Prehospital Research Articles

Smart transportation solutions for faster emergency medical services response using an enhanced whale optimization algorithm

Smart transportation solutions for faster emergency medical services response using an enhanced whale optimization algorithm

Skin heating during simulated hemorrhage lowers arterial blood pressure but not tolerance following exercise in a cold environment.

Skin heating helps avoid hypothermia in trauma victims but may influence systolic (SBP) and mean arterial blood pressures (MAP) helping guide resuscitation. We examined the effect of skin heating upon tolerance and arterial blood pressure during lower body negative pressure (LBNP) across four trials. Nine participants completed 15 exercise intervals (60 sec 88% PPO and 60 sec 10% PPO) in a cold environment (0°C, 70% RH) lowering mean skin temperature (Tsk) before undergoing LBNP to pre syncope where Tsk remained low (Cold Trial: 27.6 ± 1.1°C) or was increased via water perfused suit sixty seconds into LBNP to 32.3 ± 0.7°C (Normothermic Trial), 34.8 ± 0.4°C (Warm Trial) or 36.1 ± 0.8°C (Hot Trial). Tsk was different between trials (P = 0.001). Core temperature was not different between trials, increasing with exercise (36.9 ± 0.3°C to: 37.9 ± 0.4°C) and remaining elevated during LBNP (37.7 ± 0.4°C). During LBNP, MAP was greatest in the Cold (88 ± 7 mmHg) and relatively lowered in Normothermic (83 ± 5mmHg), Warm (82 ± 5mmHg) and Hot Trials (79 ± 7mmHg, all P ≤ 0.017 vs. Cold). SBP was greatest in Cold (111 ± 9mmHg) and Normothermic trials (110 ± 10mmHg) and relatively lowered in Warm (105 ± 7mmHg) and Hot trials (103 ± 11mmHg, both P ≤ 0.037). LBNP tolerance was not different between trials (P = 0.746). Following exercise in a cold environment, skin heating during simulated hemorrhage lowers arterial blood pressures and has implications for prehospital care of trauma victims.

Exploring Prehospital Data for Pandemic Preparedness: A Western Brazilian Amazon Case Study on COVID-19.

The timely management of rapidly evolving epidemiological scenarios caused by disease outbreaks is crucial to prevent devastating consequences. However, delayed laboratory diagnostics can hamper swift health policy and epidemic response, especially in remote regions such as the western Brazilian Amazon. The aim of the article is to analyze the impact of the COVID-19 pandemic on the volume and characteristics of emergency medical services (EMS) in Manaus, focusing on how the pandemic affected sensitive indicators such as response time and the use of advanced life support ambulances. Additionally, the study seeks to understand how changes in prehospital EMS patterns, triggered by the pandemic, could be utilized as health surveillance tools, enabling a more rapid response in epidemic scenarios. This retrospective, descriptive study included data from the SAMU (Serviço de Atendimento Móvel de Urgência) medical records between January and June 2020. A total of 45,581 calls resulted in mobile units being dispatched during this period. These patients were predominantly male (28,227, 61.9%), with a median age of 47 years (IQR 30-67). The median response time significantly increased during the pandemic, reaching a median of 45.9 min (IQR 30.6-67.7) (p < 0.001). EMS calls were reduced for trauma patients and increased for other medical emergencies, especially respiratory conditions, concomitantly to an escalation in the number of deaths caused by SARS and COVID-19 (p < 0.001). The employment of advanced life support ambulances was higher during the pandemic phase (p = 0.0007). The COVID-19 pandemic resulted in a temporary disorder in the volume and reason for EMS calls in Manaus. Consequently, sensitive indicators like the response time and the employment of advanced life support ambulances were negatively affected. Sudden prehospital EMS pattern changes could play an important role in health surveillance systems, allowing for earlier establishment of countermeasures in epidemics. The impact of the COVID-19 pandemic on prehospital EMS and its role in health surveillance should be further explored.

