Rural Emergency Medical Services Research Articles

Burden of Non-Protocolized Patient Transport Outside of Response Area on a Rural Emergency Medical Services System

Objectives Transport destination decisions by prehospital personnel depend on a combination of protocols, judgment, patient acuity, and patient preference. Non-protocolized transport outside the service area may result in unnecessary time out of service and inappropriate resource utilization. Scant research exists regarding clinician rationale for destination decisions. Methods We retrospectively reviewed one year of scene transports by a single rural, hospital-based emergency medical services (EMS) system. We collected dispatch, patient demographic, primary impression, and transport data from prehospital records and matched them to emergency department (ED) data. We characterized rationale for transport decisions and compared rates of hospital admission and specialist consultation in the ED as surrogates for decision appropriateness. Results We reviewed 2,223 patient transports, 281 of which were transported out of the service area. The most common reasons for out-of-area transport were patient preference NOT related to prior medical care (40%) and clinician judgment (24%). Admit rates were highest for per protocol (85%) and patient preference related to prior medical care (67%) groups and lowest for no explanation (41%) and clinician judgment (47%) groups. Rates of in person specialist consultation in the ED were highest in per protocol (69%) and clinician judgment (47%) groups and lowest in no explanation (23%) and patient preference NOT related to prior medical care (30%) groups. Clinician judgment was less predictive of admission and specialist consultation for non-trauma and pediatric patients than for all patients. Median time out of service was more than twice as long for out-of-area transports (140 min) compared to patients transported to the nearest facility (62 min). For out-of-area transports discharged from the ED without specialty consultation (n = 104), ambulances traveled an additional 52 miles/patient compared to theoretical transport to nearest facility. Conclusions Unit out of service time more than doubled for non-protocolized transports outside of the service area and rationale for destination decisions variably predicted admission and specialist consultation rates. Patient preference NOT related to prior medical care and, in pediatric and non-trauma populations, clinician judgment, were less predictive of admission and specialist consultation. Transport guidelines should balance rationale for transport destination and patient characteristics with resource preservation, especially in low-resource systems.

Telemedical Direction to Optimize Resource Utilization in a Rural Emergency Medical Services System.

Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers. This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality. The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019-September 10, 2020) and the post-implementation period (September 11, 2020-December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45-2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as "good." In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as "good."

A retrospective analysis of the need for on-site emergency physician presence and mission characteristics of a rural ground-based emergency medical service

BackgroundThis study aimed to address the challenges faced by rural emergency medical services in Europe, due to an increasing number of missions and limited human resources. The primary objective was to determine the necessity of having an on-site emergency physician (EP), while the secondary objectives included analyzing the characteristics of rural EP missions.MethodsA retrospective study was conducted, examining rural EP missions carried out between January 1st, 2017, and December 2nd, 2021 in Burgenland, Austria. The need for physical presence of an EP was classified based on the National Advisory Committee for Aeronautics (NACA) score into three categories; category A: no need for an EP (NACA 1–3); category B: need for an EP (NACA 1–3 along with additional medical interventions beyond the capabilities of emergency medical technicians); and category C: definite need for an EP (NACA 4–7). Descriptive statistics were used for analysis.ResultsOut of 16,971 recorded missions, 15,591 were included in the study. Approximately 32.3% of missions fell into category A, indicating that an EP’s physical presence was unnecessary. The diagnoses made by telecommunicators matched those of the EPs in only 52.8% of cases.ConclusionThe study suggests that about a third of EP missions carried out in rural areas might not have a solid medical rationale. This underscores the importance of developing an alternative care approach for these missions. Failing to address this could put additional pressure on already stretched EMS systems, risking their collapse.

