Time-critical Interventions Research Articles

Barriers and facilitators when seeking healthcare for septic children in Ghana: a single-centre qualitative study of patient caregivers and emergency department clinicians

Background/purposeSepsis is a leading cause of morbidity, mortality and healthcare utilisation for children worldwide, particularly in resource-limited regions. In Kumasi, Ghana, organ system failure and mortality in children who present...

The impact of using time critical intervention-based dispatch thresholds on lowering lights and siren use to EMS 911 incidents.

Emergency Medical Services (EMS)has historically utilized lights and sirens (L&S) to respond to 911 incidents. L&S are used in 86% of scene responses nationally; however, time critical interventions (TCIs) occur in less than 7% of these incidents. Responses with L&S are associated with increased risk of crashes and injuries. Our objective was to determine the impact of TCI-based dispatch thresholds on L&S use, dispatch accuracy, and response times. We performed a before-after retrospective evaluation of TCI-based dispatch methodology at a suburban EMS system. We categorized all EMS interventions as TCI or not, and we determined a TCI threshold above which we would use L&S. We then assigned response priorities to each call nature based on the proportion of TCIs within them. We compared historical results with those from the 6 months following implementation in terms of L&S use, dispatch accuracy, and response times. There were 13,879 responses in the "before" group and 14,117 in the "after" group. The rate of L&S use decreased from 56.2% in the before group to 27.6% in the after group, while TCIs were performed in 6.9% of responses in the before group and 7.6% in the after group. Accuracy increased from 48.8% to 75.1% and median response time increased by 0.1 min from 8.3 to 8.4 min. Using TCI-based dispatch thresholds, we decreased L&S use and increased accuracy with minimal increased response time. Our results support the use of this methodology to determine EMS response modes.

Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes

Objectives Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. Methods This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). Results Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. Conclusions In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Cis-lunar and surface missions: Health risks and potential surgical conditions

The next goal of human space exploration is to return to the Moon to stay, and to establish a new, more advanced space station in lunar orbit: the ‘Lunar Gateway’. The authors aim to contribute to this goal through undertaking an ongoing comprehensive survey of relevant published scientific literature to seek information regarding the risk of medical conditions that might require operative or non-operative surgical solutions during long-duration spaceflight. The intended outcome is to create a roadmap for future mission planning. To date, we have identified more than 50 such potential surgical conditions. Based on disease severity and mission duration, these can be classified into: (Category 1) Time-critical conditions requiring immediate surgery; (Category 2) Urgent surgical conditions requiring minor temporising surgical intervention or conservative care (these patients can return to Earth for definitive treatment); or (Category 3) Non-urgent, as these conditions do not require immediate surgical intervention, and definitive treatment can be delayed. The proposed Lunar Gateway will be an international collaboration. Reaching Gateway is anticipated to take around three days. Gateway will operate in microgravity conditions, and include a communications lab (ground support from Earth is still available with minimal signal delay), a scientific lab, and a habitat for astronauts. Transfers to and from the lunar surface will allow astronauts to undertake extra-vehicular activities (EVA). Habitation on Gateway will present similar physiological and psychological challenges as experienced on the International Space Station (ISS), with the addition of a slightly increased communications lag. The Moon is only within Earth's magnetosphere for approximately 25 % of the time, which will increase space radiation exposure compared to the ISS. Gravitational conditions will range from microgravity on Gateway to ⅙ of the Earth's gravity on the lunar surface. Considering the duration and distance necessary in order to undertake a lunar mission, time-critical surgical interventions (Category 1) will likely be necessary, such as treating a bowel perforation, or fixation for musculoskeletal trauma. For urgent conditions (Category 2), antibiotic treatment of responsive appendicitis, drainage of uncomplicated cholecystitis, or other conservative measures might be acceptable as a temporising measure. If a return to Earth is possible within three days, delayed surgery can be undertaken if the conservative measures are unsuccessful, or the condition recurs. In the case of non-urgent procedures that can be delayed (Category 3), planned evacuation to Earth is expected to be available, for example, if a malignancy develops or is detected. Anticipating the medical and surgical challenges a lunar mission presents, and subsequent adequate planning and preparation for possible surgical emergencies, will help ensure mission success. Creating a system for triaging of surgical cases will be paramount in order to guide appropriate management.

