Pre-hospital Clinicians Research Articles

Active armed offender: A novel clinical practice guideline for pre-hospital care in Ireland

Incidents involving pre-hospital clinicians responding, or being caught in, active situations of those armed with knives and guns are rising in Ireland. These high-profile and high-stress situations require prior planning to minimise loss of life and maintain the safety of paramedic staff. Better situational awareness has been identified by veteran paramedics involved in active armed offender incidents as a key priority in preventing assault of staff. This novel proposed Clinical Practice Guideline (CPG) for the Pre Hospital Emergency Council (PHEC) Ireland is based on existing similar guidelines in Australia. This CPG combines pre-hospital emergency guidelines with established tactical medicine principles from the military and police services worldwide. This CPG seeks to minimise harm to clinicians as well as inform them of appropriate clinical priorities while operating in an unsafe situation

Caring for Transgender and Gender Diverse Prehospital Patients: a NAEMSP Position Statement and Resource Document

ABSTRACT Transgender and gender diverse (TGD) people have long faced significant barriers to safely accessing medical care–especially gender-affirming care, which has been shown to strikingly improve health outcomes like suicidality and depression. In the prehospital setting, gender-affirming care amounts to showing respect for the TGD patient’s identified gender and maintaining a safe environment that fosters a positive therapeutic relationship throughout the encounter. This represents a challenge for many Emergency Medical Services (EMS) systems due to the lack of TGD-specific training for EMS clinicians, a paucity of TGD-specific research to inform EMS education and clinical care, and in some cases the resistance of EMS clinicians to such training. Transgender and gender diverse people are facing a regression in legal access to essential medical care. With this position statement, NAEMSP joins other professional medical societies in providing recommendations to improve care for TGD patients, thereby affirming TGD individuals’ right to exist as their authentic selves, as well as their entitlement to the same high-quality prehospital medical care as their cisgender peers. NAEMSP Recommends: EMS clinicians should maintain basic cultural competency regarding TGD populations, including familiarity with TGD-related health and health care disparities, consideration of TGD populations as underserved, and understanding the centrality of stigma and transphobia in creating disparities and other challenges which complicate daily life for TGD people. EMS clinicians should demonstrate cultural humility towards the TGD community, which includes self-assessment of knowledge gaps, as well as openness to new or unfamiliar ideas, information, and advice from those with different lived experiences. EMS clinicians should understand basic TGD-specific terminology and use appropriate language–including patient-identified name and pronouns–during direct patient care, in handoffs, and in documentation. EMS clinicians should treat a patient’s TGD status as sensitive health information and take care not to inadvertently disclose this information without the patient’s express permission. EMS clinicians should have a basic understanding of social transitioning and of gender-affirming medical and surgical treatments. EMS clinicians should employ a trauma-informed approach when caring for TGD patients. EMS education and training should incorporate learning domains that address comprehensive care for TGD patients, with educational content providing the specific knowledge and skills required to promote equitable care. EMS workplaces should implement policies to improve recruitment and retention of TGD personnel, covering harassment protection, non-discrimination practices, inclusive working environments, equal advancement opportunity and tailored employee benefits. Future EMS research should focus on elucidating the disparities in and barriers to prehospital care of the TGD patient population with emphasis on patient experience and education of prehospital clinicians.

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.

Elder Mistreatment Documentation by Prehospital Clinicians: An Analysis of the National Emergency Medical Services Information System Database

Objectives Elder mistreatment (EM), encompassing abuse and neglect, is a significant public health issue, affecting up to 10% of community-dwelling older adults annually. Elder mistreatment is a growing concern with a higher prevalence in institutional settings and substantial associated healthcare costs. Prehospital clinicians (PHCs) such as emergency medical technicians and paramedics are uniquely positioned to detect and report EM during their interactions with older adults in their homes. The objective of the study is to describe the rate and characteristics of EM documented by PHCs using the National Emergency Medical Services Information System (NEMSIS) database. Methods This study analyzed data from NEMSIS, which includes standardized information about PHC emergency response encounters across the United States. In 2018, 22,532,890 activations were included from 9,599 agencies in 43 states and US territories. Elder mistreatment was identified using specific International Classification of Diseases (ICD) codes related to EM. Demographic data, injury location, and associated physical findings were also examined. Results Out of 9,605,522 EMS encounters for patients aged ≥60, EM was coded in 1,765 encounters (0.02%). Most EM cases were listed as the cause of injury (64%), followed by the clinician’s first impression (25.4%). Physical abuse was the most common type of mistreatment reported (20.8%), followed by sexual abuse (18.2%), neglect (9.7%), and psychological/emotional abuse (0.34%). The median age of patients with documented EM was 72, and 62.3% were female. The most common anatomic locations of injuries were the lower extremities, head, and upper extremities. Conclusions Despite the high prevalence of EM, PHCs infrequently document EM in their encounters with older adults. Additional training and comprehensive protocols are needed to improve the identification and reporting of EM, mainly elder neglect. Empowering PHCs through education and protocol development can significantly impact the detection and intervention of EM.