Emergency Medical Service Transport Time in Rural Farm and Non-Farm Pediatric Trauma

ABSTRACT Objectives Pediatric farm injuries tend to be more severe and have poorer outcomes compared to injuries sustained in non-farm settings. Timely emergency medical service (EMS) response and transport to definitive care is crucial for optimizing outcomes for trauma patients. We aimed to determine if pediatric farm injuries were associated with longer EMS response and transport times compared to pediatric non-farm injuries in rural communities. Methods The 2021 National EMS Information System (NEMSIS) database was used to identify rural EMS activations where injured pediatric patients who were transported to a hospital. Median transport times for farm and non-farm injuries, as well as other components of prehospital time and use of air EMS transport, were compared between injuries on farms and injuries in non-farm rural settings. Results The analytic sample included 22,248 rural EMS activations for pediatric injuries, of which 156 (1%) were for pediatric farm injuries. For non-farm and farm injuries, the median transport times were 20 minutes and 28 minutes, respectively. Median total prehospital time was 50 minutes compared to 62 minutes, and 9.8% of patients with non-farm injuries versus 20.5% of those with farm injuries were transported to a hospital by air EMS units. After multivariable adjustment, farm vs. non-farm injury location was associated with a 4 minute increase in EMS transport time, but no difference in initial EMS response time, EMS time on scene, or use of air EMS units. Conclusion Among children sustaining an injury that resulted in rural EMS activation, farm injuries were associated with prolonged transport time compared to non-farm injuries, which may contribute to worse in-hospital outcomes described to pediatric farm injuries in prior research.

Rural-urban differences in emergency medical services bypass routing of stroke in North Carolina.

Acute stroke is a serious, time-sensitive condition requiring immediate medical attention. Emergency medical services (EMS) routing and direct transport of acute stroke patients to stroke centers improves timely access to care. This study aimed to describe EMS stroke routing and transports by rurality in North Carolina (NC). We conducted a retrospective study using existing data on EMS transports of suspected stroke patients in NC in 2019. The primary study outcome was EMS bypass of the nearest hospital for transport to a nonnearest hospital, determined by geographic information systems (GIS) analysis. Incident addresses were geocoded to census tracts and classified as urban, suburban, or rural by Rural-Urban Commuting Area codes. We compared the frequency of bypass and estimated additional transport times by urban, suburban, and rural incident locations. Of 3666 patients, 1884 (51%) EMS transports bypassed the nearest hospital. Bypass occurred less often for rural EMS incidents (39%) compared to those in urban (57%) and suburban (63%) tracts. The estimated additional transport time for rural bypasses of nonendovascular-capable stroke centers for endovascular-capable stroke centers was a median of 25min (interquartile range 13-33). Using GIS analysis, we found nearly half of EMS transports of suspected stroke patients in NC bypassed the nearest hospital, including noncertified hospitals and stroke centers. Bypasses occurred less often in rural areas, though incurred significantly longer transport times, compared to urban areas. These findings are important for regional stroke system planning, especially for improving rural access to acute stroke care.

Rural Emergency Medical Services Clinicians’ Perceptions and Preferences in Receiving Clinical Feedback From Hospitals: A Qualitative Needs Assessment

Objective Emergency medical services (EMS) clinicians experience dissatisfaction with the quality and quantity of clinical feedback from hospitals. Satisfaction is further diminished by the lack of a standardized systems approach. The purpose of this study was to identify rural clinicians’ perceptions and preferences regarding clinical feedback received from hospitals, the delivery mechanisms, and its impact on their relationships with health care organizations. Methods This was a qualitative study focused on EMS clinicians involved in rural prehospital care at a single Midwestern academic medical center. Using a phenomenological framework, semi-structured interviews were conducted with medical directors, service directors, fire captains, air medical personnel, emergency medical responders, emergency medical technicians, advanced emergency medical technicians, and paramedics, all of whom were selected through purposive sampling. Interviews were recorded, transcribed, and independently coded by two trained reviewers. Results Twenty participants (11 frontline clinicians and 9 administrative staff members) with a wide range of clinical experience from 14 air and ground EMS agencies were interviewed. Emerging themes included: (1) the value or usefulness of feedback; (2) desired feedback system characteristics; (3) barriers to receiving feedback; (4) utilization and application of feedback; and (5) the feedback’s impact on the relationship with health care organizations. Participants felt that clinical feedback from hospitals was especially important as a method of improving quality of care, though was rarely provided. Professional development was seen as a major benefit of receiving clinical feedback from hospitals. Conclusion Our results suggest that consistent clinical feedback provided by hospitals was valued. Establishing a culture of providing organized feedback to practicing rural EMS clinicians is important for professional development and can strengthen the relationships between EMS clinicians and hospitals. These study findings can assist in the development and implementation of a standardized feedback instrument to benefit rural EMS clinicians, patients, and the health care system as a whole.