Training for endovascular therapy of acute arterial disease and procedure-related complication: An extracorporeally-perfused human cadaver model study.

The aim of this study was to evaluate the usability of a recently developed extracorporeally-perfused cadaver model for training the angiographic management of acute arterial diseases and periprocedural complications that may occur during endovascular therapy of the lower extremity arterial runoff. Continuous extracorporeal perfusion was established in three fresh-frozen body donors via inguinal and infragenicular access. Using digital subtraction angiography for guidance, both arterial embolization (e.g., embolization using coils, vascular plugs, particles, and liquid embolic agents) and endovascular recanalization procedures (e.g., manual aspiration or balloon-assisted embolectomy) as well as various embolism protection devices were tested. Furthermore, the management of complications during percutaneous transluminal angioplasty, such as vessel dissection and rupture, were exercised by implantation of endovascular dissection repair system or covered stents. Interventions were performed by two board-certified interventional radiologists and one resident with only limited angiographic experience. Stable extracorporeal perfusion was successfully established on both thighs of all three body donors. Digital subtraction angiography could be performed reliably and resulted in realistic artery depiction. The model allowed for repeatable training of endovascular recanalization and arterial embolization procedures with typical tactile feedback in a controlled environment. Furthermore, the handling of more complex angiographic devices could be exercised. Whereas procedural success was be ascertained for most endovascular interventions, thrombectomies procedures were not feasible in some cases due to the lack of inherent coagulation. The presented perfusion model is suitable for practicing time-critical endovascular interventions in the lower extremity runoff under realistic but controlled conditions.

Predicting Hypoxia Using Machine Learning: Systematic Review.

Hypoxia is an important risk factor and indicator for the declining health of inpatients. Predicting future hypoxic events using machine learning is a prospective area of study to facilitate time-critical interventions to counter patient health deterioration. This systematic review aims to summarize and compare previous efforts to predict hypoxic events in the hospital setting using machine learning with respect to their methodology, predictive performance, and assessed population. A systematic literature search was performed using Web of Science, Ovid with Embase and MEDLINE, and Google Scholar. Studies that investigated hypoxia or hypoxemia of hospitalized patients using machine learning models were considered. Risk of bias was assessed using the Prediction Model Risk of Bias Assessment Tool. After screening, a total of 12 papers were eligible for analysis, from which 32 models were extracted. The included studies showed a variety of population, methodology, and outcome definition. Comparability was further limited due to unclear or high risk of bias for most studies (10/12, 83%). The overall predictive performance ranged from moderate to high. Based on classification metrics, deep learning models performed similar to or outperformed conventional machine learning models within the same studies. Models using only prior peripheral oxygen saturation as a clinical variable showed better performance than models based on multiple variables, with most of these studies (2/3, 67%) using a long short-term memory algorithm. Machine learning models provide the potential to accurately predict the occurrence of hypoxic events based on retrospective data. The heterogeneity of the studies and limited generalizability of their results highlight the need for further validation studies to assess their predictive performance.

Questioning approaches to consent in time critical obstetric trials: findings from a mixed-methods study

ObjectiveTrial legislation enables research to be conducted without prior consent (RWPC) in emergency situations, yet this approach has rarely been used in time-critical obstetric trials. This study explored views and...

Time is brain, so we must BEFAST: Improving stroke identification and triage in a rural emergency department.

