Prehospital Care Settings Research Articles

Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis.

Trauma is one of the leading causes of uncontrolled haemorrhage, death, and disability. Use of a tourniquet can be considered an optimal anti-haemorrhagic resource, in pre-hospital and emergency settings, and its lifesaving effect is clinically contradictory. This review aims to assess the clinical efficacy of the tourniquet in the emergency pre-hospital care setting for the management of haemorrhage. We conducted the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the PRISMA statement. We searched the following electronic databases: EMBASE, MEDLINE, and Cochrane-CENTRAL. All studies included were appraised for risk of bias. Prevalent primary outcomes were mortality and use of blood products. Secondary outcomes were related to adverse effects. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). Four studies were involved (1762 trauma patients). The adjusted odds ratio (aOR) of 0.47 (95% confidence Interval (CI) 0.19–1.16; three studies; 377 patients) for overall mortality estimates did not give a clear indication of the benefits of emergency pre-hospital tourniquets (PH-TQ) versus no pre-hospital tourniquet (NO PH-TQ) placement. The adjusted mean difference for blood product use was −3.28 (95% CI −11.22, 4.66) for packed red blood cells (pRBC) and −4.80 (95% CI −5.61, −3.99) for plasma, respectively. The certainty of evidence was downgraded to very low for all outcomes. Our results suggest an unclear effect of emergency pre-hospital tourniquet placement on overall mortality and blood product use. However, this systematic review highlights the availability of only observational studies and the absence of high quality RCTs assessing the efficacy of PH-TQs. Randomized controlled trials are needed.

Development of prehospital care quality indicators for the Australian setting: a modified RAND/UCLA appropriateness method

BackgroundGlobally, the measurement of quality is an important process that supports the provision of high-quality and safe healthcare services. The requirement for valid quality measurement to gauge improvements and monitor...

Non-medical prescribing by paramedics in emergency, urgent and critical care

This article considers some of the unique considerations and challenges that are associated with non-medical prescribing in the context of paramedic emergency care. In contrast to primary care, advanced paramedics practicing in emergency settings are more likely to encounter patients who require an immediate supply or administration of medication and access to a range of controlled drugs. Furthermore, access to medical support for prescribing decision-making, restrictions on the prescribing of controlled drugs and potential challenges in obtaining access to patient records, may also impact non-medical prescribing in these settings. Currently, very little empirical evidence has been published on the topic of non-medical prescribing in paramedic practice. Further research is required to understand whether the anticipated benefits are being realised for patients and NHS services. This is particularly the case in the context of prehospital emergency, urgent and critical care settings.

Non-pharmacological interventions for acute pain management in adult trauma victims: a scoping review.

This scoping review aimed to map non-pharmacological interventions to reduce acute pain in adult trauma victims. Acute pain is a consequence of a pathological or traumatic event, and a result of invasive or non-invasive health care procedures. Acute trauma pain, as well as its treatment, is one of the least-studied areas of acute pain. Although non-pharmacological interventions are responsible for pain relief among a significant number of patients, only a small percentage of patients receive non-pharmacological interventions. This scoping review considered all studies conducted on adult victims of trauma, aged 18 years or over, in pre-hospital emergency care, emergency rooms, and trauma-center settings. Studies were considered if they focused on non-pharmacological interventions designed to reduce acute pain, and were implemented and evaluated by health professionals. Non-pharmacological interventions of any type, duration, frequency, and intensity were considered. A comprehensive search strategy across 11 bibliometric databases and gray literature sources was developed. Full texts of selected citations were assessed in detail for eligibility by two independent reviewers. No other relevant studies were identified by searching the references of the included articles. Data extraction was performed independently by two reviewers using an instrument previously developed, and those reviewers were later responsible for its validation. Findings were then extracted directly into tables that are accompanied by a narrative summary to show how they relate to the objectives of the review conducted. This scoping review included nine studies: two retrospective cohort studies, five randomized controlled trials, one case report, and one literature review for five different countries. Non-pharmacological interventions identified and administered to trauma victims in pre-hospital settings, emergency services, and trauma centers were as follows: acupressure, auricular acupressure, auricular acupuncture, transcutaneous electrical nerve stimulation, repositioning, use of pressure relief devices, massage, heat therapy, music therapy, relaxation therapy, immobilization, ice therapy, compression, elevation, and bandage. Non-pharmacological interventions were mainly developed by nurses, physicians, and paramedics. They were, in most studies, poorly described in terms of their efficacy and were mostly reported in minor traumas, such as simple fractures or small wounds. Currently, there is no consensus for the implementation of non-pharmacological interventions in the treatment of acute trauma pain. Their application is primarily used for minor traumas, and their potential for the treatment of major traumas is yet unknown. No studies on the use of non-pharmacological interventions aimed at reducing the impact of traumatic adverse environments were identified. Further investigation on the effects of these interventions should be encouraged so that robust decisions and recommendations can be made.