Prehospital Cricothyrotomy: A narrative review of technical, educational, and operational considerations for procedure optimization

BackgroundDefinitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure. ObjectiveReview and summarize the best available evidence relating to the performance of cricothyrotomies and propose technical, educational, and operational considerations to minimize complications and optimize success of prehospital cricothyrotomies. DiscussionTechnical considerations when performing cricothyrotomy in the prehospital setting can be used to mitigate airway misplacement, mainstem intubation, and hemorrhage. Educational consideration should include focus on a singular technique, use of established curriculum, spaced repetition with either simulation or mental practice, and a focus on intention training of when to perform the procedure. The preferred technique from the National Association of EMS Physician guidelines is the surgical technique. Operational considerations to optimize a successful procedure should include checklists, preassembled kits, and robust quality improvement and insurance after a cricothyrotomy is performed. ConclusionsBy focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.

Exploring patient and system factors impacting undertriage of injured patients meeting national field triage guideline criteria.

Trauma systems save lives by coordinating timely and effective responses to injury. However, trauma system effectiveness varies geographically, with worse outcomes observed in rural settings. Prior data suggest that undertriage may play a role in this disparity. Our aim was to explore potential driving factors for decision making among clinicians for undertriaged trauma patients. We performed a retrospective analysis of the National Emergency Medical Services Information System database among patients who met physiologic or anatomic national field triage guideline criteria for transport to the highest level of trauma center. Undertriage was defined as transport to a non-level I/II trauma center. Multivariable logistic regression was used to determine demographic, injury, and system characteristics associated with undertriage. Undertriaged patients were then categorized into "recognized" and "unrecognized" groups using the documented reason for transport destination to identify underlying factors associated with undertriage. A total of 36,094 patients were analyzed. Patients in urban areas were more likely to be transported to a destination based on protocol rather than the closest available facility. As expected, patients injured in urban regions were less likely to be undertriaged than their suburban (adjusted odds ratio [aOR], 2.69; 95% confidence interval [95% CI], 2.21-3.31), rural (aOR, 2.71; 95% CI, 2.28-3.21), and wilderness counterparts (aOR, 3.99; 95% CI, 2.93-5.45). The strongest predictor of undertriage was patient/family choice (aOR, 6.29; 5.28-7.50), followed by closest facility (aOR, 5.49; 95% CI, 4.91-6.13) as the reason for hospital selection. Nonurban settings had over twice the odds of recognizing the presence of triage criteria among undertriaged patients (p < 0.05). Patients with injuries in nonurban settings and those with less apparent causes of severe injury are more likely to experience undertriage. By analyzing how prehospital clinicians choose transport destinations, we identified patient and system factors associated with undertriage. Targeting these at-risk demographics and contributing factors may help alleviate regional disparities in undertriage. Diagnostic; Level IV.

