Prehospital Triage Research Articles

Direct Transfer to the Neuroangiography Suite for Patients With Stroke.

The therapeutic focus in acute ischemic stroke over the last 2.5 decades has been to balance the benefits of rapid reperfusion therapy with the risks of treatment-related complications. Both intravenous thrombolytics and endovascular thrombectomy are proven to substantially improve outcomes in a time-dependent manner. Each minute saved in achieving successful reperfusion grants an additional week of healthy life and may salvage up to 27 million neurons. The current approach to patient triage is inherited from the preendovascular thrombectomy era of stroke care. Current workflow concentrates on stabilization, diagnosis, and decision-making in the emergency department, followed by thrombolysis if eligible and subsequent transfer to the angiography suite as needed for further treatment. Multiple efforts have been directed toward minimizing the time from first medical contact to reperfusion therapy including prehospital triage and intrahospital workflow. Novel approaches for stroke patient triage such as the direct to angio approach, (also referred to as One Stop Management) are currently in development. The concept was initially introduced as several single-center experiences. In this narrative review article, we will consider various definitions of direct to angio and its variants, discuss its rationale, review its safety and efficacy, assess its feasibility, and delineate its limitations. Further, we will address methods to overcome these limitations and the potential impact of emerging data and new technologies on the direct-to-angio approach.

Improved prehospital triage for acute cardiac care: results from HART-c, amulticentre prospective study.

Cardiac symptoms are one of the most prevalent reasons for emergency department visits. However, over 80% of patients with such symptoms are sent home after acute cardiovascular disease has been ruled out. The Hollands-Midden Acute Regional Triage-cardiology (HART-c) study aimed to investigate whether anovel prehospital triage method, combining prehospital and hospital data with expert consultation, could increase the number of patients who could safely stay at home after emergency medical service (EMS) consultation. The triage method combined prehospital EMS data, such as electrocardiographic and vital parameters in real time, and data from regional hospitals (including previous medical records and admission capacity) with expert consultation. During the 6‑month intervention and control periods 1536 and 1376patients, respectively, were consulted by the EMS. The primary endpoint was the percentage change of patients who could stay at home after EMS consultation. The novel triage method led to asignificant increase in patients who could safely stay at home, 11.8% in the intervention group versus 5.9% in the control group: odds ratio 2.31 (95% confidence interval (CI) 1.74-3.05). Of 181patients staying at home, only 1(< 1%) was later diagnosed with ACS; no patients died. Furthermore the number of interhospital transfers decreased: relative risk 0.81 (95% CI 0.67-0.97). The HART‑c triage method led to asignificant decrease in interhospital transfers and an increase in patients with cardiac symptoms who could safely stay at home. The presented method thereby reduced overcrowding and, if implemented throughout the country and for other medical specialties, could potentially reduce the number of cardiac and non-cardiac hospital visits even further.

Performance of a provincial prehospital trauma triage protocol: A retrospective audit

Objective To assess the accuracy of a five-step prehospital trauma triage protocol ( Échelle québécoise de triage préhospitalier en traumatologie (EQTPT)) to identify patients requiring urgent and specialized in-hospital trauma care in the Capitale-Nationale region – Québec. Methods The medical records of trauma patients transported by ambulance to one of the five participating emergency departments (EDs) between November 2016 and March 2017 were reviewed. Our primary outcome was the need for one of the following urgent and specialized trauma care: endotracheal intubation in the ED, administration of ≥ 2 blood products in the ED, angioembolization or surgery (excluding single limb surgery) &lt; 24 h and admission to the intensive care unit (ICU) or in-hospital trauma-related death. Results A total of 902 patients were included. The median age was 63 (interquartile range (IQR) 51) and 494 (54.8%) were female. The main trauma mechanism was falls (n = 592), followed by motor vehicle accidents (n = 201). Eighty-two (9.1%) patients required at least one urgent and specialized trauma care. Of those, 44 (53.6%) were identified as requiring transport to a level one trauma centre (steps 1–3), 16 were identified as requiring transport to a centre with a lower level of trauma designation (steps 4–5) while 22 (26.8%) did not meet any of the EQTPT criteria. For steps 1 to 3, the sensitivity was 53.7% (95% confidence interval (CI) 42.9–64.4) and the specificity was 81.7% (95% CI 79.1–84.4) in identifying patients requiring specialized trauma care. Conclusion The EQTPT lacked sensitivity and was poorly specific to identify trauma patients who need specialized in-hospital trauma care.

Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care.

Appropriate prehospital trauma triage ensures transport of children to facilities that provide specialized trauma care. There are currently no objective and generalizable scoring tool for emergency medical services to facilitate such decisions. An abnormal reverse shock index times Glasgow Coma Scale (rSIG), which is calculated using readily available parameters, has been shown to be associated with severely injured children. This study sought to determine if rSIG could be used in the prehospital setting to identify injured children who require the highest levels of care. Patients (1-18 years old) transferred from the scene to a level 1 pediatric trauma center from 2010 to 2020 with complete prehospital and emergency department vital signs, and Glasgow Coma Scale (GCS) scores were included. Reverse shock index times GCS was calculated as previously described ((systolic blood pressure/heart rate) × GCS), and the following cutoffs were used: ≤13.1, ≤16.5, and ≤20.1 for 1- to 6-, 7- to 12-, and 13- to 18-year-old patients, respectively. Trauma activation level and clinical outcomes upon arrival to the pediatric trauma center were collected. There were 247 patients included in the analysis; 66.0% (163) had an abnormal prehospital rSIG. Patients with an abnormal rSIG had a higher rate of highest-level trauma activation compared with those with a normal rSIG (38.7% vs. 20.2%, p = 0.013). Patients with an abnormal prehospital rSIG also had higher rates of intubation (28.8% vs. 9.52%, p < 0.001), intracranial pressure monitor (9.20 vs. 1.19%, p = 0.032), need for blood (19.6% vs. 8.33%, p = 0.034), laparotomy (7.98% vs. 1.19%, p = 0.039), and intensive care unit admission (54.6% vs. 40.5%, p = 0.049). Reverse shock index times GCS may assist emergency medical service providers in early identification and triage of severely injured children. An abnormal rSIG in the emergency department is associated with higher rates of intubation, need for blood transfusion, intracranial pressure monitoring, laparotomy, and intensive care unit admission. Use of this metric may help to speed the identification, care, and treatment of any injured child. Prognostic and Epidemiological; Level IV.

Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study.

Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70-11.74). MTA was <1.0% for 18 (27%) countries and 0 for 7 (10%) countries. There was a 460-fold disparity between the highest and lowest nonzero MTA regions and low-income countries had 88% lower MTA compared with high-income countries. The global MT operator availability was 16.5% of optimal and the MT center availability was 20.8% of optimal. On multivariable regression, country income level (low or lower-middle versus high: odds ratio, 0.08 [95% CI, 0.04-0.12]), MT operator availability (odds ratio, 3.35 [95% CI, 2.07-5.42]), MT center availability (odds ratio, 2.86 [95% CI, 1.84-4.48]), and presence of prehospital acute stroke bypass protocol (odds ratio, 4.00 [95% CI, 1.70-9.42]) were significantly associated with increased odds of MTA. Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country's per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

Development and Asian-wide validation of the Grade for Interpretable Field Triage (GIFT) for predicting mortality in pre-hospital patients using the Pan-Asian Trauma Outcomes Study (PATOS)