Measurement and monitoring patient safety in prehospital care: a systematic review.

Prehospital care is potentially hazardous with the possibility for patients to experience an adverse event. However, as compared to secondary care, little is known about how patient safety is managed in prehospital care settings. The objectives of this systematic review were to identify and classify the methods of measuring and monitoring patient safety that have been used in prehospital care using the five dimensions of the Measuring and Monitoring Safety (MMS) framework and use this classification to identify where there are safety 'blind spots' and make recommendations for how these deficits could be addressed. Searches were conducted in January 2020, with no limit on publication year, using Medline, PsycInfo, CINAHL, Web of Science and Academic Search. Reference lists of included studies and existing related reviews were also screened. English-language, peer-reviewed studies concerned with measuring and monitoring safety in prehospital care were included. Two researchers independently extracted data from studies and applied a quality appraisal tool (the Quality Assessment Tool for Studies with Diverse Designs). A total of 5301 studies were screened, with 52 included in the review. A total of 73% (38/52) of the studies assessed past harm, 25% (13/52) the reliability of safety critical processes, 1.9% (1/52) sensitivity to operations, 38.5% (20/52) anticipation and preparedness and 5.8% (3/52) integration and learning. A total of 67 methods for measuring and monitoring safety were used across the included studies. Of these methods, 38.8% (26/67) were surveys, 29.9% (20/67) were patient records reviews, 14.9% (10/67) were incident reporting systems, 11.9% (8/67) were interviews or focus groups and 4.5% (3/67) were checklists. There is no single method of measuring and monitoring safety in prehospital care. Arguably, most safety monitoring systems have evolved, rather than been designed. This leads to safety blind spots in which information is lacking, as well as to redundancy and duplication of effort. It is suggested that the findings from this systematic review, informed by the MMS framework, can provide a structure for critically thinking about how safety is being measured and monitored in prehospital care. This will support the design of a safety surveillance system that provides a comprehensive understanding of what is being done well, where improvements should be made and whether safety interventions have had the desired effect.

Abstract 247: Cardiac Arrest Management in Rural Prehospital Care

Introduction: Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. We analyzed a nationwide database of emergency medical services (EMS) incidents in the US to describe treatment patterns and the odds of return of spontaneous circulation (ROSC) among rural OHCA patients. Methods: Using the 2018 National EMS Informational System dataset, we analyzed OHCA incidents where CPR provided by EMS was documented. We excluded incidents in which trauma was involved, patient age <18 years, transport was not by completed by an advanced life support unit, or response time >60 minutes. The primary outcome was ROSC during the EMS incident. Multivariable logistic regression was performed comparing rural, suburban, and urban settings while controlling for age and gender, incident location type, response time, CPR prior to EMS arrival, arrest witnessed by EMS, initial rhythm, epinephrine administration, mechanical CPR, and advanced airway used. Results: A total of 60,281 OHCA incidents were identified for inclusion, including 5,013 (8.6%) in rural settings. Rural OHCA patients achieved ROSC in 28.8% of cases, compared to 33.0% in urban or suburban settings (p<0.001). Neither age nor gender significantly differed between settings (Table 1). Rural OHCA incidents had greater response times (7.5 vs. 5.9 minutes, p<0.001) and were less likely to receive epinephrine (71.6% vs. 74.9%, p<0.001). Further, EMS were more likely to use mechanical CPR (29.8% vs. 28.1%, p=0.01) and less likely to provide an advanced airway (56.3% vs. 50.5%, p<0.001) for rural OHCA. On multivariable logistic regression, rural OHCA patients had lower odds of achieving ROSC than urban OHCA patients after controlling for other factors (0.80, 95%CI: 0.75-0.86). Conclusion: In this national sample of EMS-treated OHCA, rural patients were less likely to achieve ROSC than patients in urban or suburban settings.