Drug Misuse Among Pediatric Patients: Encounters in the Prehospital Field

Background Few data describing prehospital pediatric substance misuse exist. The objective of this study was to characterize substance misuse in North Carolina pediatric patients receiving emergency medical services (EMS) care. Methods We conducted a retrospective cross-sectional study of patients aged &lt; 16 years transported by EMS for substance misuse. Data were obtained from a statewide repository including patients treated for confirmed or suspected misuse of marijuana, alcohol, benzodiazepines, opioids, stimulants, acetaminophen, antidepressants, or other drugs. Results Of 45,855 EMS encounters, 448 patients misused drugs. Most patients were female (56.7%), White (50.9%), adolescent (73.8%), and resided in Central North Carolina (54.0%). A plurality of cases was rural (46.2%), followed by urban (27.9%) and regional city/suburban counties (25.7%). Calls most often originated in residential locations (68.5%). Drugs identified during EMS calls included alcohol (24.2%), marijuana (24.2%), benzodiazepines (8.8%), antidepressants (8.8%), stimulants (6.8%), opioids (5.9%), and other medications (17.6%). Motivations for drug use were recreational (58.4%), self-harm (24.6%), and accidental (17.0%). Limitations Due to insufficient data documentation, one EMS system was removed from analysis. Additionally, misclassification of type of drug or intention of drug use is possible due to the use of free-text patient narratives. Conclusions EMS responded to a vast variety of drug misuse among pediatric patients including prescription medications, alcohol, marijuana, and illicit drugs. Accidental ingestions occurred exclusively in infant/preschool ages and intent for recreation or self-harm primarily occurred in adolescents. By increasing awareness of the more common pediatric patient characteristics associated with the type and reason for drug use, EMS agencies can improve pediatric readiness among prehospital clinicians.

Supporting Families and Our Own

Out-of-hospital cardiac arrest (OHCA) can have significant adverse sequelae for both the patient’s families, as well as the responding EMS clinicians. Despite advances in medicine, 90% of OHCA result in death. The sudden and unexpected nature of these events, adds to the complexity of grief for the surviving family members. OHCA specifically has been shown to have deleterious mental health impacts on EMS clinicians who have self-reported experiencing negative emotions after delivering bad news to families such as a death notification. Given the grim prognosis associated with OHCA outcomes and associated emotional fallout, we must find ways to better support our patients, families, and EMS clinicians. The goal of this paper is to offer recommendations and tools that can be used by EMS clinicians to better address the emotional burden experienced by families during an OHCA resuscitation. Many Pre-hospital clinicians receive limited training around the psychologic and emotional consequences that accompany OHCA scenarios. Currently no national curriculum or writings that the authors are aware of have covered the concept of how to run an emotionally supportive OHCA. The following is an expert consensus of recommendations from a group of experienced EMS clinicians, a child life specialist, a licensed clinical social worker and physicians with backgrounds in emergency medicine, palliative care and EMS. The strategies outlined would ideally be utilized by first responders helping to anticipate and subsequently support the emotional needs of families. The strategies range from ways to enhance communication, help combat common misperceptions from families around cardiac arrest and prepare EMS clinicians for what to do if a resuscitation is unsuccessful. Ultimately the goal of this paper is to provide the tools to help EMS clinicians better align themselves with families to minimize the emotional impact on all involved.

Mapping Prehospital Clinician Impression to Hospital-Based Diagnoses in Children Transported to the Hospital by Emergency Medical Services

Objectives Emergency medical services (EMS) serves a critical role in the delivery of services to children with out-of-hospital emergencies. The EMS clinicians’ initial field diagnoses, termed “impressions,” facilitate focused patient assessments, guide the application of prehospital treatment protocols, and help determine transport destination. We sought to evaluate the concordance of the EMS clinician impression to a child’s hospital-based diagnosis. Methods We retrospectively studied de-identified pediatric (<18 years old) scene runs transported to the hospital and with available linked hospital data from the 2021 ESO Data Collaborative, a multi-agency prehospital electronic health record dataset. EMS impressions and primary emergency department or admission-based diagnoses were categorized into one of twenty-one major groups in the Diagnosis Grouping System. We identified the most common hospital-based discharge diagnoses and evaluated for the agreement between EMS impression and hospital-based diagnosis using Cohen’s Kappa statistic. Results We included 35,833 pediatric transports from the scene with linked prehospital and in-hospital data (median age 11 years, interquartile range, 3-15 years; 50.9% male). The most common categories for both EMS impressions and hospital-based diagnoses were as follows respectively: trauma (26.1%; 24.6%), neurologic diseases (18.9%; 16.4%), psychiatric and behavioral diseases and substance use disorder (11.8%; 11.6%), and respiratory diseases (11.1% and 9.5%). A total of 23,224 out of 35,833 patients, or 64.8%, had concordant EMS impressions and hospital-based diagnoses. There was high agreement between common EMS impression and in-hospital diagnoses (trauma 77.3%; neurologic diseases 70.3%; respiratory diseases 64.5%; and psychiatric, behavioral disease and substance use disorder 73.9%). Hospital-based diagnoses demonstrated moderate concordance with prehospital data (Cohen’s κ = 0.59). Conclusions We found moderate concordance between EMS primary impression and hospital diagnoses. The EMS encounter is brief and without capabilities of advanced testing, but initial impressions may influence the basis of the triage assignment and interventions during the hospital-based encounter. By evaluating EMS impressions and ultimate hospital diagnoses, pediatric protocols may be streamlined, and specific training emphasized in pursuit of improving patient outcomes. Future work is needed to examine instances of discordance and evaluate the impact on patient care and outcomes.

