), male (77.1%), located in Afghanistan (67.8%), injured by explosives (43.1%). Most subjects survived to hospital discharge (90.2%). The most frequently performed interventions were tourniquet placement (6.6%), intubation (6.1%), supplemental oxygen (11.7%), IV access (24.8%), IV fluids (13.3%), IO access (5.1%), and hypothermia prevention (44.5%). The most frequently administered medications were antibiotics (6.2%) and opioids (15.0%). Most procedural and medication interventions occurred in subjects injured by explosives (43.1%) and gunshot wounds (22.1%). Conclusions: Pediatric subjects comprised over 1 in 13 casualties treated in the joint theaters with the majority injured by explosives. Vascular access and hypothermia prevention interventions were the most frequently performed procedures.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

BackgroundThe optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care. ObjectiveWe sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality. MethodsWe conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered. ResultsThere were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score−predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47–1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96–1.08). ConclusionsWe found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

Miscommunication as a risk focus in patient safety : Work process analysis in prehospital emergency care

In an analysis of acritical incident reporting system (CIRS) in out-of-hospital emergency medicine, it was demonstrated that in 30% of cases deficient communication led to athreat to patients; however, the analysis did not show what exactly the most dangerous work processes are. Current research shows the impact of poor communication on patient safety. An out-of-hospital workflow analysis collects data about key work processes and risk areas. The analysis points out confounding factors for asufficient communication. Almost 70% of critical incidents are based on human factors. Factors, such as communication and teamwork have an impact but fatigue, noise levels and illness also have amajor influence. (I)CIRS database analysis The workflow analysis was based on 247 CIRS cases. This was completed by participant observation and interviews with emergency doctors and paramedics. The 247 CIRS cases displayed 282 communication incidents, which are categorized into 6 subcategories of miscommunication. One CIRS case can be classified into different categories if more communication incidents were validated by the reviewers and four experienced emergency physicians sorted these cases into six subcategories. (II)Workflow analysis The workflow analysis was carried out between 2015 and 2016 in Jena and Berlin, Germany. The focal point of research was to find accumulation of communication risks in different parts of prehospital patient care. During 30 h driving with emergency ambulances, the author interviewed 12members of the emergency medical service of which5 were emergency physicians and 7paramedics. A total of 11internal medicine cases and one automobile accident were monitored. After patient care the author asked in a15-min interview if miscommunication or communication incidents occurred. (I)CIRS analysis Between 2005 and 2015, 845 reports were reported to the database. The experts identified 247 incident reports with communication failure. All communication aspects were analyzed and classified. We identified 282 communication incidents. (II)Workflow analysis The analysis showed three phases of prehospital patient care: 1.incoming emergency call and dispatch of ambulance service, 2.prehospital treatment, 3.transportation to ahospital. Overall, the number of incidences is increasing as a consequence of parallel workflows. Category1 was particularly significant and predominantly, paramedics criticized that emergency physicians did not acknowledge their advice (n = 73 vs. n = 9). Category3 with n = 63, category4 with n = 20 and category2 with n = 13 were the major reasons for incidents. Abetter interface communication helps to coordinate patient transfer and is an option for optimizing resources. Frequent training in communication is an option to avoid incidents.

Peak expiratory flow rate

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontlines, highlighting the importance of these skills and how to perform them. In this issue, Andrew Kirk discusses peak expiratory flow rates and the management of asthma patients in pre-hospital care.

Abstract TP248: Identifying Characteristics of Patients With Suspected Stroke by Paramedics but not by Emergency Medical Dispatchers Using Natural Language Processing and Machine Learning

Introduction: Accurate stroke identification during 9-1-1 calls by emergency medical dispatchers (EMDs) results in improved acute stroke care, but EMDs only identify 50% of strokes. Structured analysis of 9-1-1 calls has identified words and phrases used by laypersons associated with stroke; however, the words and phrases used by paramedics to describe suspected stroke patients, when EMDs do not suspect stroke, have not been reported. Hypothesis: Key words and phrases in the free text of prehospital records for patients suspected of having acute stroke by paramedics but not by EMDs can be identified by natural language processing (NLP) and machine learning. Methods: In an emergency medical services (EMS) system with a single municipal fire-based EMS provider agency and a central dispatch center with standardized protocols, we performed a retrospective study of de-identified prehospital records of patient encounters between January 2013 and December 2016 where paramedics suspected stroke. Using NLP, we identified and extracted 2,500 candidate features from free-text sections of the prehospital patient care report and transformed the dataset into two separate document-feature matrices where: a) EMDs and paramedics concurred on stroke impression and b) EMDs and paramedics were discordant. Latent Dirichlet Allocation, a topic-modeling technique, was used to cluster features into 50 topics, which were then compared to identify key words. We also used machine learning model linear support vector machines to select other key words. Results: Among 9,436 EMS suspected stroke encounters, EMDs identified acute stroke in 4,761 (50.5%) of cases. The following words and phrases were used by paramedics in cases where EMDs did not identify stroke: “blunt head trauma,” “blurred double vision,” “blurry vision,” “mastectomy,” “hypothyroidism,” “dysrhythmia,” and “tachypnea.” Conclusions: NLP and machine learning can identify words and phrases in free-text sections of prehospital records of patients in which paramedics suspected stroke and EMDs did not. Adapting EMD protocols to include specific words and phrases consistently used by paramedics to describe patients with acute stroke may help improve EMD recognition during the 9-1-1 call.

Zbrinjavanje pacijenata sa AKS u GZZHMP Beograd

Introduction. Treating patients suffering from acute myocardial infarction with ST elevation (STEMI) represents a challenge and new treatment possibilities with better outcomes are always sought. The Emergency Medical Aid Service holds the key role in prehospital care of patients with STEMI and administers dual antiplatelet therapy: MONA (Morphine, Oxygen, Nitroglycerin, Aspirin) + clopidogrel or ticagrelor, with the aim of enhancing the reperfusion effect. Objective: To determine the incidence of prehospital treatment of STEMI with dual antiplatelet therapy, as well as the time passed from the first contact with the 194 operator to the admission of the patient to the hospital. Methods: Retrospective analysis of the period between January 1st 2014. and December 31st 2017. The diagnosis was based on medical history as described by the patient, clinical findings and ecg tracings. In patients diagnosed with STEMI, dual antiplatelet therapy was administered and monitored. Time passed from the first contact with the 194 operator to admission to the hospital was also measured. Results: Out of the total number of 8843 patients with acute coronary syndrome, who were treated by the Emergency Medical Aid Service, 2982 were diagnosed with STEMI. Dual antiplatelet therapy was administered to 40.29% of the patients in 2014, while that percentage grew to 70.01% in 2017. Of that percentage in 2017, 60.38% received MONA and ticagrelor, while 9.63% received MONA and clopidogrel. Women have been proven to suffer from STEMI at a later age (70.17±13.05 years of age) than men (61.89±13.43 years of age). Also, 75% of the patients are admitted to the hospital within 65.77 minutes from the moment of the first contact with the 194 operator. Conclusion: During the period in question, a significant rise in application of antiplatelet therapy has been noted. The transfer time of STEMI patients is an important factor of prehospital treatment. Continuous education of Emergency Medical Aid teams enables advances of diagnostic and therapeutic measures in prehospital conditions. .