An Evaluation of the Non-Emergency Medical Transportation System of Rural Southern Illinois

The purpose of the study was to determine if disparities existed in the non-emergency medical transportation (NEMT) system in the lower 34 counties of southern Illinois. NEMT is described as the transfer of individuals from a pre-hospital care setting to care facilities, and ongoing care transfer of individuals from pre-hospital care settings. Several research themes developed during the study. These themes included an underserved rural population by non-emergency medical transportation, negative health consequences, and an ineffective use of medical staff’s time. Two types of data collection were used in the collection of information about the non-urgent medical transportation system. Qualitative research consisted of three focus groups, made-up of various stakeholders within the medical community. The quantitative research consisted of the collection of 250 surveys from various participating healthcare professionals. The results of the data collected indicated that the rural population of southern Illinois is inadequately served by the NEMT system. It also indicated that due to insufficient non-urgent medical transportation, patients and medical staff alike had undue burdens placed on them because of missed appointments, lack of timely healthcare services, reduced effectiveness of patient care, and medical staff distress.

Feeling safe or unsafe in prehospital emergency care: A qualitative study of the experiences of patients, carers and healthcare professionals

To determine the feelings of safety among patients taken to hospital after requesting urgent care, based on their experiences and those of their carers and prehospital emergency care professionals. Little research has been performed into the perception of safety in prehospital emergency care settings worldwide, from either the perspective of the patients or from that of healthcare professionals. Exploratory qualitative study using focus groups in Spain. The participants were patients that requested care through the emergency telephone service, their carers and the professionals of the emergency care teams. The structured sampling design was based on an intentional, nonprobability selection following pragmatic criteria. Seven groups of patients/carers and two groups of professionals were formed (65 participants). The recordings were fully transcribed before their validation and codes were assigned to ensure anonymity. The ATLAS.ti software was used for the analysis. The authors took into account the COREQ checklist for qualitative studies. Neither group provided a clear definition of the meaning of feeling safe. It appeared easier to give examples that had a positive or negative influence on their perception of feeling safe. During the analysis of the discourse, six categories were detected after grouping the related codes. For most of the patients' feeling of being safe or very safe arose from the perception of calmness, trust and protection. Defining the perception of safety was not easy. The factors with the greatest effect on feeling safe were related to Information and communication, Person-centred care and Professional competency, without losing sight of other factors such as Accessibility and response times of the emergency teams, Equipment and Healthcare setting. The findings could be used as a knowledge base in future research and for implementing procedures for improving perceptions of safety among patients.

Child public health part 2: prevention and where paramedics contribute

The second part of the series on child public health explores the levels of prevention implemented in order to hinder diseases from affecting the lives of children, and how paramedics implement prevention strategies in their practice both in prehospital and primary care settings.

A View from the Frontline: Palliative and Ethical Considerations of the COVID-19 Pandemic.

A View from the Frontline: Palliative and Ethical Considerations of the COVID-19 Pandemic.

Bypass: an integrated hip fracture care pathway.

The incidence of hip fractures is expected to increase over the coming years, placing a greater burden on limited resources. A high volume of patients is brought to hospitals that do not have the resources necessary to provide definitive care. Optimal care involves a coordinated and integrated system of trauma care. The hip fracture care pathway introduced between a referring peripheral hospital and our institution represents a coordinated multidisciplinary approach to patient care. To describe and report on the outcomes over an 18-month period of the integrated hip fracture care pathway between referring peripheral hospitals and our institution. A retrospective analysis of the prospectively maintained hip fracture database over an 18-month period. Between March 2017 and September 2018, 86 consecutive patients were referred to our institution through a new referral pathway. Of these, 69 patients came from the Emergency Department of the referring hospital and 17 arrived via bypass. All 86 patients were managed on a specialist orthopaedic ward. The average length of stay was 4.28days, with maximum of 13 and minimum of 2days. Over 84% of patients underwent definitive treatment within 48h of a diagnosed hip fracture. The fragmented approach to the management of trauma patients both in a pre-hospital and hospital care setting is a cause for concern. Our integrated hip fracture referral pathway, incorporating bypass of the referring hospital, represents a multidisciplinary care pathway for the management of patients with fractured neck of femur and can have potential benefits including improved patient outcomes, allowing the optimal allocation of resources and providing training opportunities.

Transposing Lateral Flow Immunoassays to Capillary-Driven Microfluidics Using Self-Coalescence Modules and Capillary-Assembled Receptor Carriers.