Identifying trigger cues for hospital blood transfusions based on ensemble of machine learning methods

BackgroundTraumatic shock is the leading cause of preventable death with most patients dying within the first six hours from arriving to the hospital. This underscores the importance of prehospital interventions, and growing evidence suggests prehospital transfusion improves survival. Optimizing transfusion triggers in the prehospital setting is key to improving outcomes for patients in hemorrhagic shock. Our objective was to identify factors associated with early in-hospital transfusion requirements available to prehospital clinicians in the field to develop a simple algorithm for prehospital transfusion, particularly for patients with occult shock.MethodsWe included trauma patients transported by a single critical care transport service to a level I trauma center between 2012 and 2019. We used logistic regression, Fast and Frugal Trees (FFTs), and Bayesian analysis to identify factors associated with early in-hospital blood transfusion as a potential trigger for prehospital transfusion.ResultsWe included 2,157 patients transported from the scene or emergency department (ED) of whom 207 (9.60%) required blood transfusion within four hours of admission. The mean age was 47 (IQR = 28 – 62) and 1,480 (68.6%) patients were male. From 13 clinically relevant factors for early hospital transfusions, four were incorporated into the FFT in following order: 1) SBP, 2) prehospital lactate concentration, 3) Shock Index, 4) AIS of chest (sensitivity = 0.81, specificity = 0.71). The chosen thresholds were similar to conventional ones. Using conventional thresholds resulted in lower model sensitivity. Consistently, prehospital lactate was among most decisive factors of hospital transfusions identified by Bayesian analysis (OR = 2.31; 95% CI 1.55 – 3.37).ConclusionsUsing an ensemble of frequentist statistics, Bayesian analysis and machine learning, we developed a simple, clinically relevant prehospital algorithm to help identify patients requiring transfusion within 4 h of hospital arrival.

A prediction model for prehospital clinical deterioration: The use of early warning scores.

Various prognosticative approaches to assist in recognizing clinical deterioration have been proposed. To date, early warning scores (EWSs) have been evaluated in hospital with limited research investigating their suitability in the prehospital setting. This study evaluated the predictive ability of established EWSs and other clinical factors for prehospital clinical deterioration. A retrospective cohort study investigating adult patients of all etiologies attended by Queensland Ambulance Service paramedics between January 1, 2018, and December 31, 2020, was conducted. With logistic regression, several models were developed to predict adverse event outcomes. The National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Queensland Adult Deterioration Detection System (Q-ADDS), and shock index were calculated from vital signs taken by paramedics. A total of 1,422,046 incidents met the inclusion criteria. NEWS, MEWS, and Q-ADDS were found to have comparably high predictive ability with area under the receiver operating characteristic curve (AUC-ROC) between 70% and 90%, whereas shock index had relatively low AUC-ROC. Sensitivity was lower than specificity for all models. Although established EWSs performed well when predicting adverse events, these scores require complex calculations requiring multiple vital signs that may not be suitable for the prehospital setting. This study found NEWS, MEWS, and Q-ADDS all performed well in the prehospital setting. Although a simple shock index is easier for paramedics to use in the prehospital environment, it did not perform comparably to established EWSs. Further research is required to develop suitably performing parsimonious solutions until established EWSs are integrated into technological solutions to be used by prehospital clinicians in real time.

