Prehospital Care Settings Research Articles

Abstract WP261: Non-English-preferring Patients Have No Differences in Stroke Symptom Recognition or Emergency Care Time Metrics

Introduction: The influence of patients’ language preference on the delivery of acute ischemic stroke (AIS) care in the pre-hospital and in-hospital emergency care settings is scarcely known. We hypothesize that stroke knowledge differences may be associated with non-English preferring (NEP) patients having slower time from symptom discovery to hospital presentation and less engagement of emergency medical services (EMS) than English preferring (EP) patients. Language barriers may also interfere with the delivery of time-sensitive emergency department care. Objectives: To identify whether language preference is associated with differences in patients’ time from stroke symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DIT), and door-to-needle (DTN) time. Methods: We identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003-04/2014. Data was abstracted from the institution’s Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DIT, and 4) DTN time. Results: Of 3,190 AIS patients who met inclusion/exclusion criteria, 9.4% were NEP (n=300). Time from symptom discovery to arrival, and EMS utilization were not significantly different between NEP and EP patients in unadjusted or adjusted analyses (overall median time 157 minutes, IQR 55-420; EMS utilization: 65% vs. 61.3% p=0.21). There was no significant difference between NEP and EP patients in DIT or in likelihood of DIT ≤ 25 minutes in unadjusted or adjusted analyses (overall median 59 minutes, IQR 29-127; DIT ≤ 25 minutes 24.3% vs. 21.3% p=0.29). There was also no significant different in DTN time or in likelihood of DTN ≤ 60 minutes in unadjusted or adjusted analyses (overall median 53 minutes, IQR 36-73; DTN ≤ 60 minutes 62.5% vs. 58.2% p=0.60). Conclusion: Non-English-preferring patients have similar response to stroke symptoms as reflected by EMS utilization and time from symptom discovery to hospital arrival. Similarly, NEP patients have no differences in in-hospital AIS care metrics of DIT and DTN time.

Evidence-Based Guidelines for Fatigue Risk Management in EMS: Formulating Research Questions and Selecting Outcomes

ABSTRACTBackground: Greater than half of Emergency Medical Services (EMS) personnel report work-related fatigue, yet there are no guidelines for the management of fatigue in EMS. A novel process has been established for evidence-based guideline (EBG) development germane to clinical EMS questions. This process has not yet been applied to operational EMS questions like fatigue risk management. The objective of this study was to develop content valid research questions in the Population, Intervention, Comparison, and Outcome (PICO) framework, and select outcomes to guide systematic reviews and development of EBGs for EMS fatigue risk management. Methods: We adopted the National Prehospital EBG Model Process and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for developing, implementing, and evaluating EBGs in the prehospital care setting. In accordance with steps one and two of the Model Process, we searched for existing EBGs, developed a multi-disciplinary expert panel and received external input. Panelists completed an iterative process to formulate research questions. We used the Content Validity Index (CVI) to score relevance and clarity of candidate PICO questions. The panel completed multiple rounds of question editing and used a CVI benchmark of ≥0.78 to indicate acceptable levels of clarity and relevance. Outcomes for each PICO question were rated from 1 = less important to 9 = critical. Results: Panelists formulated 13 candidate PICO questions, of which 6 were eliminated or merged with other questions. Panelists reached consensus on seven PICO questions (n = 1 diagnosis and n = 6 intervention). Final CVI scores of relevance ranged from 0.81 to 1.00. Final CVI scores of clarity ranged from 0.88 to 1.00. The mean number of outcomes rated as critical, important, and less important by PICO question was 0.7 (SD 0.7), 5.4 (SD 1.4), and 3.6 (SD 1.9), respectively. Patient and personnel safety were rated as critical for most PICO questions. PICO questions and outcomes were registered with PROSPERO, an international database of prospectively registered systematic reviews. Conclusions: We describe formulating and refining research questions and selection of outcomes to guide systematic reviews germane to EMS fatigue risk management. We outline a protocol for applying the Model Process and GRADE framework to create evidence-based guidelines

Which Videolaryngoscope Should We Use in Airway Management?