Point-of-care (POC) immunodiagnostic tests play a crucial role in enabling rapid and correct diagnosis of diseases in prehospital care, emergency, and remote settings. In this work, we present a silicon-based, capillary-driven microfluidic chip integrating two microfluidic modules for the implementation of highly miniaturized immunoassays. Specifically, we apply state-of-the-art microfluidic technology to demonstrate a one-step immunoassay for the detection of the cardiac marker troponin I in human serum using sample volumes of ∼1 μL and with a limit of detection (LOD) of ∼4 ng mL-1 within 25 min. The microfluidic modules discussed here broadly map functionalities found in standard lateral flow assays. We implement a self-coalescence module (SCM) for the controlled reconstitution and delivery of inkjet-spotted and dried detection antibodies (dAbs). This allows for homogeneous dissolution of 1.3 ng of fluorescently labeled dAbs in 416 nL of the sample used for the assay. We also show how to immobilize receptors inside closed microfluidic devices in <30 s using bead lane modules inside which microbeads functionalized with capture antibodies (cAbs) are self-assembled. The resulting bead lane module, with a volume of ∼3 × 10-5 mm3, is positioned across the flow path and holds ∼300 5 μm-diameter microbeads. Altogether, these capillary-driven elements allow for the manipulation of samples and reagents with an unprecedented precision and control, paving the way for the next generation of POC immunodiagnostics.

Association between the Japan Coma Scale scores at the scene of injury and in-hospital outcomes in trauma patients: an analysis from the nationwide trauma database in Japan

ObjectiveJapan Coma Scale (JCS) is a grading system used to evaluate disturbed consciousness in prehospital care settings. We aimed to identify the association between the JCS levels at the scene...

The State of Infection Control Among Los Angeles County (LAC) Emergency Medical Services (EMS) Providers

Infection control (IC) in the pre-hospital care setting by EMS providers is important to protect themselves and patients receiving emergency care and being transported between healthcare facilities. From 2016-17, LAC Department of Public Health (DPH) collaborated with LAC Emergency Medical Services Agency (EMSA) to assess and improve IC among EMS providers. DPH/EMSA adapted tools from the Centers for Disease Control and Prevention designed for healthcare facilities to assess EMS IC policies and practices. Large and small EMS agencies/companies were assessed to ensure a representative sample. Policies were reviewed, and observations made by DPH/EMSA nurses during ride alongs in >2 ambulances per provider. Fourteen providers were assessed. Eleven had a designated infection control officer (DICO). Thirteen had written IC policies; 12 reviewed and updated them annually. All required IC training for new staff, but only 59% assessed skills post-training and 31% audited across four IC topics. Twelve had written policies for cleaning/disinfection. Twelve had a policy for influenza vaccination; however, the median vaccination rate was only 55% (range 1-99%). Observations showed handwashing occurred before patient contact for 7% of assessments, glove use in 100% and hand hygiene after removing gloves in 79%. Staff cleaned the ambulance after each patient encounter; cleaning high touch surfaces in 79% and replaced cleaners/disinfectants when appropriate in 89%. EMS providers are an important part of the healthcare system as they transport patients in and out of hospitals and other healthcare facilities. Overall, findings were encouraging, but ensuring up-to-date policies for all areas of IC, monitoring competencies, and observing practices to assess adherence may improve IC. In 2018, LAC hosted an IC train-the-trainer course for DICOs to bring proper IC practices back to their agencies/companies. LAC DPH and EMSA will continue to work with EMS providers to improve IC policies and practices.

Interventions to Decrease Use in Prehospital and Emergency Care Settings Among Super-Utilizers in the United States: A Systematic Review.

Interest in high users of acute care continues to grow as health care organizations look to deliver cost-effective and high-quality care to patients. Since "super-utilizers" of acute care are responsible for disproportionately high health care spending, many programs and interventions have been implemented to reduce medical care use and costs in this population. This article presents a systematic review of the peer-reviewed and grey literature on evaluations of interventions to decrease prehospital and emergency care use among U.S. super-utilizers. Forty-six distinct evaluations were included in the review. The most commonly evaluated intervention was case management. Although a number of interventions reported reductions in prehospital and emergency care utilization and costs, methodological and study design weaknesses-especially regression to the mean-were widespread and call into question reported positive findings. More high-quality research is needed to accurately assess the impact of interventions to reduce prehospital and emergency care use in the super-utilizer population.

The Italian emergency medical system between evidence and risk of corporatism: the "Bologna case". Part I: the evidence / Part II: medical ethics and law.