Field triage is critical in injury patients as the appropriate transport of patients to trauma centers is directly associated with clinical outcomes. Several prehospital triage scores have been developed in Western and European cohorts; however, their validity and applicability in Asia remains unclear. Therefore, we aimed to develop and validate an interpretable field triage scoring systems based on a multinational trauma registry in Asia. This retrospective and multinational cohort study included all adult transferred injury patients from Korea, Malaysia, Vietnam, and Taiwan between 2016 and 2018. The outcome of interest was a death in the emergency department (ED) after the patients' ED visit. Using these results, we developed the interpretable field triage score with the Korea registry using an interpretable machine learning framework and validated the score externally. The performance of each country's score was assessed using the area under the receiver operating characteristic curve (AUROC). Furthermore, a website for real-world application was developed using R Shiny. The study population included 26,294, 9404, 673 and 826 transferred injury patients between 2016 and 2018 from Korea, Malaysia, Vietnam, and Taiwan, respectively. The corresponding rates of a death in the ED were 0.30%, 0.60%, 4.0%, and 4.6% respectively. Age and vital sign were found to be the significant variables for predicting mortality. External validation showed the accuracy of the model with an AUROC of 0.756-0.850. The Grade for Interpretable Field Triage (GIFT) score is an interpretable and practical tool to predict mortality in field triage for trauma. This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (Grant Number: HI19C1328).

Towards exploring current challenges and future opportunities relating to the prehospital triage of patients with traumatic brain injury: a mixed-methods study protocol

IntroductionTraumatic brain injury (TBI) is a major global health burden that results in disability and loss of health. Identifying those patients who require specialist neuroscience care can be challenging due...

Geospatial Analysis of Prehospital Triage and Early Potential Preventable Traumatic Deaths.

Severely injured patients often depend on prompt prehospital triage for survival. This study aimed to examine the under-triage of preventable or potentially preventable traumatic deaths. A retrospective review of Harris County, TX, revealed 1848 deaths within 24hours of injury, with 186 being preventable or potentially preventable (P/PP). The analysis evaluated the geospatial relationship between each death and the receiving hospital. Out of the 186 P/PP deaths, these were more commonly male, minority, and penetrating mechanisms when compared with NP deaths. Of the 186 PP/P, 97 patients were transported to hospital care, 35 (36%) were transported to Level III, IV, or non-designated hospitals. Geospatial analysis revealed an association between the location of initial injury and proximity to receiving Level III, IV, and non-designated centers. Geospatial analysis supports proximity to the nearest hospital as one of the primary reasons for under-triage.

Abstract WP37: Prehospital Stroke Scales Outperform National Institutes Of Health Stroke Scale In Predicting Large Vessel Occlusion In A Large Telestroke Network

Introduction: Prehospital telestroke is increasingly utilized in mobile stroke units and telemedicine-enabled ambulances for acute ischemic stroke (AIS). While the NIHSS remains the standard for telestroke assessment, simpler scales have been validated to help paramedics recognize large vessel occlusion (LVO) strokes but have not been evaluated in a traditional telestroke network. We aimed to determine the accuracy of common LVO scales in a large academic telestroke practice. Methods: This retrospective study included all telestroke consults performed in a large academic telestroke network from 2019 to 2020. Patients were excluded if no NIHSS or vessel imaging was performed. We recorded presenting NIHSS, site of vessel occlusion, and discharge diagnosis. LVO was defined as an acute occlusion of the internal carotid artery and/or M1 middle cerebral artery. The NIHSS was used to calculate 7 LVO scales (RACE, C-STAT, FAST-ED, 3I-SS, PASS, VAN, and G-FAST). Diagnostic performance was assessed by calculating sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy using the established thresholds of each scale. These results were compared to NIHSS at thresholds of 6, 8, and 10. Area under curve (AUC) was calculated using c-statistics by treating scales as continuous variables. Results: A total of 625 patients were included, 373/625 (59.7%) of which were diagnosed with AIS at discharge. LVO was identified in 78/625 (12.5%) patients. VAN was the most sensitive prehospital stroke scale (83.3%), whereas 3I-SS ≥ 4 was the most specific (95.2%). Both the RACE and FAST-ED scales demonstrated superior accuracy and AUC compared to the NIHSS (Table 1). Conclusions: To our knowledge, this is the first study assessing LVO scale accuracy in a large telestroke network. As use of prehospital telestroke grows, this study highlights several scales that may allow for faster prehospital triage decisions without sacrificing accuracy.