Comparison of Palliative Knowledge and Self-Efficacy Expectation of German Paramedics Between a Rural and an Urban Structured Emergency Medical Service Area.

Differences in the German emergency medical service (EMS) can be seen in the countryside in contrast to the city with regard to travel distances to hospitals and in the access routes of EMS-physicians. In order to investigate the success of establishment of palliative crisis cards associated with training and the rural and urban EMS structures, two urban and two rural EMS areas were compared using the Paramedic Palliative Care Test (PARPACT). Methods: The PARPACT includes test items on palliative knowledge (PK, maximum score: 15 points) and palliative self-efficacy expectations (PSE, maximum score: 18 points), as well as items on palliative attitudes in dealing with palliative care patients. We used a 4-point Likert-type scale. For data analysis, nonparametric tests (χ-test and Mann-Whitney U test) were used in addition to descriptive analysis (frequencies, means, medians, standard deviations, and ranges). Results: In total, 291 out of 750 ambulance or EMS personnel participated in the voluntary survey. Rural ambulance or EMS personnel answered the PK-questions correctly more often on average (mean: 11.19, SD: 1.85) than urban ambulance or EMS personnel (mean: 9.18, SD: 2.39; Mann-Whitney U test: U=5040.000, P=.001). In addition, ambulance or EMS personnel with the highest level of training (3-year-trained paramedics) performed better in PK (mean: 10.38, SD: 2.31) than less intensively training ambulance or EMS personnel (mean: 9.58, SD: 2.43; Mann-Whitney U-test: U=8446.500, P=.004). In terms of PSE, rural ambulance or EMS personnel also achieved higher mean PSE-scores (mean: 12.55, SD: 2.60) than urban ambulance or EMS personnel (mean: 9.77, SD: 3.41; Mann-Whitney U-test: U=5148.500, P=.001). Conclusions: Better training in the EMS is associated with improved PK compared to less qualified nonphysician EMS staff. The establishment of palliative crisis cards and the structures in the city alone do not lead to improved knowledge and PSE.

Abstract 410: Differences in Survivability of Out-of-Hospital Cardiac Arrest in Rural versus Urban Minnesota

Background: Out-of-Hospital Cardiac Arrest (OHCA) survival has improved in North America due to improved awareness, training, and bystander CPR. An important factor complicating OHCA survival is location on initial arrest, due to distance and access to emergency medical services (EMS). Aims: We sought to examine characteristics of OHCA encounters in Minnesota and determine underlying factors for differences in OHCA survival in rural versus urban areas. Methods: We examined data from the Cardiac Arrest Registry to Enhance Survival (CARES) registry between 2013-2021 in Minnesota. The analyses included encounters from 31 EMS services across the state. The Office of Management and Budget (OMB) county rural-urban classification schema was used to designate categories of rural (non-metropolitan counties of less than 50,000 population) versus urban (metropolitan counties with populations of 50,000 or more). Results: We identified 21,257 patient encounters, of which 3,524 (16.6%) of encounters were designated as rural and 17,733 (83.4%) as urban. In our cohort, patients were predominately male. Rural arrest patients tended to be older (mean age, 64.5 vs 60.6 years, p<0.01) and had a higher prevalence of heart disease (32.2% vs 26.9%, p<0.01). Rural arrests were more likely to be witnessed (57.1% vs 51.6%, p<0.01), receive bystander CPR (42.3% vs 35.2%, p<0.01), and have AED use prior to EMS arrival (55.7% vs 53.5%, p<0.01). The average time for EMS arrival at scene of arrest was longer among rural encounters (12.9 vs 10.6 minutes; p<0.01). Overall, survival-to-discharge was significantly lower among rural versus urban communities (9.3% vs 13.1%, p<0.01). Conclusion: In this analysis of the CARES dataset in Minnesota, there were significant differences in survival characteristics between rural vs urban OHCA patients. These findings warrant greater investment in rural EMS agencies and modifiable resuscitation practices to improve survival among rural communities.

Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST-elevation myocardial infarction.

ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients. We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death. Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%). Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min.

Prehospital Surgical Airway Management Skills in a Rural Emergency Medical Service System.

The objective of this study is to describe the education, training, and use of prehospital surgical airways in a rural Emergency Medical Service (EMS) system. We conducted an internet-based survey instrument of all advanced life support (ALS) EMS agencies in a seven-county rural EMS system in Pennsylvania. ALS agencies were queried regarding basic demographic information as well as the number of surgical airways performed in the previous 10 years as well as the education and training of EMS providers in surgical airways. The survey was completed by 11 of 20 ALS EMS agencies in our region (55% rate of return). The content and frequency of training varied considerably among EMS agencies. Only four prehospital surgical airways were performed during the study period. One patient survived to hospital discharge to home. Surgical airways are an infrequently performed procedure in the rural prehospital setting.There is no universally accepted standard for teaching or evaluating the competency of this potentially life-saving procedure. Further efforts to establish a core educational curriculum appear warranted.

‘On the inside I’m grossed out and wanting to puke’: Exploring professional facework and emotional labour as impression management tools in rural emergency medical services

Abstract In the foothills of rural Appalachia, situations arise where emergency medical services (EMS) providers—such as paramedics and emergency medical technicians—must reflect professionalism in their ‘face’. However, as EMS providers practice facework in their organizational roles, it is important to consider how they manage professionalism when emotional labour and dirty work are required, such as when supporting patients from underserved rural communities. Guided by 181 hours of participant observation with 23 interviews with EMS providers from two county-wide EMS organizations, this organizational ethnography reveals the value of impression management strategies in the form of emotional labour. Notably, such practices aid in EMS providers’ maintenance of professional face as they encounter face threats on the job. In such moments, EMS providers utilize emotional labour in their corrective and preventive facework. Importantly, this research makes a meaningful theoretical and practical contribution to organizational communication by illustrating the value of impression management, emotional labour, and facework that aid in the management of professionalism.

Virtual Rural Trauma Team Development Course: Trying to Zoom in on a Solution.

The COVID-19 pandemic prevented centers from providing in-person interactive training programs such as the Rural Trauma Team Development Course. Adapting the course to a virtual platform is an option, yet little is known regarding the feasibility of using this format. This study aimed to evaluate the feasibility of providing a virtual rural trauma development course during COVID-19. This is a descriptive study of emergency medical technicians, nurses, emergency department technicians, and physicians from four rural community health care facilities and local emergency medical services who participated in a virtual Rural Trauma Team Development Course held in November 2021 which was transformed into a virtual platform using live remote interactive lectures, recorded case-based scenarios, and interactive virtual-based questions. The course was evaluated by the changes instituted at the centers based on program recommendations and a participant survey. A total of 41 participants were studied, of whom 31 (75%) returned the emailed postprogram survey. The majority (>75%) of respondents rated the activity as very good, with course objectives met. All four facilities instituted changes following the program, including enhancing policy and procedures, guidelines, advancing performance improvement triggers, and equipment acquisition. Individual-reported participant satisfaction was very high. The Rural Trauma Team Development Course can be provided virtually and is a feasible option for trauma centers to provide initial trauma management in the rural community in a safe pandemic-restrictive atmosphere.