Scientific issues. An effective pre-hospital emergency care needs trained health care professionals, technological and therapeutic resources, but not always the emergency systems performance is data-driven. There are three fundamental models of pre-hospital care. The first one (Anglo-American) is based on the professional paramedic provision of care. Another model (Franco-German) is built on the physician-led approach. The last one, derived from the franco-german model, is the nurse-led model described as the new profession in the pre-hospital care setting. Many studies compare the benefits of having physicians or nurses or paramedics on the field. The findings of this narrative literature review show that: 1) there is no a better model than the other; 2) the best performance depends on one hand on the expertise required case by case of those responding, on the other on the quality of dispatching process, contrary to what the Bologna's General Medical Council held; 3) regardless of the adopted model, the task shifting (the skills and expertise passed from physicians on other specialized health care workers) is considered around the world as the best way to balance health care demand and supply in the pre-hospital emergency setting. Professional ethics and legal issues. By means of the transformation of principles of medical ethics in rules binding for professionals, the code of medical ethics (CME) gains relevance within the legal system, especially through case law and disciplinary responsibility. Moreover, the CME is gaining growing attention, both at the normative and judicial levels, due to its ability to regulate important aspects of professional conduct, which may have consequences for medical practice and for the patient's fundamental rights. Notwithstanding this role, the interrelations between law and medical ethics, the binding value of the CME and the related position in the hierarchy of norms are still controversial, lacking a proper regulation and a proper set of safeguards measures. A disciplinary action against doctors acting outside the professional activities, namely as a council member proposing a legal act, must be based on solid grounds relating to the protection of fundamental rights. Such a disciplinary authority requires legal definitions, safeguards and judicial remedies beyond those being met at present. The analysis shows how specific elements and devices should still be taken into consideration from both procedural and content perspectives to shape a more coherent model of relationships between law and medical ethics.

Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative.

Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain. A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important. Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%). These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.

Automated External Defibrillator (AED) Use Among Paramedics in the Emergency Department – What are the Obstacles in Using the Automated External Defibrillator in the Pre-Hospital Care Settings?

Automated External Defibrillator (AED) Use Among Paramedics in the Emergency Department – What are the Obstacles in Using the Automated External Defibrillator in the Pre-Hospital Care Settings?

Capillary and venous lactate measurements with a handheld device compared to venous blood-gas analysis for emergency patients

Background/aimEarly identification of lactate levels may have a large impact on triage classification and assist in identifying critically ill patients. A handheld device provides a rapid and timesaving measurement of lactate levels adapted to work in a prehospital care setting. I.e., the device is small, fast, and easy-to-use. The aim of this study was to evaluate the Accutrend Plus handheld lactate analyzer in comparison to the reference in-hospital method.MethodsPatients triaged as minimum yellow according to the RETTS System (Rapid Emergency Triage and Treatment System) and transported to hospital by ambulance were selected and a written consent to participate was obtained prior to inclusion in the study. Capillary (CAP) and venous (VEN) blood were analyzed with Accutrend Plus (AP). Venous blood samples were analyzed at the local hospital laboratory (GEM premier 4000) within 20 min from sampling. All sampling was conducted by two registered nurses specially trained in prehospital care.Results480 lactate measurements were performed in 160 patients. The mean difference between measurements in capillary blood compared with the reference method was 0.7 mmol/L and for venous blood 0.9 mmol/L. The limits of agreement from the Bland-Altman plot was − 0.9 to + 2.5 mmol/L and and − 0.1 to + 1.9 mmol/L, for CAP and VEN compared with GEM.ConclusionOur results shows low accuracy and low precision with VEN / CAP measurements of lactate compared to reference GEM.

A retrospective analysis of ketamine administration by critical care paramedics in a pre-hospital care setting.

Objective:This project aims to describe pre-hospital use of ketamine in trauma by South East Coast Ambulance Service critical care paramedics and evaluate the occurrence of any side effects or adverse events.Methods:A retrospective analysis of patients receiving pre-hospital ketamine for trauma between 16 March 2013 and 30 April 2017. Administrations were identified from Advanced Life Saving Interventions and Procedures reports submitted by the clinician and, later, from an electronic database. Each was scrutinised for patient demographics, doses and reports of side effects or adverse events.Results:A total of 510 unique administrations were identified. Following the exclusion of 61 records, 449 (88.0%) administrations remained. The most common indication for administration of ketamine was lower limb injury, with 228 (50.8%) administrations. Ketamine was only administered intravenously, and the median dose of ketamine for all administrations was 30 mg (interquartile range 20–40 mg). The gender split was dominated by males who accounted for 302 (67.3%) administrations compared to 147 (32.7%) females. The median age of patients was 44 years (interquartile range 28–58 years), with women on average being older than men. Telephone calls to a consultant were made for 243/449 (54.1%) of the administrations, reflecting a need for sanctioning of the drug, advice on dosages or indications, for example.Conclusions:Critical care paramedics within a well governed system are able to safely administer ketamine within an approved dosing regimen under a Patient Group Direction. Median doses are in keeping with nationally approved guidelines. Reported side effects were within the described frequencies in the British National Formulary. Prospective studies are now needed in order to confirm the safety and efficacy of ketamine administration among the advanced paramedic population.