Abstract WP39: Subhairline Electroencephalography For Detection Of Large Vessel Occlusion Stroke

Introduction: Endovascular thrombectomy (EVT) for large vessel occlusion stroke of the anterior circulation (LVO-a) can only be performed in selected hospitals. A prehospital triage instrument with which paramedics can reliably identify patients with an LVO-a stroke would enable direct routing of these patients to the right hospital and would consequently improve patient outcome. Electroencephalography (EEG) has previously shown to discriminate between patients with and without an LVO-a stroke. In this study, the diagnostic accuracy of subhairline EEG for LVO-a stroke was evaluated. Methods: A 3-minute EEG recording was performed in 35 patients who were presented to the emergency room with a suspected stroke or known LVO-a stroke, as soon as possible after presentation, and prior to potential EVT. Recordings were performed using 9 self-adhesive electrodes placed on the forehead and behind the ears. We evaluated the diagnostic accuracies of EEG features quantifying frequency band power (relative delta, theta, alpha and lower beta powers and power ratios), brain symmetry (pairwise derived Brain Symmetry Index [pdBSI]) and connectivity (Magnitude Squared Coherence [MSC] and Weighted Phase Lag Index) for LVO-a stroke using receiver operating characteristic analysis. Optimal cut-off points were determined as the maximum sensitivity at a specificity of ≥ 80% for LVO-a stroke. Results: Median age was 75 (IQR 67-81) years and 20/35 (57%) patients were male. 13/35 (37%) patients had an LVO-a stroke, 12/35 (34%) a non-LVO-a ischemic stroke, 4/35 (11%) a transient ischemic attack and 6/35 (17%) a stroke mimic. Median onset-to-EEG-time was 250 (IQR 118-535) minutes. Recordings of all patients were of sufficient quality to calculate frequency band power and brain symmetry measures. The connectivity measures could not be calculated for 3 LVO-a stroke patients. The highest diagnostic accuracy for LVO-a stroke was reached by the MSC in the delta frequency band (AUC 0.80; sensitivity 80%; specificity 82%) and the pdBSI in the theta frequency band (AUC 0.78; sensitivity 77%; specificity 82%). Conclusions: Subhairline EEG is a promising instrument for detection of LVO-a stroke, but validation in a larger study population and in the prehospital setting is necessary.

The potential of point-of-care diagnostics to optimise prehospital trauma triage: a systematic review of literature

PurposeIn the prehospital care of potentially seriously injured patients resource allocation adapted to injury severity (triage) is a challenging. Insufficiently specified triage algorithms lead to the unnecessary activation of a trauma team (over-triage), resulting in ineffective consumption of economic and human resources. A prehospital trauma triage algorithm must reliably identify a patient bleeding or suffering from significant brain injuries. By supplementing the prehospital triage algorithm with in-hospital established point-of-care (POC) tools the sensitivity of the prehospital triage is potentially increased. Possible POC tools are lactate measurement and sonography of the thorax, the abdomen and the vena cava, the sonographic intracranial pressure measurement and the capnometry in the spontaneously breathing patient. The aim of this review was to assess the potential and to determine diagnostic cut-off values of selected instrument-based POC tools and the integration of these findings into a modified ABCDE based triage algorithm.MethodsA systemic search on MEDLINE via PubMed, LIVIVO and Embase was performed for patients in an acute setting on the topic of preclinical use of the selected POC tools to identify critical cranial and peripheral bleeding and the recognition of cerebral trauma sequelae. For the determination of the final cut-off values the selected papers were assessed with the Newcastle–Ottawa scale for determining the risk of bias and according to various quality criteria to subsequently be classified as suitable or unsuitable. PROSPERO Registration: CRD 42022339193.Results267 papers were identified as potentially relevant and processed in full text form. 61 papers were selected for the final evaluation, of which 13 papers were decisive for determining the cut-off values. Findings illustrate that a preclinical use of point-of-care diagnostic is possible. These adjuncts can provide additional information about the expected long-term clinical course of patients. Clinical outcomes like mortality, need of emergency surgery, intensive care unit stay etc. were taken into account and a hypothetic cut-off value for trauma team activation could be determined for each adjunct. The cut-off values are as follows: end-expiratory CO2: < 30 mm/hg; sonography thorax + abdomen: abnormality detected; lactate measurement: > 2 mmol/L; optic nerve diameter in sonography: > 4.7 mm.DiscussionA preliminary version of a modified triage algorithm with hypothetic cut-off values for a trauma team activation was created. However, further studies should be conducted to optimize the final cut-off values in the future. Furthermore, studies need to evaluate the practical application of the modified algorithm in terms of feasibility (e.g. duration of application, technique, etc.) and the effects of the new algorithm on over-triage. Limiting factors are the restriction with the search and the heterogeneity between the studies (e.g. varying measurement devices, techniques etc.).