Acquisition of Prehospital Stroke Severity Scale is associated with shorter door-to-puncture times in patients with prehospital notifications transported directly to a thrombectomy center

BackgroundWe sought to identify systemic factors influencing door-to-puncture times (DTP) among patients with pre-arrival notifications presenting directly to a comprehensive stroke center (CSC) and undergoing emergent mechanical thrombectomy (MT).MethodsIn this...

Firearm Injuries in Children: Four-year Experience from a Rural Tertiary Care Centre of Northern India.

Firearm injuries (FAIs) continue to be a global public health problem possessing substantial emotional, physical and financial burdens on hospital resources. Although FAIs are rare in children, their incidence is gradually increasing. The aim of this study was to evaluate various aspects of FAI in children that were managed at a tertiary care centre located in the rural part of India. This clinical observational study of children <18 years of age, all due to FAI, was conducted at a tertiary care centre located in the rural part of India. Data of all children admitted with FAI over 4 years from January 2016 to December 2019 were collected. Recorded data included age, sex, motive (intentional/unintentional) and circumstances leading to injury, type and license status of firearm used, time of injury, pre-hospital care, mode of transport to hospital, duration between injury and arrival to hospital, body parts and organs injured, trauma scores, management, complications, length of hospital stay and outcomes. The recorded data were entered into a worksheet and analysed. Out of 283 cases of FAI admitted, only 24 were children with age <18 years (8.48%). The mean age was 12.66 years (male:female = 2.4:1). Sixteen were intentional (66.67%) and eight were unintentional (33.33%). The family feud was the most common reason in case of intentional FAI (43.75%), and mishandling was the most common reason in case of unintentional FAI. Country made gun was the most common firearm used (62.5%). The chest and upper back were the most common sites of injury (54.16%). Intercostal drainage tube insertion was the most common surgical procedure performed (33.33%). There were three mortalities (12.5%). The present study found that intentional FAIs in children were more common than unintentional FAIs with family feuds and mishandling being the most common causes, respectively. The unlicensed country-made gun was the most common firearm causing injury in children.

The impact of real-time feedback on ventilation quality during out-of-hospital cardiac arrest: A before-and-after study

IntroductionVentilations are a critical component of cardiopulmonary resuscitation (CPR). There is conflicting evidence, however, on the most appropriate method of ventilation during cardiac arrest management. Recent evidence has suggested that regardless of the optimal ventilation strategy, ventilations are often not delivered compliant with guideline recommendations. Recent technological advancements have allowed for accurate measurement and real-time feedback of ventilation rate and volume during resuscitation. Simulation studies have found significant improvements in ventilations with the use of real-time feedback during simulated cardiac arrest. The use of feedback has not been studied in clinical practice.The objective of this study was to determine whether the use of real-time feedback improves compliance with pre-defined targets for ventilation rate and volume during out-of-hospital cardiac resuscitation. MethodsThis was a before-and-after study with four paramedic services in Ontario, Canada. We enrolled adult, out-of-hospital cardiac arrest (OHCA) patients where the ZOLL Accuvent® device was utilized to measure ventilation rate and volume. In the before phase (without feedback), the Accuvent® was used to measure ventilations, however, providers were blinded to the real-time feedback. In the after phase (with feedback), the feedback dashboard was activated and providers used the real-time feedback to guide their ventilations. All other aspects of resuscitation remained consistent throughout the study. The main objective of the study was to compare the proportion of each case that was compliant with pre-defined ventilation targets with real-time feedback and without real-time feedback. We also examined the use of advanced airways on ventilation quality and examined for associations between ventilation parameters and return of circulation. ResultsWe enrolled 412 patients in the study (191 in the before phase without feedback and 221 in the after phase with feedback). Overall, we found significant improvements in both ventilation rate and volume in the after phase (with real-time feedback) compared to the before phase (without real-time feedback). We did not find any differences in ventilation compliance with or without advanced airways, or intra-arrest or post-cardiac arrest. ConclusionThe use of real-time feedback was associated with an increased proportion of ventilations that were compliant with pre-defined targets during cardiac resuscitation. Further work is required to improve the use of real-time ventilation feedback, and to determine the impact of ventilations on patient outcomes.