Aim of review: This review elaborates on the role of different videolaryngoscopes in modern airway management and whether the outcomes of studies on patients and on manikins help anesthesiologists in determining which videolaryngoscope we should prefer.Methods: We reviewed the articles comparing the performance of different videolaryngoscopes published in the last decade.Recent findings: Airway problems that occur during the introduction of general anesthesia in the operating theatre, prehospital, emergency department and intensive care setting are commonly managed by skilled anesthesiologists. However, anticipated and unanticipated difficult airways do occur. Very seldom do these difficult airways result in a can't ventilate-can't intubate scenario, with potential death and brain damage as devastating outcomes. Standard Macintosh Laryngoscopy (SML) has its limitations, with Cormack-Lehane grade III-IV and percentage of glottic opening (POGO) scores of 0 being called difficult laryngoscopy. Percent of Intubation success with the direct classic Macintosh blade laryngoscopy (DML), without the use of adjuncts, is often limited to 90% (95% with adjuncts and extra manoeuvers). Videolaryngoscopy offers superiority over direct laryngoscopy as it allows an improved view of the larynx (Cormack-Lehane grade I-II; POGO 50-100%) and results in an almost 100% intubation success rate with decreased intubation time. In the rare event that an intubation attempt with a Macintosh blade videolaryngoscope (VLS) is not successful, acute angled blades can be used, or a combination technique offers an alternative. The market offers several videolaryngoscopes with alternative options (channelled, non-channelled, acute angled and Macintosh blades), each with their own indications. At this moment, there is no videolaryngoscope available which offers a solution for all problems. With our review we hope to determine the scope, based on publications in the last decade.Summary: Videolaryngoscopes have improved airway management and reduced airway related morbidity and mortality by improving the glottic view (laryngoscopy) and first attempt intubation success. Videolaryngoscopy is useful in video-guided insertion of endotracheal tubes, supraglottic airway devices, temperature probes and nasogastric tubes. However, not all videolaryngoscopes are created equally as there are definite differences which anesthesiologists must be aware of in order to make the best choice for individual patients. This review concluded that the most favored videolaryngoscope was the Pentax-Airway Scope of the channelled videolaryngoscopes and the Karl Storz C-MAC of the non-channelled videolaryngoscopes. However, the C-MAC VLS is the most versatile and can be used for direct and indirect laryngoscopy. Citation: Andre van Zundert, Cienwen Town, Lizanne Dagleish, Heather Reynolds. Which videolaryngoscope should we use in airway management? J Anesth Perioper Med 2016; 3: 247-57. doi: 10.24015/JAPM.2016.0034This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Acute Traumatic Pain in the Prehospital and Emergency Department Setting

Pain is a common complaint in the emergency and acute care settings. Adequate control of a child’s pain is important for improved patient assessments and can have long-term benefits affecting future medical care. Pain in children may be difficult to distinguish from anxiety, but there are validated tools to assist in objectively quantifying the severity pain in children of all ages. Pharmacologic as well as non-pharmacologic pain therapies can be effective. Providers who practice in the prehospital, emergency department, and other acute care settings should consider standardized protocols or guidelines for ensuring that pain is assessed and treated in a timely and safe manner.

What's in this Issue?

What's in this Issue?

Skills development at a paramedic accident simulation centre.

Practice simulation in acute and pre-hospital care settings is a growing area of interest for clinicians and health educationalists, and there is much evidence to support its use (Pike and O'Donnell 2010). Most simulation is delivered through computer-aided software or in virtual environments, however last year the University of Hertfordshire opened an accident simulation centre which is an outdoor facility that offers pre- and post-registration paramedics the opportunity to experience a range of scenarios in a 'real life' but secure environment. This article describes how the centre enables students to apply theory to practice in complex situations, such as managing patients injured in road traffic collisions.