Accuracy of a Prehospital Triage Protocol in Predicting In-Hospital Mortality and Severe Trauma Cases among Older Adults.

Background: Prehospital trauma triage tools are not tailored to identify severely injured older adults. Our trauma triage protocol based on a three-tier trauma severity grading system (A, B, and C) has never been studied in this population. The objective was to assess its accuracy in predicting in-hospital mortality among older adults (≥65 years) and to compare it to younger patients. Methods: A retrospective multicenter cohort study, from 2011 to 2021. Consecutive adult trauma patients managed by a mobile medical team were prospectively graded A, B, or C according to the initial seriousness of their injuries. Accuracy was evaluated using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Results: 8888 patients were included (14.1% were ≥65 years). Overall, 10.1% were labeled Grade A (15.2% vs. 9.3% among older and younger adults, respectively), 21.9% Grade B (27.9% vs. 20.9%), and 68.0% Grade C (56.9% vs. 69.8%). In-hospital mortality was 7.1% and was significantly higher among older adults regardless of severity grade. Grade A showed lower sensitivity (50.5 (43.7; 57.2) vs. 74.6 (69.8; 79.1), p < 0.0001) for predicting mortality among older adults compared to their younger counterparts. Similarly, Grade B was associated with lower sensitivity (89.5 (84.7; 93.3) vs. 97.2 (94.8; 98.60), p = 0.0003) and specificity (69.4 (66.3; 72.4) vs. 74.6 (73.6; 75.7], p = 0.001) among older adults. Conclusions: Our prehospital trauma triage protocol offers high sensitivity for predicting in-hospital mortality including older adults.

Impact of prehospital stroke triage implementation on patients with intracerebral hemorrhage.

Little is known about how prehospital triage using large vessel occlusion (LVO) stroke prediction scales affects patients with intracerebral hemorrhage (ICH). We aimed to investigate whether the Stockholm Stroke Triage System (SSTS) implemented in 2017 has affected timing and outcomes of acute ICH neurosurgery, and to assess system triage accuracy for ICH with a neurosurgical indication or LVO thrombectomy. Observational cohort study. In the Stockholm Region, we compared surgical timing, functional outcome, and death at 3 months in patients transported by code-stroke ground ambulance who had ICH neurosurgery, 2 years before versus 2 years after SSTS implementation. We also calculated triage precision metrics for treatment with either ICH neurosurgery or thrombectomy. A total of 36 patients undergoing ICH neurosurgery were included before SSTS implementation and 30 after. No significant difference was found in timing of neurosurgery [median 7.5 (4.9-20.7) versus 9.1 (6.1-12.5) h after onset], distribution of functional outcomes (median 4 versus 4), and death at 3 months [3/29 (9%) versus 5/35 (17%)] before versus after implementation, respectively. The SSTS routed a larger proportion of patients subsequently undergoing ICH neurosurgery directly to the comprehensive stroke center: 13/36 (36%) before versus 18/30 (60%) after implementation. Overall system triage accuracy for ICH neurosurgery or thrombectomy was high at 90%, with 92% specificity and 65% sensitivity. The SSTS, initially designed for prehospital LVO stroke triage, routed more patients with neurosurgical indication for ICH directly to the comprehensive stroke center. This did not significantly affect surgical timing or outcomes.

Understanding Regional Trauma Centers and managing a trauma care system in South Korea: a systematic review.