Modernizing payment to critical access hospitals: A proposal for the next iteration of the Flex Program.

Modernizing payment to critical access hospitals: A proposal for the next iteration of the Flex Program.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review.

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

A Partnership Between Rural EMS and AT&T FirstNet to Provide Tele-emergency Care.

This report from the field describes a partnership between an academic medical center emergency department, rural emergency medical services, and AT&T FirstNet, a nationwide high-speed broadband network for public safety, to pilot-test clinical consults via telemedicine in a medically underserved area. We describe the methods, outcomes, and implications for practice.

Prehospital portable ultrasound for safe and accurate prehospital needle thoracostomy: a pilot educational study

BackgroundSimulated needle thoracostomy (NT) using ultrasound may reduce potential injury, increase accuracy, and be as rapid to perform as the traditional landmark technique following a brief educational session. Our objective was to determine if the use of an educational session demonstrating the use of handheld ultrasound to Emergency Medical Services (EMS) staff to facilitate NT was both feasible, and an effective way of increasing the safety and efficacy of this procedure for rural EMS providers.MethodsA pre/post-educational intervention on a convenience sample of rural North American EMS paramedics and nurses. Measurement of location and estimated depth of placement of needle thoracostomy with traditional landmark technique was completed and then repeated using handheld ultrasound following a training session on thoracic ultrasound and correct placement of NT.ResultsA total of 30 EMS practitioners participated. Seven were female (23.3%). There was a higher frequency of dangerous structures underlying the chosen location with the landmark technique 9/60 (15%) compared to the ultrasound technique 1/60 (1.7%) (p = 0.08). Mean time-to-site-selection for the landmark technique was shorter than the ultrasound technique at 10.7 s (range 3.35–45 s) vs. 19.9 s (range 7.8–50 s), respectively (p < 0.001). There was a lower proportion of correct location selection for the landmark technique 40/60 (66.7%) when compared to the ultrasound technique 51/60 (85%) (p = 0.019). With ultrasound, there was less variance between the estimated and measured depth of the pleural space with a mean difference of 0.033 cm (range 0–0.5 cm) when ultrasound was used as compared to a mean difference of 1.0375 cm (range 0–6 cm) for the landmark technique (95% CI for the difference 0.73–1.27 cm; p < 0.001).ConclusionsTeaching ultrasound NT was feasible in our cohort. While time-to-site-selection for ultrasound-guided NT took longer than the landmark technique, it increased safe and accurate simulated NT placement with fewer identified potential iatrogenic injuries.

Emergency medical services in rural and urban Saudi Arabia: A qualitative study of Red Crescent emergency personnel' perceptions of workforce and patient factors impacting effective delivery.

Individuals who experience a traumatic injury or an acute illness are often reliant on initial healthcare assessment and support from a pre-hospital emergency medical service (EMS). These community-based support models perform a vital role in the provision of life-saving support, but research indicates that the availability, accessibility and resources of EMS are not equivalent in rural and urban areas, and there has been little recognition of the issues facing rural EMS provision outside of the USA, Europe and Australia. The purpose of the current study was to examine the lived experiences of Saudi Arabian EMS personnel, defined as emergency medical technicians, paramedics and local station managers. A semi-structured interview approach was used to collect data from 20 interviewees (10 each with rural and urban personnel) in the Riyadh region of the Kingdom of Saudi Arabia. This methodology was used to identify the key issues that these staff face in their day-to-day work practice and ascertain factors that may lead to service delivery issues in rural and urban areas. Data analyses identified three thematic categories impacting EMS delivery; two of these, Personnel Factors and Patient Factors, are the focus of this paper. The participants noted a number of key issues, including a lack of appropriate local training and limited resources in rural areas, as well as general areas of concern regarding the wider EMS staff demographic makeup and poor public awareness about the exact role of the EMS. Three key recommendations arising from this study include specialised training and ongoing accessible education for rural EMS staff to allow for better support for patients; consideration of supplementing the current EMS with additional external specialist staff; and the development and implementation of national public education programmes focusing on the role of the EMS within the community.