Role of Information Technology in Implementation of Telemedicine System

Introduction: Telemedicine is the wide description of providing medical and healthcare services by means of telecommunications.Methodology: A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,230 abstracts that were reviewed, result of 39 articles and 3 books and author 's experiences were gathered.Findings:Technologies do not only assist medical practitioners and patients receiving treatment, they also benefit perfectly healthy people by providing a wide range of general health assessments.Conclusion: telemedicine is medical services through the use of telecommunications.

Learning by simulation in prehospital emergency care - an integrative literature review.

Acquiring knowledge and experience on high-energy trauma is often difficult due to infrequent exposure. This creates a need for training which is specifically tailored for complex prehospital conditions. Simulation provides an opportunity for ambulance nurses to focus on the actual problems in clinical practice and to develop knowledge regarding trauma care. The aim of this study was to describe what ambulance nurses and paramedics in prehospital emergency care perceive as important for learning when participating in simulation exercises. An integrative literature review was carried out. Criteria for inclusion were primary qualitative and quantitative studies, where research participants were ambulance nurses or paramedics, working within prehospital care settings, and where the research interventions involved simulation. It was perceived important for the ambulance nurses' learning that scenarios were advanced and possible to simulate repeatedly. The repetitions contributed to increase the level of experience, which in turn improved the patients care. Moreover, realism in the simulation and being able to interact and communicate with the patient were perceived as important aspects, as was debriefing, which enabled the enhancement of knowledge and skills. The result is presented in the following categories: To gain experience, To gain practice and To be strengthened by others. Learning through simulation does not require years of exposure to accident scenes. The simulated learning is enhanced by realistic, stressful scenarios where ambulance nurses interact with the patients. In this study, being able to communicate with the patient was highlighted as a positive contribution to learning. However, this has seldom been mentioned in a previous research on simulation. Debriefing is important for learning as it enables scrutiny of one's actions and thereby the possibility to improve and adjust one's caring. The effect of simulation exercises is important on patient outcome.

Management of pain in pre-hospital settings.

Assessment and management of pain in pre-hospital care settings are important aspects of paramedic and clinical team roles. As emergency department waiting times and delays in paramedic-to-nurse handover increase, it becomes more and more vital that patients receive adequate pre-hospital pain relief. However, administration of analgesia can be inadequate and can result in patients experiencing oligoanalgesia, or under-treated pain. This article examines these issues along with the aetiology of trauma and the related socioeconomic background of traumatic injury. It reviews validated pain-assessment tools, outlines physiological responses to traumatic pain and discusses some of the misconceptions about the provision of effective analgesia in pre-hospital settings.

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature.

Spinal immobilisation has been a mainstay of trauma care for decades and is based on the premise that immobilisation will prevent further neurological compromise in patients with a spinal column injury. The aim of this systematic review was to examine the evidence related to spinal immobilisation in pre-hospital and emergency care settings. In February 2015, we performed a systematic literature review of English language publications from 1966 to January 2015 indexed in MEDLINE and Cochrane library using the following search terms: 'spinal injuries' OR 'spinal cord injuries' AND 'emergency treatment' OR 'emergency care' OR 'first aid' AND immobilisation. EMBASE was searched for keywords 'spinal injury OR 'spinal cord injury' OR 'spine fracture AND 'emergency care' OR 'prehospital care'. There were 47 studies meeting inclusion criteria for further review. Ten studies were case series (level of evidence IV) and there were 37 studies from which data were extrapolated from healthy volunteers, cadavers or multiple trauma patients. There were 15 studies that were supportive, 13 studies that were neutral, and 19 studies opposing spinal immobilisation. There are no published high-level studies that assess the efficacy of spinal immobilisation in pre-hospital and emergency care settings. Almost all of the current evidence is related to spinal immobilisation is extrapolated data, mostly from healthy volunteers.