ДОСРОЧНОЕ ОСВОБОЖДЕНИЕ ОСУЖДЕННОГО ОТ ОТБЫВАНИЯ НАКАЗАНИЯ В ЭКСТРЕМАЛЬНЫХ УСЛОВИЯХ: НЕКОТОРЫЕ ПРОБЛЕМЫ РЕГУЛИРОВАНИЯ

Based on the analysis of the provisions of the Federal Constitutional Law «On the State of Emergency», the Criminal Code of the Russian Federation, the Penal Code of the Russian Federation and other normative legal acts, a number of shortcomings in the regulation of parole, replacement of the unserved part of the punishment with a milder one and release from punishment due to the illness of the convicted person, accepted by the court in extreme conditions, that is, when natural disasters occur or a state of emergency or martial law is imposed. The article focuses on a number of issues: suspension of the convict’s right to apply for early release, leaving the possibility of such treatment with the administration of the institution or body executing the punishment; attribution of the convict’s participation in emergency rescue and other urgent work to the criteria for parole or replacement of the unserved part of the punishment with a milder one; imputation of post-penitentiary responsibilities related to the elimination of the consequences of extreme conditions; etc.

Mapping Glasgow Coma scale to AVPU scores among adults in the prehospital setting

ObjectiveTo develop a translation between the Glasgow Come Scale and the Alert-Verbal-Pain-Unresponsive (AVPU) scale among adults with out-of-hospital emergencies. MethodsWe performed a retrospective analysis of adults (≥18 years) from the 2022 National Emergency Medical Services (EMS) Information System with a ground scene encounter with a concurrently documented GCS and AVPU assessment. Using a training partition of 2.5 million encounters, we performed a grid search to identify all combinations of mutually exclusive cutpoints which divided the GCS into four segments. We identified the combination with the highest Kappa statistic and reported metrics of performance in this sample in the test partition. ResultsWe identified 16,321,299 encounters with a concurrent AVPU and GCS. Using the AVPU scale, 93.3 % were classified as Alert; 2.9 % as Verbal; 1.5 % as Pain; and 2.3 % as Unresponsive. Using a grid-based search, optimal cutpoints were identified when using a GCS of 14–15 for Alert, 10–13 for Verbal, 7–9 for Pain, and 3–6 for Unresponsive. Cohen's Kappa was 0.63 in the test partition, indicating substantial agreement. Intraclass F1 score varied across different alertness levels and were 0.97 for “Alert”, 0.43 for “Verbal”, 0.49 for “Pain”, and 0.83 for “Unresponsive”. Findings were similar in analyses performed by age group and by the presence or absence of trauma. ConclusionWe report an optimal crosswalk between the AVPU and GCS scales. Performance in the Verbal and Pain categories was lower than the Alert and Unresponsive categories. These findings may facilitate clinician handovers between EMS and non-EMS clinicians.

Use of Emergency Mental Health Dispatch Training by a 9-1-1 Medical Dispatcher Assisting a Caller Expressing Suicidal Intent: A Case Report.