The Use of Portable Oxygen Concentrators in Low-Resource Settings: A Systematic Review.

Portable oxygen concentrators (POCs) are medical devices that use physical means to separate oxygen from the atmosphere to produce concentrated, medical-grade gas. Providing oxygen to low-resources environments, such as austere locations, military combat zones, rural Emergency Medical Services (EMS), and during disasters, becomes expensive and logistically intensive. Recent advances in separation technology have promoted the development of POC systems ruggedized for austere use. This review provides a comprehensive summary of the available data regarding POCs in these challenge environments. PubMed, Google Scholar, and the Defense Technical Information Center were searched from inception to November 2021. Articles addressing the use of POCs in low-resource settings were selected. Three authors were independently involved in the search, review, and synthesis of the articles. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. The initial search identified 349 articles, of which 40 articles were included in the review. A total of 724 study subjects were associated with the included articles. There were no Level I systematic reviews or randomized controlled trials. Generally, POCs are a low-cost, light-weight tool that may fill gaps in austere, military, veterinary, EMS, and disaster medicine. They are cost-effective in low-resource areas, such as rural and high-altitude hospitals in developing nations, despite relatively high capital costs associated with initial equipment purchase. Implementation of POC in low-resource locations is limited primarily on access to electricity but can otherwise operate for thousands of hours without maintenance. They provide a unique advantage in combat operations as there is no risk of explosive if oxygen tanks are struck by high-velocity projectiles. Despite their deployment throughout the battlespace, there were no manuscripts identified during the review involving the efficacy of POCs for combat casualties or clinical outcomes in combat. Veterinary medicine and animal studies have provided the most robust data on the physiological effectiveness of POCs. The success of POCs during the coronavirus disease 2019 (COVID-19) pandemic highlights the potential for POCs during future mass-casualty events. There is emerging technology available that combines a larger oxygen concentrator with a compressor system capable of refilling small oxygen cylinders, which could transform the delivery of oxygen in austere environments if ruggedized and miniaturized. Future clinical research is needed to quantify the clinical efficacy of POCs in low-resource settings.

A Multi-Objective Optimization Approach for Emergency Medical Service Facilities Location-Allocation in Rural Areas.

PurposeThe location of emergency medical service (EMS) facilities is a basic facility location problem. Many scholars have examined this kind of problem, but research on the location of EMS facilities in rural areas is still lacking. Different from urban areas, the location optimization of EMS facilities in rural areas must consider the accessibility of roads. The objective of this study conducted the optimal locations of new EMS stations and construction/upgrading of transfer links aiming to improve the medical emergency efficiency of mountain rural areas.MethodsThree multi-objective models were constructed to examine the effects of varying assumptions (suppose existing roads cannot be upgraded, existing roads can be upgraded, and existing roads can be upgraded and new roads can be constructed) about minimizing the population considered uncovered (response time from the residential to the EMS station less than or equal to 0.5 h), time spent traveling from the residential area to the EMS station, construction costs for building new emergency facilities, and costs for improving or building new roads. Furthermore, we developed an improved multi-objective simulated annealing algorithm to examine the problem of optimizing the design of rural EMS facilities.ResultsWe tested the models and algorithm on the Miao Autonomous County of Songtao, Guizhou Province, China. According to the actual situation of the case area, the models and algorithm were tested with the assumption that only three new EMS stations would be constructed. The number of people not covered by EMS stations decreased from 30.7% in Model 1 to 22% in Model 2, and then to 18.9% in Model 3.ConclusionOur study showed that the traffic network had a significant impact on the location optimization of EMS stations in mountainous rural areas. Improving the traffic network conditions could effectively improve the medical emergency efficiency of mountain rural areas.

Rural Emergency Medical Services Training Grant (SAMHSA)

Rural Emergency Medical Services Training Grant (SAMHSA)