An integrated community team works with the London ambulance service: perspectives on the emerging role of physiotherapists in pre-hospital care

Background: The UK National Health Service’s (NHS) initiative to move more care to the community in order to provide quality and cost-effective intervention has been a key focus of its strategy for over a decade. This has seen the establishment of the integrated community multidisciplinary team (MDT) and the development of further emerging roles for allied health professionals (AHP). Specifically, extended scope physiotherapists (ESP) are now playing active roles as members and leaders of MDTs in emergency, pre-hospital and urgent care settings. Purpose: A new care pathway was established in June 2014 between the London Ambulance Service (LAS) and the Integrated Community Response Service (ICRS) in North West London. It was set up with the philosophy that integrated care teams with enhanced clinical training should be able to successfully manage appropriate acute (but not immediately life-threatening) LAS cases in the community. Methods: Clinical members of the ICRS spent observation days with the LAS and discussions between members took place before ‘going live’ with the pathway. Regular meetings continue to be held with the LAS as part of its ongoing development.Within the system, referrals are received via telephone and discussed with the daily clinical coordinator to determine appropriateness. The ICRS receives referrals 7 days a week between 7 am and 7 pm. Once the referral is accepted, the ICRS responds accordingly within a 2-hour window and provides clinical intervention and management for approximately 7 days. The number of referrals received between June and September 2014 were collected and analysed. The reason for referral, the team members involved, the interventions and the overall outcome of each case were recorded. Results: The number of referrals received from the LAS between June and September 2014 increased by 100%. All patients referred by the LAS and accepted by the ICRS were subsequently assessed and managed in the community by the ICRS clinicians. Inappropriate referrals were declined verbally on the phone. Considering specific case examples, the physiotherapist demonstrated autonomy in assessment, intervention and case management. Conclusion(s): An appropriate LAS case can be referred to an integrated community MDT and managed accordingly. Each patient accepted by the ICRS received interventions from at least three members of the MDT and therefore the direct impact of the physiotherapist alone is unknown. The LAS and the ICRS have successfully demonstrated that they can collaboratively work together in managing acute patients in the community in North West London. Implications: There is an emerging role for physiotherapists in emergency, urgent and pre-hospital care and in response to an appropriate LAS referral. Further research is required into emerging physiotherapy roles. Consideration of merging roles, scope of practice, educational programs and health economics is also required.

Intramuscular midazolam versus intravenous lorazepam for the prehospital treatment of status epilepticus in the pediatric population.

To examine the effectiveness of intramuscular (IM) midazolam versus intravenous (IV) lorazepam for the treatment of pediatric patients with status epilepticus (SE) in the prehospital care setting. This multicenter clinical trial randomized patients diagnosed with SE to receive either IM midazolam or IV lorazepam administered by paramedics in the prehospital care setting. Included in this secondary analysis were only patients younger than 18 years of age. Evaluated were the associations of the treatment group (IM vs. IV) with the primary outcome, defined as seizure cessation prior to emergency department (ED) arrival, and with patient characteristics, time to important events, and adverse events. Descriptive statistics and 99% confidence intervals (CIs) were used for the analysis. Of 893 primary study subjects, 120 met criteria for this study (60 in each treatment group). There were no differences in important baseline characteristics or seizure etiologies between groups. The primary outcome was met in 41 (68.3%) and 43 (71.7%) of subjects in the IM and IV groups, respectively (risk difference [RD] -3.3%, 99% CI -24.9% to 18.2%). Similar results were noted for those younger than 11 years (RD -1.3%, 99% CI -25.7% to 23.1%). Time from initiating the treatment protocol was shorter for children who received IM midazolam, mainly due to the shorter time to administer the active treatment. Safety profiles were similar. IM midazolam can be rapidly administered and appears to be safe and effective for the management of children with SE treated in the prehospital setting. The results must be interpreted in the context of the secondary analysis design and sample size of the study.