The Korean government initiated a plan to designate and establish Regional Trauma Centers to reduce the preventable trauma death rate to <20% so as to be on par with advanced countries by 2020. This initiative was undertaken because the reported preventable trauma death rate was close to 40% in South Korea from 1997 to 2009. This review aimed to provide an overview of these Regional Trauma Centers and discuss further development of the trauma care system to assess its performance. As of September 2021, 15 Regional Trauma Centers had been established through a metropolitan-based designation process. Each center has been equipped with Level-I facilities. These Regional Trauma Centers have had 2 positive effects; namely, an increase in the number of severely injured patients attending these centers and a decrease in the national preventable trauma death rate from 30.5% in 2015 to 19.9% in 2017. The establishment of Regional Trauma Centers can lead to improved performance, maximal efficiency, and reduction of preventable deaths in trauma patients. They can also play a key role in prehospital triage and transportation in the trauma care system.

The Aspects of Running Artificial Intelligence in Emergency Care; a Scoping Review.

Artificial Inteligence (AI) application in emergency medicine is subject to ethical and legal inconsistencies. The purposes of this study were to map the extent of AI applications in emergency medicine, to identify ethical issues related to the use of AI, and to propose an ethical framework for its use. A comprehensive literature collection was compiled through electronic databases/internet search engines (PubMed, Web of Science Platform, MEDLINE, Scopus, Google Scholar/Academia, and ERIC) and reference lists. We considered studies published between 1 January 2014 and 6 October 2022. Articles that did not self-classify as studies of an AI intervention, those that were not relevant to Emergency Departments (EDs), and articles that did not report outcomes or evaluations were excluded. Descriptive and thematic analyses of data extracted from the included articles were conducted. A total of 137 out of the 2175 citations in the original database were eligible for full-text evaluation. Of these articles, 47 were included in the scoping review and considered for theme extraction. This review covers seven main areas of AI techniques in emergency medicine: Machine Learning (ML) Algorithms (10.64%), prehospital emergency management (12.76%), triage, patient acuity and disposition of patients (19.15%), disease and condition prediction (23.40%), emergency department management (17.03%), the future impact of AI on Emergency Medical Services (EMS) (8.51%), and ethical issues (8.51%). There has been a rapid increase in AI research in emergency medicine in recent years. Several studies have demonstrated the potential of AI in diverse contexts, particularly when improving patient outcomes through predictive modelling. According to the synthesis of studies in our review, AI-based decision-making lacks transparency. This feature makes AI decision-making opaque.

How stroke care has changed in Slovakia in the last 5 years.

Although stroke patients in Slovakia had been treated according to European recommendations, no network of primary and comprehensive stroke centers had been officially established; the ESO recommended quality parameters had not been fulfilled. Therefore, the Slovak Stroke Society decided to change the stroke management concept and introduced mandatory evaluation of quality parameters. This article focuses on key success factors of the change in stroke management in Slovakia and presents the 5-year results and perspectives for the future. We processed data from the stroke register at the National Health Information Center, which is mandatory in Slovakia for all hospitals designated as primary and secondary stroke care centers. Since 2016, we have started to change stroke management. New National Guideline for Stroke Care was prepared in 2017 and published in 2018 as a Recommendation of the Ministry of Health of the Slovak Republic. The recommendation included pre-hospital as well as in-hospital stroke care, a network of primary stroke centers (hospitals administering intravenous thrombolysis - 37), and secondary stroke centers (hospitals treating with intravenous thrombolysis + endovascular treatment (ET) - 6). A stroke priority was instituted, having equally high priority as myocardial infarction. More efficient in-hospital workflow and pre-hospital patient triage shortened the time to treatment. Prenotification became mandatory in all hospitals. Non-contrast CT, and CT angiography is mandatory in all hospitals. In patients with suspected proximal large-vessel occlusion the EMS stays at the CT facility in primary stroke centers until the CT angiography is finished. If LVO is confirmed, the patient is transported to an EVT secondary stroke center by the same EMS. From 2019 all secondary stroke centers offer endovascular thrombectomy in a 24/7/365 system. We consider the introduction of quality control one of the most critical steps in stroke management. The result of these activities is 25.2% of patients treated with IVT and 10.2% by endovascular treatment, and median DNT 30 min. Number of patients screened for dysphagia increased from 26.4% in 2019 to 85.9% in 2020. In the most of the hospitals the proportion of ischemic stroke patients discharged with antiplatelets and in case of AF with anticoagulants was >85%. Our results indicate that it is possible to change stroke management at a single hospital and national level. For continuous and further improvement, regular quality monitoring is necessary; therefore, the results of stroke hospital management are presented regularly once a year at national and international level. Collaboration with the "Second for Life" patient organization is very important for the "time is brain" campaign in Slovakia. Due to the change in stroke management over the last 5 years, we have reduced the time for acute stroke treatment and improved the proportion of patients with acute treatment, and in this area, we have achieved and exceeded the goals of the Stroke Action Plan for Europe for 2018-2030. Nevertheless, we still have many insufficiencies in stroke rehabilitation and post-stroke nursing that need to be addressed.