Shoalhaven District Memorial Hospital is a rural (MM3) secondary hospital which is over an hour travel time from the nearest tertiary centre. The objective of the present study was to pilot the implementation of the BEFAST (Balance, Eyes, Face, Arms, Speech and Time) stroke screening tool at the ED, and determine whether its usage improved timely stroke detection. During initial implementation and training (October-December 2019), triage nurses consulted with senior medical officers before activating stroke calls. Data were collected for the subsequent 24 months (January 2020-2022), and retrospective records for confirmed strokes during a 24-month period prior to BEFAST implementation (October 2017-2019) were also collected. The main outcome measures were triage category, CT scan result time, discharge destination, length of stay (LOS) and Modified Rankin Score (MRS). After BEFAST implementation, patients (n = 268) were three times more likely to be triaged at category 1 or 2, and door-to-CT scan time was reduced by 20.7 min on average. More patients were discharged to their usual residence and more quickly (LOS 7.9 vs 11.1 days). MRS 90 days after stroke was less, and patients were nearly twice as likely to experience an improvement in neurological symptoms. Patient outcomes were improved after implementation of the BEFAST stroke triage tool. More stroke patients were identified upon presentation to the ED, and in a timely fashion. For those with a stroke diagnosis, time-critical interventions can take place earlier, allowing patients to return home sooner, and with less disability.

Stakeholders’ perspectives on clinical trial acceptability and approach to consent within a limited timeframe: a mixed methods study

ObjectivesThe Bronchiolitis Endotracheal Surfactant Study (BESS) is a randomised controlled trial to determine the efficacy of endo-tracheal surfactant therapy for critically ill infants with bronchiolitis. To explore acceptability of BESS,...

The value of shock index, modified shock index and age shock index to predict mortality and hospitalisation in a district level emergency centre

IntroductionTriage is the most important step in patients’ journey through an Emergency Centre (EC) and directly impacts time to critical actions. Triage tools, like the South African Triage Scale, are however not designed to predict patient outcomes. The shock index (SI), modified shock index (MSI) and age shock index (ASI) are clinical markers derived from vital signs and correlate with tissue perfusion in critically ill patients. This study aimed to assess the value of SI, MSI and ASI to predict mortality and the need for hospitalisation in all adult patients presenting to a district level emergency centre in South Africa. MethodsThis diagnostic study was performed as a retrospective observational study, using data from an existing electronic registry at a district level hospital emergency centre over a period of 24 months. All adult patients who presented to Mitchells Plain Hospital were eligible for inclusion. Sensitivity, specificity and likelihood ratios were calculated for each variable as a predictor of mortality and hospitalisation with pre-determined thresholds. ResultsDuring the study period of 24 months, a total of 61 329 patients ≥ 18 years old presented to the EC with 60 599 included in the final sample. A red SATS triage category (+LR = 7.2) and SI ≥1.3 (+LR = 4.9) were the only two predictors with any significant clinical value. The same two markers performed well for both patients with and without trauma and specifically for patients who died while under the care of the emergency centre. DiscussionThe study demonstrated that patients with a SI≥1.3 at triage have a significantly higher likelihood to die or require hospitalisation, whether the presenting complaint is trauma related or not, especially to predict mortality while under the care of the EC. Incorporating this marker as a triage alert could expedite the identification of patients requiring time critical interventions and improve patient throughput in the emergency centre.

613 The Use of an Online Sepsis Screening Tool to Improve the Initial Management of Sepsis

Abstract Aim The aim of the project was to improve the adherence to sepsis management guidelines in Trauma and Orthopaedic patients through the use of an online Sepsis Screening Tool (SST). This was created to increase recognition of the early signs of sepsis to guide time critical interventions thus improving patient care. Method A retrospective audit of adult Trauma and Orthopaedic inpatients with a NEWS2 score of over 5, or 3 in one parameter, or a new suspected infection within a seven-day period was conducted in July 2020, March 2021 and August 2021 for each audit cycle respectively. We then assessed whether the SST and time critical interventions had been completed. Results After the initial audit in July 2020 showed the use of the SST and achievement of time critical interventions was poor, we introduced several interventions including information posters, and sepsis teaching for junior doctors. Further interventions were implemented after repeat audit cycles, including the incorporation of the SST within daily nursing safety huddles. By August 2021 the use of the SST had increased from 10% to 54%. This was associated with improved adherence to the sepsis management guidelines including correct observation frequency and medical review within 1 hour. Communication of a sepsis diagnosis to patients and family members also improved. Conclusions The completion of the SST increased adherence to sepsis management guidelines in our patients. We therefore recommend the use of Sepsis Screening Tools to identify patients at risk of sepsis and to improve their initial management.