A growing number of individuals with unmet mental health needs in the United States rely on emergency medical services during mental health crises, and 9-1-1 emergency medical dispatchers (EMD) are often a critical lifeline to help. Unfortunately, current industry-standard dispatching protocols and training required for EMD certification largely lack specificity for managing 9-1-1 calls related to mental health emergencies. The purpose of this report is to illustrate the value of additional targeted training for EMDs that enables them to more effectively assist callers struggling with mental illness or suicidal thoughts. We review a 9-1-1 call in which an EMD utilized specific strategies and language learned during a 3-day emergency mental health dispatch (EMHD) training course to assist a middle-aged male who was expressing suicidal intent with a firearm. Key principles and phrasing from the training were used successfully by the EMD to dissuade the caller from self-harm, and he was ultimately safely met by first responders on scene and transported for care. We also share post-call recollections and reactions from the EMD to demonstrate how in addition to reducing risks for callers and their families, EMHD training has the potential to reduce on-scene risks for field responders and may increase confidence and mitigate negative stress responses in EMDs. Emergency medical services systems in the United States should continue to explore enhanced training and protocols to improve care for 9-1-1 callers experiencing mental health crises.

Drones reduce the time to defibrillation in a highly visited non-urban area: A randomized simulation-based trial

IntroductionOut-of-hospital cardiac arrest (OHCA) has a high global incidence and mortality rate, with early defibrillation significantly improving survival. Our aim was to assess the feasibility of autonomous drone delivery of automated external defibrillators (AED) in a non-urban area with physical barriers and compare the time to defibrillate (TTD) with bystander retrieval from a public access defibrillator (PAD) point and helicopter emergency medical services (HEMS) physician performed defibrillation. MethodsThis randomized simulation-based trial with a cross-over design included bystanders performing AED retrievals either delivered by automated drone flight or on foot from a PAD point, and simulated HEMS interventions. The primary outcome was the time to defibrillation, with secondary outcomes comparing workload, perceived physical effort, and ease of use. ResultsThirty-six simulations were performed. Drone-delivered AED intervention had a significantly shorter TTD [2.2 (95 % CI 2.0–2.3) min] compared to PAD retrieval [12.4 (95 % CI 10.4–14.4) min] and HEMS [18.2 (95 % CI 17.1–19.2) min].The self-reported physical effort on a visual analogue scale for drone-delivered AED was significantly lower versus PAD [2.5 (1 – 22) mm vs. 81 (65–99) mm, p = 0.02]. The overall mean workload measured by NASA-TLX was also significantly lower for drone delivery compared to PAD [4.3 (1.2–11.7) vs. 11.9 (5.5–14.5), p = 0.018]. ConclusionThe use of drones for automated AED delivery in a non-urban area with physical barriers is feasible and leads to a shorter time to defibrillation. Drone-delivered AEDs also involve a lower workload and perceived physical effort than AED retrieval on foot.

Learner evaluation of an immersive virtual reality mass casualty incident simulator for triage training

BackgroundTo minimize loss of life, modern mass casualty response requires swift identification, efficient triage categorization, and rapid hemorrhage control. Current training methods remain suboptimal. Our objective was to train first responders to triage a mass casualty incident using Virtual Reality (VR) simulation and obtain their impressions of the training’s quality and effectiveness.We trained subjects in a triage protocol called Sort, Assess, Lifesaving interventions, and Treatment and/or Transport (SALT) Triage then had them respond to a terrorist bombing of a subway station using a fully immersive virtual reality simulation. We gathered learner reactions to their virtual reality experience and post-encounter debriefing with a custom electronic survey. The survey was designed to gather information about participants’ demographics and prior experience, including roles, triage training, and virtual reality experience. We then asked them to evaluate the training and encounter and the system’s potential for training others.ResultsWe received 375 completed evaluation surveys from subjects who experienced the virtual reality encounter. Subjects were primarily paramedics, but also included medical learners as well as other emergency medical service (EMS) professionals. Most participants (95%) recommended the experience for other first responders and rated the simulation (95%) and virtual patients (91%) as realistic. Ninety-four percent (94%) of participants rated the virtual reality simulator as “excellent” or “good.” We observed some differences between emergency medical service and medical professionals regarding their prior experience with disaster response training and their opinions on how much the experience contributed to their learning. We observed no differences between subjects with extensive virtual reality experience and those without.ConclusionsOur virtual reality simulator is an automated, customizable, fully immersive virtual reality system for training and assessing personnel in the proper response to a mass casualty incident. Participants perceived the simulator as an adequate alternative to traditional triage and treatment training and believed that the simulator was realistic and effective for training. Prior experience with virtual reality was not a prerequisite for the use of this system.