An application example of translational science in disaster medicine: From grant to deliverables

The Sendai Framework for Disaster Risk Reduction 2015–2030 recognizes the importance of increasing resilience to disasters, a target that the Horizon 2020 funded project Novel Integrated Toolkit for Enhanced Pre-Hospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE) is aiming to achieve by supporting the preparedness of first responders during sudden onset disasters (SODs) and related mass casualty incidents (MCIs) through an innovative toolkit featuring different technological solutions. This manuscript aims to describe the translational science (TS) methodology adopted to guide the development of the NIGHTINGALE toolkit. The multi-stage process featured three different scoping reviews, three Modified Delphi studies and subsequent translation of consensus statements into evidence-based tools and guidelines on triage, prehospital life support and damage control interventions, and prehospital processes during SODs and MCIs. This manuscript shows the potential of the TS methodology to translate grant requirements into deliverables based on scientific evidence and a sound research approach.

Hybrid‐Mobile Stroke Unit: Opening the Indication Spectrum for Stroke Mimics and Beyond

Background Despite proven benefits, the use of single‐purpose mobile stroke units (MSUs) has raised concerns about their effective and cost‐efficient integration into clinical practice, especially when considered for operation in nonurban areas. The MSU concept may benefit from opening the indication spectrum to include frequent stroke mimics and additional emergencies. Methods The current observational study evaluated benefits for the treatment and triage decision‐making of use of an MSU with extended capabilities (Hybrid‐MSU), also including radiography, ultrasonography, extended point‐of‐care laboratory, ECG, electroencephalography, and advanced medications. Apart from patients with a dispatch code for “stroke”, the ambulance was also dispatched to those with codes for “seizures”, “falls with head trauma”, “headache”, “unconsciousness”, “infection and pandemic”, “chest pain”, and “breathing problems”. Results For 250 patients treated by the Hybrid‐MSU, but not for 250 conventionally treated patients, the prehospital diagnostic workup allowed, apart from treatment with stroke thrombolytics (n=15), prehospital administration of specific anticonvulsants (n=15), antibiotics (n=5), early secondary stroke prophylaxis with aspirin (n=49), and the Sepsis Six bundle (n=2). Prehospital diagnosis avoided 215 (86.0%) admissions to the emergency department, either by management at home (n=116, 46.4%) or by directly transferring patients to the required specialized wards (n=99, 39.6%). Conclusion The current study demonstrates the feasibility of the use of a Hybrid‐MSU and indicates its potential benefits for prehospital treatment and triage decision‐making. Opening the indication spectrum, together with an act‐alone ability, could be a key in the future integration of MSUs into routine health care.