Procedural sedation by advanced practice providers in the emergency medical service in the Netherlands: a retrospective study

BackgroundProcedural sedation and analgesia (PSA) is a technique of administering sedatives to induce a state that allows the patient to tolerate painful procedures while maintaining cardiorespiratory function, a condition that is frequently desired prehospital. Non-physician prehospital clinicians often have a limited scope of practice when it comes to providing analgesia and sedation; sometimes resulting in a crew request for back-up from physician-staffed prehospital services.“. This is also the case if sedation is desirable. Advanced practice providers (APPs), who are legally authorized and trained to carry out this procedure, may be a solution when the physician-staffed service is not available or will not be available in time.MethodsThe aim of this study is to gain insight in the circumstances in which an APP, working at the Dutch ambulance service “RAV Brabant MWN” from January 2019 to December 2022, uses propofol for PSA or to provide sedation. With this a retrospective observational document study we describe the characteristics of patients and ambulance runs and evaluates the interventions in terms of safety.ResultsDuring the study period, the APPs administered propofol 157 times for 135 PSA and in 22 cases for providing sedation. The most common indication was musculoskeletal trauma such as fracture care or the reduction of joint dislocation. In 91% of the situations where propofol was used, the predetermined goal e.g. alignment of fractured extremity, repositioning of luxated joint or providing sedation the goal was achieved. There were 12 cases in which one or more adverse events were documented and all were successfully resolved by the APP. There were no cases of laryngospam, airway obstruction, nor anaphylaxis. None of the adverse events led to unexpected hospitalization or death.ConclusionDuring the study period, the APPs performed 135 PSAs and provided 22 sedations. The success rate of predetermined goals was higher than that stated in the literature. Although there were a number of side effects, their incidences were lower than those reported in the literature, and these were resolved by the APP during the episode of care. Applying a PSA by an APP at the EMS “RAV Brabant MWN” appears to be safe with a high success rate.

Assessment of Ventilation Using Adult and Pediatric Manual Resuscitators in a Simulated Adult Patient.

The bag-valve-mask (BVM) or manual resuscitator bag is used as a first-line technique to ventilate patients with respiratory failure. Volume-restricted manual resuscitator bags (eg, pediatric bags) have been suggested to minimize overventilation and associated complications. There are studies that both support and caution against the use of a pediatric resuscitator bag to ventilate an adult patient. In this study, we evaluated the ability of pre-hospital clinicians to adequately ventilate an adult manikin with both an adult- and pediatric-size manual resuscitator bag without the assistance of an advanced airway or airway adjunct device. This study was conducted at an international conference in 2022. Conference attendees with pre-hospital health care experience were recruited to ventilate an adult manikin using a BVM for 1 min with both an adult and pediatric resuscitator bag, without the use of adjunct airway devices, while 6 ventilatory variables were collected or calculated: tidal volume (VT), breathing frequency, adequate breaths (VT > 150 mL), proportion of adequate breaths, peak inspiratory pressure (PIP), and estimated alveolar ventilation (EAV). A total of 208 participants completed the study. Ventilation with the adult-sized BVM delivered an average VT of 290.4 mL compared to 197.1 mL (P < .001) when using the pediatric BVM. PIP with the adult BVM was higher than with the pediatric BVM (10.6 cm H2O vs 8.6 cm H2O, P < .001). The median EAV with the adult bag (1,138.1 [interquartile range [IQR] 194.0-2,869.9] mL/min) was markedly greater than with the pediatric BVM (67.7 [IQR 0-467.3] mL/min, P < .001). Both pediatric- and adult-sized BVM provided lower ventilation volumes than those recommended by professional guidelines for an adult. Ventilation with the pediatric BVM was significantly worse than with the adult bag when ventilating a simulated adult subject.

Brain Injury Associated Shock: An Under-Recognized and Challenging Prehospital Phenomenon.