Global emergency medicine research priorities: a mapping review.

Recognizing and prioritizing research areas in emergency care is crucial for generating evidence and advancing research programs, aiming to enhance health outcomes for both individuals and populations. The objective of this review is to document global clinical and nonclinical research priorities. The Emergency Medicine Education and Research by Global Experts network, consisting of 22 sites across six continents, conducted a mapping review of publications on emergency medicine research priorities (2000-2022) across seven databases. We included studies with replicable methodologies for determining research priorities, excluding those limited to individual diseases. Three reviewers independently screened, selected, and categorized results into clinical and nonclinical topics. Discrepancies were resolved by an independent investigator and consensus. Outcomes measures and analysis include descriptive analysis of research priorities grouped into clinical and nonclinical topics, characteristics of publications including countries represented in the author list, target audience (such as researchers or policy makers), participants (e.g. patients), and methods (e.g. Delphi) of priority setting. Among 968 screened papers, 57 publications from all WHO regions were included. Most (36, 63%) had authors from only a single country, primarily in North America and Europe. Patient representatives were included in only 10 (18%). Clinical research priorities clustered into resuscitation, cardiology, central nervous system, emergency medical services, infectious disease, mental health, respiratory disease, and trauma. Distribution was broad in North America and Europe but focused on infectious diseases and resuscitation in Africa and Asia. Eleven nonclinical topics included access to care, health policy, screening/triage, social determinants of health, staffing, technology/simulation, shared decision making, cross-sectoral collaboration, education, patient-centered care, and research networks. Nonclinical topics were broad in Europe and America, focused on access to care and health screening in Africa, and mostly absent in other WHO regions. Published research priorities in emergency medicine are heterogeneous and geographically limited, mostly containing groups of authors from the same country. The majority of publications in global research priority setting stem from Western countries, covering a broad spectrum of clinical and nonclinical topics. Research priorities from Africa and Asia tend to focus on specific issues more prevalent in those regions of the world.

Association between pre-arrest left ventricular ejection fraction and survival in nontraumatic out-of-hospital cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) poses major public health issues. Pre-arrest heart function is a prognostic factor, but the specific contribution of pre-arrest echocardiographic evaluation in predicting OHCA outcome remains limited. The primary objective was to investigate the association between left ventricular ejection fraction (LVEF) measured in echocardiography prior to OHCA and survival to hospital discharge. This multicenter retrospective cohort study analyzed data from the National Taiwan University Hospital and its affiliated hospitals. We included adult nontraumatic OHCA patients who were treated by the emergency medical services (EMS) and underwent echocardiography within 6 months prior to the OHCA event from January 2016 to December 2022. Data included demographics, preexisting diseases, resuscitation events, and echocardiographic reports. The primary outcome was the survival to hospital discharge after post-arrest care. Statistical analysis involved multivariable logistic regression to modify potential confounders, reported as adjusted odds ratio (aOR) and 95% confidence interval (CI), and evaluate the association between echocardiographic findings and survival to hospital discharge. This study analyzed 950 patients, with 33.6% surviving to discharge. A higher pre-arrest LVEF was independently associated with increased survival. Compared to patients with LVEF < 40%, those with LVEF between 40% and 60% had significantly higher odds of survival (aOR = 3.68, 95% CI = 2.14-6.35, P < 0.001), and those with LVEF > 60% had even greater odds of survival (aOR = 5.46, 95% CI = 3.09-9.66, P < 0.001). There was also an association between lower tricuspid regurgitation pressure gradient and survival (aOR = 0.98, 95% CI = 0.97-1.00, P = 0.015). Younger age, male gender, dyslipidemia, stroke, cancer, witnessed arrest, initial shockable rhythm, and shorter low-flow time are other significant predictors of survival. In adult, nontraumatic, EMS-treated OHCA patients, a higher LVEF 6 months prior to OHCA was associated with improved survival at hospital discharge.