The Saunders report into the Manchester arena attack

Journal of Paramedic PracticeVol. 14, No. 12 CommentaryThe Saunders report into the Manchester arena attackTom MallinsonTom MallinsonEmail:E-mail Address: [email protected]Lecturer, College of Remote and Offshore Medicine, MaltaSearch for more papers by this authorTom MallinsonPublished Online:6 Dec 2022https://doi.org/10.12968/jpar.2022.14.12.490AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Aldington D, Jagdish S. The fentanyl ‘lozenge’ story: from books to battlefield. J R Army Med Corps. 2014;160(2):102–104. https://doi.org/10.1136/jramc-2013-000227 Crossref, Google ScholarCarenzo L, McDonald A, Grier G. Pre-hospital oral transmucosal fentanyl citrate for trauma analgesia: preliminary experience and implications for civilian mass casualty response. Br J Anaesth. 2022;128(2):e206–e208. https://doi.org/10.1016/j.bja.2021.08.017 Crossref, Google ScholarEllerton JA, Greene M, Paal P. The use of analgesia in mountain rescue casualties with moderate or severe pain. Emerg Med J. 2013;30(6):501–505. https://doi.org/10.1136/emermed-2012-202291 Crossref, Google ScholarEvents Industry Forum. The purple guide to health, safety and welfare at music and other events. 2022. https://www.thepurpleguide.co.uk (accessed 24 November 2022) Google ScholarGrassin-Delyle S, Shakur-Still H, Picetti R et al.. Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial. Br J Anaesth. 2021;126(1):201–209. https://doi.org/10.1016/j.bja.2020.07.058 Crossref, Google ScholarJESIP. Working Together, Saving Lives. 2022. https://www.jesip.org.uk/ (accessed 28 November 2022) Google ScholarManchester Arena Inquiry. Volume 2: emergency response. 2022. https://manchesterarenainquiry.org.uk/report-volume-two (accessed 24 November 2022) Google ScholarNational Ambulance Resilience Unit. National Amnulance Resilience Unit: Preparing for the future, protecting lives today.. 2022, https://naru.org.uk/ (accessed 28 November 2022) Google ScholarOakeshott JE, Griggs JE, Wareham GM, Lyon RM; Kent Surrey Sussex Air Ambulance Trust. Feasibility of prehospital freeze-dried plasma administration in a UK helicopter emergency medical service. Eur J Emerg Med. 2019;26(5):373–378. https://doi.org/10.1097/MEJ.0000000000000585 Crossref, Google ScholarPark CL, Langlois M, Smith ER et al.. How to stop the dying, as well as the killing, in a terrorist attack. BMJ. 2020;368:m298. https://doi.org/10.1136/bmj.m298 Crossref, Google ScholarVassallo J, Moran CG, Cowburn P, Smith J. New NHS prehospital major incident triage tool: from MIMMS to MITT. Emerg Med J. 2022;39(11):800–802. https://doi.org/10.1136/emermed-2022-212569 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 December 2022Volume 14Issue 12ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 6 December 2022 Published in print 2 December 2022 Information© MA Healthcare LimitedPDF download

Do direct admissions to trauma centers have a survival benefit compared to inter-hospital transfers in severe trauma?

To compare mortality among severe and critically injured patients who were directly admitted (DA) to level I trauma center (TCI) or level II trauma center (TCII) with those who were transferred to a TCI after being initially admitted to a TCII. A cohort study of severe and critically injured patients (Injury Severity Score 16-75) hospitalized between 2010 and 2019 using data from the National Program for Trauma Registration. Multivariate logistic regression models estimated mortality risk, including stratified analyses. Of the 27,131 hospitalizations, 9.5% were transfers, 60.1% were DA to TCI and 30.4% were DA to TCII. Children ages ≤ 17years, Non-Jews (minority), critical injuries (ISS 25-75), head injuries (AIS ≥ 3) and fall injuries were significantly more frequent among transfers, compared with the DA groups. Evacuation by emergency medical services was less frequent among transfers. After accounting for possible confounders, transfers had a greater risk of in-hospital mortality [DA to TCI vs transfer, OR (95% CI) 0.61 (0.52-0.72); DA to TCII vs transfer, OR (95% CI) 0.78 (0.65-0.94)]. In stratified analyses, these mortality differences persisted among the sub-group of patients who sustained critical injuries, among the patients with non-penetrating injuries, among the elderly ages ≥ 65year and during the first 2weeks of hospitalization. This study has intervention implications that should be directed primarily at prehospital triage and the inter-hospital transfer processes. In addition, there may be a need to optimize the capabilities of regional trauma systems along with continuous performance evaluations and actions as required.