Hemodynamic collapse in multi-trauma patients with severe traumatic brain injury (TBI) poses both a diagnostic and therapeutic challenge for prehospital clinicians. Brain injury associated shock (BIAS), likely resulting from catecholamine storm, can cause both ventricular dysfunction and vasoplegia but may present clinically in a manner similar to hemorrhagic shock. Despite different treatment strategies, few studies exist describing this phenomenon in the early post-injury phase. This retrospective observational study aimed to describe the frequency of shock in isolated TBI in prehospital trauma patients and to compare their clinical characteristics to those patients with hemorrhagic shock and TBI without shock. All prehospital trauma patients intubated by prehospital medical teams from New South Wales Ambulance Aeromedical Operations (NSWA-AO) with an initial Glasgow Coma Scale (GCS) of 12 or less were investigated. Shock was defined as a pre-intubation systolic blood pressure under 90mmHg and the administration of blood products or vasopressors. Injuries were classified from in-hospital computed tomography (CT) reports. From this, three study groups were derived: BIAS, hemorrhagic shock, and isolated TBI without shock. Descriptive statistics were then produced for clinical and treatment variables. Of 1,292 intubated patients, 423 had an initial GCS of 12 or less, 24 patients (5.7% of the original cohort) had shock with an isolated TBI, and 39 patients had hemorrhagic shock. The hemodynamic parameters were similar amongst these groups, including values of tachycardia, hypotension, and elevated shock index. Prehospital clinical interventions including blood transfusion and total fluids administered were also similar, suggesting they were indistinguishable to prehospital clinicians. Hemodynamic compromise in the setting of isolated severe TBI is a rare clinical entity. Current prehospital physiological data available to clinicians do not allow for easy delineation between these patients from those with hemorrhagic shock.

Physiological Variability during Prehospital Stroke Care: Which Monitoring and Interventions Are Used?

Prehospital care is a fundamental component of stroke care that predominantly focuses on shortening the time between diagnosis and reaching definitive stroke management. With growing evidence of the physiological parameters affecting long-term patient outcomes, prehospital clinicians need to consider the balance between rapid transfer and increased physiological-parameter monitoring and intervention. This systematic review explores the existing literature on prehospital physiological monitoring and intervention to modify these parameters in stroke patients. The systematic review was registered on PROSPERO (CRD42022308991) and conducted across four databases with citation cascading. Based on the identified inclusion and exclusion criteria, 19 studies were retained for this review. The studies were classified into two themes: physiological-monitoring intervention and pharmacological-therapy intervention. A total of 14 included studies explored prehospital physiological monitoring. Elevated blood pressure was associated with increased hematoma volume in intracerebral hemorrhage and, in some reports, with increased rates of early neurological deterioration and prehospital neurological deterioration. A reduction in prehospital heart rate variability was associated with unfavorable clinical outcomes. Further, five of the included records investigated the delivery of pharmacological therapy in the prehospital environment for patients presenting with acute stroke. BP-lowering interventions were successfully demonstrated through three trials; however, evidence of their benefit to clinical outcomes is limited. Two studies investigating the use of oxygen and magnesium sulfate as neuroprotective agents did not demonstrate an improvement in patient's outcomes. This systematic review highlights the absence of continuous physiological parameter monitoring, investigates fundamental physiological parameters, and provides recommendations for future work, with the aim of improving stroke patient outcomes.

Public support for and concerns regarding pediatric dose optimization for seizures in emergency medical services: An exception from informed consent (EFIC) trial.

Federal regulations allow exception from informed consent (EFIC) to study emergent conditions when obtaining prospective consent is not feasible. Little is known about public views on including children in EFIC studies. The Pediatric Dose Optimization for Seizures in EMS (PediDOSE) trial implements age-based, standardized midazolam dosing for pediatric seizures. The primary objective of this study was to determine public support for and concerns about the PediDOSE EFIC trial. The secondary objective was to assess how support for PediDOSE varied by demographics. We conducted a mixed-methods study in 20 U.S. communities. Participants reviewed information about PediDOSE before completing an online survey. Descriptive data were generated. Univariable and multivariable logistic regression analysis identified factors associated with support for PediDOSE. Reviewers identified themes from free-text response data regarding participant concerns. Of 2450 respondents, 79% were parents/guardians, and 20% had a child with previous seizures. A total of 96% of respondents supported PediDOSE being conducted, and 70% approved of children being enrolled without prior consent. Non-Hispanic Black respondents were less likely than non-Hispanic White respondents to support PediDOSE with an adjusted odds ratio (aOR) of 0.57 (95% CI 0.42-0.75). Health care providers were more likely to support PediDOSE, with strongest support among prehospital emergency medicine clinicians (aOR 5.82, 95% CI 3.19-10.62). Age, gender, parental status, and level of education were not associated with support of PediDOSE. Common concerns about PediDOSE included adverse effects, legal and ethical concerns about enrolling without consent, and potential racial bias. In communities where this study will occur, most respondents supported PediDOSE being conducted with EFIC and most approved of children being enrolled without prior consent. Support was lowest among non-Hispanic Black respondents and highest among health care providers. Further research is needed to determine optimal ways to address the concerns of specific racial and ethnic groups when conducting EFIC trials.

Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers

ObjectiveNational efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, emphasizing the need to maintain pediatric readiness in these settings. We aimed to characterize emergency medical services (EMS) utilization from outpatient offices and urgent care centers to better understand pediatric readiness needs. MethodsWe performed a retrospective cross-sectional analysis of EMS encounters using the National Emergency Medical Services Information System, a nationally representative EMS registry (2019–2022). We included four years of EMS encounters of children (<18 years old) that originated from an outpatient office or urgent care center. We described characteristics, including patient demographics, prehospital clinician impression, therapies, and procedures performed. ResultsOf 179,854,336 EMS encounters during the study period, 164,387 pediatric encounters originated at an outpatient setting. Most EMS encounters originated from outpatient offices. Evening and weekend EMS encounters more frequently originated from urgent care centers. The most common impressions were respiratory distress (n = 60,716), systemic illness (n = 23,583), and psychiatric/behavioral health (n = 13,273). Ninety-four percent of EMS encounters resulted in transportation to a hospital. ConclusionsEMS encounters from outpatient settings most commonly originate from outpatient offices, relative to urgent care settings, where pediatric emergency readiness may be limited. It is important that outpatient settings and providers are ready for varied emergencies, including those occurring for a behavioral health concern, and that readiness guidelines are updated to address these needs.

Factors that influence child conveyance decisions made by prehospital clinicians

Introduction: The decision to convey children to emergency departments is complex. This study aimed to identify barriers and enablers to making appropriate decisions, along with areas of disparity in this decision-making process by ambulance clinicians. Methods: A rapid evidence review was conducted. MEDLINE, CINAHL and PubMed were searched from 2012 to July 2023. Critical appraisal and thematic synthesis were performed. Results: Three studies were identified, which highlights the lack of research in this area. Five themes were identified: provision of care; equipment and protocols; exposure, experience and confidence; emotional and social circumstances; and education or skill set. Findings: Enhanced paediatric education is required before and after registration to ensure appropriate conveyance and address clinicians' lack of exposure, experience and confidence. Protocols and guidelines should be drawn up to support decision-making for lower-acuity child patients. Specialist paediatric roles are required in ambulance services to support clinicians and provide advanced patient-centred care. Conclusions: The findings of this review provide a basis for discussion and clinical practice improvement. Research to determine the clinical and cost effectiveness of implementing prehospital specialist paediatric roles is required.

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

ObjectiveHospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to...

Assessing the Feasibility of On-Shift Simulation to Improve Capacity Assessments by EMS Clinicians

Objective&#x0D; Determining the decision-making capacity of patients in the prehospital setting is a high-risk area for EMS systems. This risk is only enhanced by the growing prevalence of mental, neurological, and substance use disorders. This study sought to evaluate the feasibility of on-shift simulation as an educational method, in this case to improve EMS clinicians’ ability and confidence in performing capacity assessments. &#x0D; Methods&#x0D; This was a prospective experimental feasibility study performed at an urban, tertiary, academic medical center that operates its own EMS service. All participants were active EMTs or Paramedics. Subjects completed a pretest containing 10 patient scenarios addressing specific components of a complete capacity assessment. For each, participants were asked to decide if the patient had capacity and to rate how confident they were. They then participated in a simulated encounter with a standardized patient, designed to evaluate and teach skills in capacity assessment. A post-scenario debrief and didactic session were conducted. Lastly, subjects took a post-test consisting of the same 10 scenarios and confidence assessments.&#x0D; Results&#x0D; 22 subjects completed the study. While there was no significant difference between the number of scenarios answered correctly before and after the intervention (9.18 vs 9.27), participants’ confidence scores did significantly increase (87.2 to 95.2, p &lt; 0.001). This increase was driven by scenarios pertaining to mild dementia, pediatrics, and substance use.&#x0D; Conclusions&#x0D; Prehospital clinicians were able to correctly assess capacity in a variety of scenarios. A didactic session including a simulated patient encounter led to a significant increase in participants’ confidence in performing capacity assessments. This study revealed specific areas in which clinicians would likely benefit from further education, but further research is needed to ensure generalizability.