I-gel insertion with modified jaw thrust technique.

Sir, Since the introduction of i-gel in modern anaesthesia practice, it is widely used by the anaesthesiologists, accident and emergency department personnel and in pre-hospital care setting. The reported first attempt success rate is 86%[1] with primary (manufacturer's recommended) insertion technique. The manufacturers have also advised alternative manoeuvres to overcome the i-gel insertion difficulties by use of reverse i-gel insertion technique and jaw thrust. Rotational i-gel insertion[2] technique and tongue stabilization manoeuvre[3] are other useful methods. However, manufacturer's recommended jaw thrust manoeuvre technique is not widely supported.[3] Manufacturer's jaw thrust i-gel insertion technique is to seek the help of other's hand (requesting assistant help) to thrust the jaw while inserting the i-gel. The operator harmonisation is the key for successful placement with this technique. Lack of synchronisation may lead to insertion failure, trauma and prolong insertion time. This is mainly due to incoordination between the operator and the ‘helping’ hand. We have devised a modified jaw thrust i-gel insertion technique. Once the pre-insertion preparation is ensured and patient is in sniffing morning air position, the i-gel is grasped firmly along with the integral bite block with cuff facing the patient's chin. Chin needs to be gently pressed down before inserting i-gel into patient's mouth. Then it is slid towards hard palate with a gentle push until it reaches the soft palate or oropharynx. Then modified jaw thrust technique is applied by lifting the angle of mandible with little fingers and other fingers to stabilise the jaw [Figure 1a], and then gently pushing the i-gel with thumbs [Figure 1b] till the final placement position by checking for the integral bite block mark at incisor teeth. Figure 1 (a) Index finger lifting angle of mandible and other fingers stabilizing the jaw (b) i-gel pushed to final position using thumbs This technique creates room at hypopharynx by displacing tongue and other oral cavity structures. The force of thumb allows the i-gel to stay in centre and to the correct final position. This smooth insertion technique is favourable in terms of minimal possibility of oral cavity abrasions, trauma and displacement. After encountering repeated difficulties with i-gel insertion by standard insertion technique, we now use the modified jaw thrust technique routinely; it is easier, takes shorter insertion time and is less traumatic then the standard insertion technique. This technique can be considered as an alternative to standard insertion techniques and true efficacy can be ascertained by randomised controlled trials.

Pre-Hospital Use of Intravenous In-Line Fluid Warmers to Reduce Morbidity and Mortality for Major Trauma Patients: A Review of the Current Literature

Introduction In-line fluid warmers are an established treatment for delivering warmed intravenous (IV) fluid in the hospital setting. Recently their potential application within the pre-hospital setting has been highlighted to potentially reduce mortality and morbidity. Currently ambulance paramedics only administer warmed fluid to patients assessed as hypothermic, and this fluid is subject to further cooling on exposure to ambient environmental conditions. This review examined the peer-reviewed literature to determine the available evidence for in-line fluid warmer effectiveness and potential inclusion in pre-hospital emergency care. Methods A review of the electronic literature, including the Medline and Ebscohost databases was conducted using the terms “intravenous fluid warmers” “hypothermia”, “ trauma”, “ fluid”, “coagulopathy”, “ acidosis”, “hypothermia and trauma patients”, “accidental hypothermia”, “lethal triad” and “trauma care”. Articles were included if they represented a study of in-line fluid warmers within the surgical, general hospital or pre-hospital emergency care settings. Articles not available in English or as full text were excluded. Results The review identified 23 relevant articles for analysis. Of note, up to 40% of trauma patients with signs of hypoperfusion were reported to arrive at hospital in a hypothermic state post-incident. Hypothermia plays a significant role in contributing to the ‘triad of death’- a condition that results in poor patient outcomes and high mortality rates. Conclusion This review identified that current pre-hospital practice does not prescribe warmed fluid to the normothermic trauma patient. The review also identified that there is a need for in-line fluid warmers in ambulance practice to prevent or limit hypothermia and reduce patient morbidity and mortality associated with trauma.

Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment.

The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.

Cardiac arrest in pre-hospital care setting – 10 years of experience

Cardiac arrest in pre-hospital care setting – 10 years of experience

Nurse-to-nurse referral of patients in early pregnancy

This article describes the development, testing, evaluation and implementation of a nurse-to-nurse referral pathway between two trusts. The aim of the pathway is to improve care for women with per vaginam bleeding in early pregnancy in emergency situations, and the article suggests how it can be used in pre-hospital and primary care settings.

Factors Associated With the Adoption of a Patient Education Intervention Among First Responders, King County, Washington, 2010–2011

IntroductionThis study investigated facilitators and barriers to adoption of an at-scene patient education program by firefighter emergency medical technicians (EMTs) in King County, Washington.MethodsWe consulted providers of emergency medical services (EMS) to develop a patient education pamphlet in the form of a tear-off sheet that could be attached to the EMT medical incident report. The pamphlet included resources for at-scene patient education on high blood pressure, blood glucose, falls, and social services. The program was launched in 29 fire departments in King County, Washington, on January 1, 2010, and a formal evaluation was conducted in late 2011. We developed a survey based on diffusion theory to assess 1) awareness of the pamphlet, 2) evaluation of the pamphlet attributes, 3) encouragement by peers and superiors for handing out the pamphlet, 4) perceived behavioral norms, and 5) demographic variables associated with self-reported adoption of the at-scene patient education program. The survey was completed by 822 (40.1%) of 2,047 firefighter emergency medical technicians. We conducted bivariate and multivariable analyses to assess associations between independent variables and self-reported adoption of the program.ResultsAdoption of the at-scene patient education intervention was significantly associated with positive evaluation of the pamphlet, encouragement from peers and superiors, and perceived behavioral norms. EMS providers reported they were most likely to hand out the pamphlet to patients in private residences who were treated and left at the scene.ConclusionAttributes of chronic disease prevention programs and encouragement from peers and supervisors are necessary in diffusion of patient education interventions in the prehospital care setting.

An Hypnotic Suggestion: Review of Hypnosis for Clinical Emergency Care

BackgroundHypnosis has been used in medicine for nearly 250 years. Yet, emergency clinicians rarely use it in emergency departments or prehospital settings. ObjectiveThis review describes hypnosis, its historical use in medicine, several neurophysiologic studies of the procedure, its uses and potential uses in emergency care, and a simple technique for inducing hypnosis. It also discusses reasons why the technique has not been widely adopted, and suggests methods of increasing its use in emergency care, including some potential research areas. DiscussionA limited number of clinical studies and case reports suggest that hypnosis may be effective in a wide variety of conditions applicable to emergency medical care. These include providing analgesia for existing pain (e.g., fractures, burns, and lacerations), providing analgesia and sedation for painful procedures (e.g., needle sticks, laceration repair, and fracture and joint reductions), reducing acute anxiety, increasing children's cooperation for procedures, facilitating the diagnosis and treatment of acute psychiatric conditions, and providing analgesia and anxiolysis for obstetric/gynecologic problems. ConclusionsAlthough it is safe, fast, and cost-effective, emergency clinicians rarely use hypnosis. This is due, in part, to the myths surrounding hypnosis and its association with alternative-complementary medicine. Genuine barriers to its increased clinical use include a lack of assured effectiveness and a lack of training and training requirements. Based on the results of further research, hypnosis could become a powerful and safe nonpharmacologic addition to the emergency clinician's armamentarium, with the potential to enhance patient care in emergency medicine, prehospital care, and remote medical settings.

The need of a health technology assessment perspective in emergency medicine

The need of a health technology assessment perspective in emergency medicine