Hybrid emergency care at the home for patients – A multiple case study

IntroductionHealthcare systems worldwide are facing numerous challenges, such as an aging population, reduced availability of hospital beds, staff reductions and closure of emergency departments (ED). These issues can exacerbate crowding and boarding problems in the ED, negatively impacting patient safety and the work environment. In Sweden a hybrid of prehospital and intrahospital emergency care has been established, referred to in this article as Medical Emergency Team (MET), to meet the increasing demand for emergency care. MET, consisting of physicians and nurses, moving emergency care from EDs to patients’ home. Physicians and nurses may encounter challenges in their healthcare work, such as limited resources for example medical equipment, sampling and examination, in unfamiliar varying home environments. There is a lack of knowledge about how these challenges can influence patient care. Therefore, the aim of this study was to explore the healthcare work of the METs when addressing patients’ emergency care needs in their homes, with a focus on the METs reasoning and actions.MethodsUsing a qualitative multiple case study design, two METs in southwestern Sweden were explored. Data were collected from September 2023 – January 2024 and consist of field notes from participant observations, short interviews and written reflections. A qualitative manifest content analysis with an inductive approach was used as the analysis method.ResultThe result of this study indicates that physicians and nurses face several challenges in their daily work, such as recurring interruptions, miscommunication and faltering teamwork. Some of these problems may arise because physicians and nurses are not accustomed to working together as a team in a different care context. These challenges can lead to stress, which ultimately can expose patients to unnecessary risks.ConclusionWhen launching a new service like METs, which is a hybrid of prehospital and intrahospital emergency care, it is essential to plan and prepare thoroughly to effectively address the challenges and obstacles that may arise. One way to prepare is through team training. Team training can help reduce hierarchical structures by enabling physicians and nurses to feel that they can contribute, collaborate, and take responsibility, leading to a more dynamic and efficient work environment.

Resilience as Safety Culture in German Emergency Medical Services: Examining Irritation and Burnout.

The stress levels in emergency services are enormous. The resulting stress can range from psychological irritation to burnout. This study examines the importance of resilience in the German EMS and its significance for the risk of irritation and burnout among EMS personnel. A quantitative cross-sectional online survey was conducted among 285 EMS personnel in Germany. Resilience was measured by the RS-13 Scale, irritation by the Irritation Scale (IS), and burnout by the Maslach Burnout Inventory (MBI). Sociodemographic and job-related data were also collected. A classification into resilient groups was used to compare stress levels. More than one-third (39%) of the participants had a low level of resilience. EMS personnel with high levels of resilience had significantly lower scores on the cognitive and emotional irritation dimensions, as well as on the burnout dimensions of emotional exhaustion and cynicism. Resilience plays an important role in the safety culture of emergency services. The results support the hypothesis that high levels of resilience lead to less stress and help people cope better with stress. Almost two-fifths of the participants had lower resilience, underscoring the need for safe communication and targeted measures to strengthen resilience. Regular training, a supportive work environment, and promoting team cohesion and social support can improve emergency responders' mental health and job performance. Future research should develop specific intervention strategies and evaluate their effectiveness to ensure the long-term health of emergency responders and improve the quality of emergency care.