Acceptability of Australian prehospital care quality indicators: An explanatory sequential mixed methods study

Background Systematically developed quality indicators (QIs) facilitate the measurement and monitoring of quality of care and ultimately meaningful quality improvement. The aim of this study was to evaluate the acceptability of a predetermined suite of 84 scientifically valid prehospital care QIs from the provider perspective. Methods An explanatory sequential mixed methods study design was used. Quantitative data were obtained from 36 participants of an online survey in which they rated the acceptability of the QIs using a five-point numerical rating scale. Qualitative data were gathered by conducting semi-structured interviews with a purposive sample of nine survey participants. The successional collection of quantitative and qualitative data facilitated integrated interpretations and conclusions about the acceptability of the QIs. Results Generally, the acceptability of all QIs in the suite was rated highly. Data suggested a positive association between acceptability and other key characteristics of QIs. QIs that were seen as clear, supported by scientific evidence, practical and meaningful tended to be more acceptable than those which were not. The benefits of outcome type QIs were recognised, but participants raised concerns about their sensitivity in the measurement of prehospital quality of care. To be acceptable, QIs which included time intervals needed to be specific about time-critical interventions. Further, the high acceptability of the QIs was explained by a connection to participants’ professional values and qualities. Assessing the QIs’ acceptability from a healthcare provider perspective meant that QIs on patient satisfaction frequently received lower ratings. Conclusion The findings of this study provide evidence of the acceptability of prehospital care providers of a proposed suite of QIs. Future research should evaluate the feasibility and reliability of the QIs. There is also a need to investigate how acceptable the proposed QIs are to patients and communities.

Management of Poisonings and Intoxications.

Poisoning occurs after exposure to any of a number of substances, including medicines, which can result in severe toxicity including death. The nephrologist may be involved in poisonings that cause kidney disease and for targeted treatments. The overall approach to the poisoned patient involves the initial acute resuscitation and performing a risk assessment, whereby the exposure is considered in terms of the anticipated severity and in the context of the patient's status and treatments that may be required. Time-critical interventions such as gastrointestinal decontamination ( e.g. , activated charcoal) and antidotes are administered when indicated. The nephrologist is usually involved when elimination enhancement techniques are required, such as urine alkalinization or extracorporeal treatments. There is increasing data to guide decision making for the use of extracorporeal treatments in the poisoned patient. Principles to consider are clinical indications such as whether severe toxicity is present, anticipated, and/or will persist and whether the poison will be significantly removed by the extracorporeal treatment. Extracorporeal clearance is maximized for low-molecular weight drugs that are water soluble with minimal protein binding (<80%) and low endogenous clearance and volume of distribution. The dosage of some antidotes ( e.g. , N-acetylcysteine, ethanol, fomepizole) should be increased to maintain therapeutic concentrations once the extracorporeal treatment is initiated. To maximize the effect of an extracorporeal treatment, blood and effluent flows should be optimized, the filter with the largest surface area selected, and duration tailored to remove enough poison to reduce toxicity. Intermittent hemodialysis is recommended in most cases when an extracorporeal treatment is required because it is the most efficient, and continuous kidney replacement therapy is prescribed in some circumstances, particularly if intermittent hemodialysis is not readily available.

Low-Cost "Telesimulation" Training Improves Real Patient Pediatric Shock Outcomes in India.

IntroductionPediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COVID-19 pandemic restrictions on in-person simulation led us to the development of telesimulation for shock. We hypothesized that telesimulation training would improve pediatric shock recognition, process of care, and patient outcomes in both simulated and real patient settings.Materials and MethodsWe conducted a prospective quasi-experimental interrupted time series cohort study over 9 months. We conducted 40 telesimulation sessions for 76 participants in teams of 3 or 4, utilizing the video telecommunication platform (Zoom©). Trained observers recorded time-critical interventions on real patients for the pediatric emergency teams composed of residents, fellows, and nurses. Data were collected on 332 pediatric patients in shock (72% of whom were in septic shock) before, during, and after the intervention. The data included the first hour time-critical intervention checklist, patient hemodynamic status at the end of the first hour, time for the resolution of shock, and team leadership skills in the emergency room.ResultsThere was a significant improvement in the percent completion of tasks by the pediatric emergency team in simulated scenarios (69% in scenario 1 vs. 93% in scenario 2; p < 0.001). In real patients, completion of tasks as per time-critical steps reached 100% during and after intervention compared to the pre-intervention phase (87.5%), p < 0.05. There was a significant improvement in the first hour hemodynamic parameters of shock patients: pre (71%), during (79%), and post (87%) intervention (p < 0.007 pre vs. post). Shock reversal time reduced from 24 h pre-intervention to 6 h intervention and to 4.5 h post intervention (p < 0.002). There was also a significant improvement in leadership performance assessed by modified Concise Assessment of Leader Management (CALM) instrument during the simulated (p < 0.001) and real patient care in post intervention (p < 0.05).ConclusionTelesimulation training is feasible and improved the process of care, time-critical interventions, leadership in both simulated and real patients and resolution of shock in real patients. To the best of our knowledge, this is one of the first studies where telesimulation has shown improvement in real patient outcomes.

1083 A REVIEW OF FAST DATA IN TALLAGHT UNIVERSITY HOSPITAL, AND THE IMPACT OF COVID ON TREATMENT

Abstract Introduction Stroke is a leading cause of morbidity. Current guidelines advise maximum of 4.5 hours post symptom onset for thrombolysis, and 24 hours for thrombectomy. (1) Delay between symptom onset and treatment is associated with an inferior outcome. Thrombolysis is available in 27 Irish centers. Average rate of thrombolysis is 11%. (3) Fewer than half of stroke patients arrived in hospital within three hours of symptom onset in 2019. (4) Median door-to-needle time is 48 minutes. Method FAST calls in Tallaght University Hospital, from 2/7/19–1/7/21, were included in this analysis (n = 594). Results 160 FAST calls took place pre-Covid (20/month), and 434 post-Covid (27.12/month). Time of symptom onset was recorded in 390 cases. Time patients last seen well was known in 185 cases, unknown time of onset in 19. After review by the stroke clinician, FAST imaging was obtained in 78% of cases (n = 464). Of these, 34 cases of FAST imaging were performed for inpatients. Average time from registration to CT was 35:24 minutes pre covid, and 45:52 minutes post. 9.7% of patients were thrombolysed. The median door-to-needle time was 41 minutes pre-Covid(n = 21, 2.625/month), and 54 minutes after (n = 37, 2.3/month). Thrombectomy was performed in 46 cases. 222 patients were diagnosed with an ischaemic stroke, 50 had TIA and 48 had haemorrhagic strokes. Other diagnoses included migraine (6.7%, n = 40), seizures (6.7%, n = 40) and Bells Palsy (3.7%, n = 22). 55% (n = 330) of cases were registered to ED with FAST call between the hours of 9 am-5 pm. 27% (n = 161) of cases occurred during the night shift. Conclusion The median door-to-needle times were below national median pre-Covid, and longer post-pandemic, with an increase in the rate of presentation in the same time-frame. This report highlights the effect of the pandemic on time-critical patient interventions in stroke and the need to stratify services to respond to structural challenges.