Out-of-hospital cardiac arrest in Bahrain: National retrospective cohort study

AimThere is limited research on Out-of-hospital cardiac arrest (OHCA) in the Gulf Cooperation Council (GCC) and especially in Bahrain. This is the first study to describe the incidence, characteristics, and outcomes of OHCA in Bahrain. MethodsThis was a retrospective national observational study on OHCA patients in Bahrain using the Utstein framework for resuscitation. Data was collected between 1st July 2022 to 30th June 2023 from the electronic medical records of the only three governmental hospitals emergency departments (EDs) and National Ambulance (NA). ResultsThe annual incidence of OHCA attended by (Emergency Medical Services) EMS was nearly 21 per 100,000 population. The majority were males (n = 228, 68.8 %) with median age of 65 years (IQR=49–78). Most OHCA cases were witnessed (n = 265, 81 %), with (n = 247, 76 %) happened at home/residence. Rates for bystander CPR was low (n = 122, 36.8 %) and bystander automated external defibrillator (AED) was not performed in any of the cases. The OHCA cases transported by the NA was (n = 314, 94.8 %), with median response time of 9 min (IQR=7–12). However, only (n = 20, 6.0 %) were witnessed by EMS, and (n = 7, 2.1 %) received EMS defibrillation for shockable rhythms. First monitored rhythms included shockable rhythm in (n = 28, 8.5 %) versus non-shockable rhythm in (n = 303, 91.5 %). In the EDs, return of spontaneous circulation was achieved in (n = 60, 18.1 %) cases. But survival rate to hospital discharge at 30-day was (n = 4, 1.2 %) and survival rate to hospital discharge with good neurological outcomes was (n = 0, 0 %). Conclusion: In Bahrain the estimated annual incidence of OHCA is 21 individuals per 100,000 population, with a very low survival rate. Solutions should focus on community-level CPR and AED training, evaluating OHCA care provided by EMS, and establishing OHCA registry.

Prevalence, predictors and outcomes of self-reported feedback for EMS professionals: a mixed-methods diary study

BackgroundProviding feedback to healthcare professionals and organisations on performance or patient outcomes may improve care quality and professional development, particularly in Emergency Medical Services (EMS) where professionals make autonomous, complex decisions and current feedback provision is limited. This study aimed to determine the content and outcomes of feedback in EMS by measuring feedback prevalence, identifying predictors of receiving feedback, categorising feedback outcomes and determining predictors of feedback efficacy.MethodsAn observational mixed-methods study was used. EMS professionals delivering face-to-face patient care in the United Kingdom’s National Health Service completed a baseline survey and diary entries between March-August 2022. Diary entries were event-contingent and collected when a participant identified they had received feedback. Self-reported data were collected on feedback frequency, environment, characteristics and outcomes. Feedback environment was measured using the Feedback Environment Scale. Feedback outcomes were categorised using hierarchical cluster analysis. Multilevel logistic regression was used to assess which variables predicted feedback receipt and efficacy. Qualitative data were analysed using content analysis.Results299 participants completed baseline surveys and 105 submitted 538 diary entries. 215 (71.9%) participants had received feedback in the last 30 days, with patient outcome feedback the most frequent (n = 149, 42.8%). Feedback format was predominantly verbal (n = 157, 73.0%) and informal (n = 189, 80.4%). Significant predictors for receiving feedback were a paramedic role (aOR 3.04 [1.14, 8.00]), a workplace with a positive feedback-seeking culture (aOR 1.07 [1.04, 1.10]) and white ethnicity (aOR 5.68 [1.01, 29.73]). Feedback outcomes included: personal wellbeing (closure, confidence and job satisfaction), professional development (clinical practice and knowledge) and service outcomes (patient care and patient safety). Feedback-seeking behaviour and higher scores on the Feedback Environment Scale were statistically significant predictors of feedback efficacy. Solicited feedback improved wellbeing (aOR 3.35 [1.68, 6.60]) and professional development (aOR 2.58 [1.10, 5.56]) more than unsolicited feedback.ConclusionFeedback for EMS professionals was perceived to improve personal wellbeing, professional development and service outcomes. EMS workplaces need to develop a culture that encourages feedback-seeking to strengthen the impact of feedback for EMS professionals on clinical decision-making and staff wellbeing.

Consensus Statement of the National Association of EMS Physicians International Association of Fire Chiefs and the International Association of Chiefs of Police: Best Practices for Collaboration Between Law Enforcement and Emergency Medical Services During Acute Behavioral Emergencies

Emergency Medical Services (EMS) and law enforcement (LE) frequently work as a team in encounters with individuals experiencing acute behavioral emergencies manifesting with severe agitation and aggression. The optimal management is a rehearsed, coordinated effort by law enforcement and EMS providing the necessary interventions to address behaviors that endanger the patient, the responders, and the public. The purpose of this document is to provide guidance and direction in the shared responsibility of managing and caring for a person displaying behavioral instability with irrational, agitated, and/or violent behavior. This is a discussion of the roles of law enforcement, 9-1-1 call centers (hereafter referred to as the Emergency Call Centers or “ECCs”), Fire, and EMS. A coordinated and unified response enhances the safety and effective management of potentially serious situations posed by individuals experiencing such acute behavioral emergencies. This paper provides the framework for an approach endorsed by NAEMSP, IACP, and the IAFC.

Clinicians’ experience of barriers and facilitators to care delivery of an extracorporeal cardiopulmonary resuscitation service for out-of-hospital cardiac arrest: a qualitative survey

BackgroundOut-of-hospital cardiac arrest (OHCA) survival in the UK remains overall poor with fewer than 10% of patients surviving to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) is a developing therapy option that can improve survival in select patients if treatment begins within an hour. Clinicians' perspectives are a pivotal consideration to the development of effective systems for OHCA ECPR, but they have been infrequently explored. This study investigates clinicians' views on the barriers and facilitators to establishing effective systems to facilitate transport of OHCA patients for in-hospital ECPR.MethodsIn January 2023, Thames Valley Air Ambulance (TVAA) and Harefield Hospital developed an ECPR partnership pathway for conveyance of OHCA patients for in-hospital ECPR. The authors of this study conducted a survey of clinicians across both services looking to identify clear barriers and positive contributors to the effective implementation of the programme. The survey included questions about technical and non-technical barriers and facilitators, with free-text responses analysed thematically.ResultsResponses were received from 14 pre-hospital TVAA critical care and 9 in-hospital clinicians’ representative of various roles and experiences. Data analysis revealed 10 key themes and 19 subthemes. The interconnected themes, identified by pre-hospital TVAA critical care clinicians as important barriers or facilitators in this ECPR system included educational programmes; collectiveness in effort and culture; teamwork; inter-service communication; concurrent activity; and clarity of procedures. Themes from in-hospital clinicians’ responses were distilled into key considerations focusing on learning and marginal gains, standardising and simplifying protocols, training and simulation; and nurturing effective teams.ConclusionThis study identified several clear themes and subthemes from clinical experience that should be considered when developing and modelling an ECPR system for OHCA. These insights may inform future development of ECPR programmes for OHCA in other centres. Key recommendations identified include prioritising education and training (including regular simulations), standardising a ‘pitstop style’ handover process, establishing clear roles during the cannulation process and developing standardised protocols and selection criteria. This study also provides insight into the feasibility of using pre-hospital critical care teams for intra-arrest patient retrieval in the pre-hospital arena.

Aggressive Hyperkalemia Treatment in the Prehospital Setting

This is a case of profound unstable hyperkalemia encountered in the American pre-hospital 911 setting, with subsequent aggressive treatment and stabilization. Although hyperkalemia may be present in the prehospital setting, it is difficult to diagnose without laboratory testing or a reliable history of illness. It is frequently encountered in the pre-hospital setting, especially in communities with high levels of comorbidities and multiple dialysis centers. However, in the spectrum of hyperkalemia presentations, many of these patients are either early in their disease presentation or found when already in cardiac arrest. Early identification and rapid, aggressive treatment are paramount to decreasing morbidity and mortality in these patient populations. This case shows how aggressive prehospital critical care can have a significant impact on patient outcomes.