Prolonged Automated Robotic TCD Monitoring in Acute Severe TBI: Study Design and Rationale.

Transcranial Doppler ultrasonography (TCD) is a portable, bedside, noninvasive diagnostic tool used for the real-time assessment of cerebral hemodynamics. Despite the evident utility of TCD and the ability of this technique to function as a stethoscope to the brain, its use has been limited to specialized centers because of the dearth of technical and clinical expertise required to acquire and interpret the cerebrovascular parameters. Additionally, the conventional pragmatic episodic TCD monitoring protocols lack dynamic real-time feedback to guide time-critical clinical interventions. Fortunately, with the recent advent of automated robotic TCD technology in conjunction with the automated software for TCD data processing, we now have the technology to automatically acquire TCD data and obtain clinically relevant informationin real-time. By obviating the need for highly trained clinical personnel, this technology shows great promise toward a future of widespread noninvasive monitoring to guide clinical care in patients with acute brain injury. Here, we describe a proposal for a prospective observational multicenter clinical trial to evaluate the safety and feasibility of prolonged automated robotic TCD monitoring in patients with severe acute traumatic brain injury (TBI). We will enroll patients with severe non-penetratingTBI with concomitant invasive multimodal monitoring including, intracranial pressure, brain tissue oxygenation, and brain temperature monitoring as part of standard of care in centers with varying degrees of TCD availability and experience. Additionally, we propose to evaluate the correlation of pertinent TCD-based cerebral autoregulation indicessuch as the critical closing pressure, and the pressure reactivity index withthe brain tissue oxygenationvaluesobtained invasively. The overarching goal of this study is to establish safety and feasibility of prolonged automated TCD monitoring for patients with TBI in the intensive care unit and identify clinically meaningful and pragmatic noninvasive targets for future interventions.

Differences in time-critical interventions and radiological examinations between adult and older trauma patients: A national register-based study.

Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients hold important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations. Retrospective analysis of the Norwegian Trauma Registry for 2015 through 2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score of 9 or greater were included, dichotomized into age groups 16 years to 64 years and 65 years or older. Prehospital and emergency department clinical management, advanced airway management, chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests. There were 9543 patients included, of which 28% (n = 2711) were 65 years or older. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.57-0.71), conveyed by air ambulance (OR, 0.65; 95% CI, 0.58-0.73), and transported directly to a trauma center (OR, 0.86; 95% CI, 0.79-0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with New Injury Severity Score of 25 or greater, showing lower rates for older adults (advanced airway management: OR, 0.60; 95% CI, 0.47-0.76; chest decompression: OR, 0.46; 95% CI, 0.25-0.85; x-ray chest: OR, 0.54; 95% CI, 0.39-0.75; x-ray pelvis: OR, 0.69; 95% CI, 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups. Older trauma patients were less likely to receive advanced prehospital care compared with younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities. Therapeutic/Care Management; Level III.

Development of a Clinical Decision Support System for Smart Algorithms in Emergency Medicine.

The development of clinical decision support systems (CDSS) is complex and requires user-centered planning of assistive interventions. Especially in the setting of emergency care requiring time-critical decisions and interventions, it is important to adapt a CDSS to the needs of the user in terms of acceptance, usability and utility. In the so-called ENSURE project, a user-centered approach was applied to develop the CDSS intervention. In the context of this paper, we present a path to the first mockup development for a CDSS interface by addressing Campbell's Five Rights within the CDSS workflow.

Community emergency medicine throughout the UK and Ireland: a comparison of current national activity

BackgroundCommunity emergency medicine (CEM) aims to bring highly skilled, expert medical care to the patient outside of the traditional ED setting. Currently, there are several different CEM models in existence...

Cardiac arrest in special circumstances.

European Resuscitation Council Guidelines for Cardiopulmonary Resuscitation prioritize treatments like chest compression and defibrillation, known to be highly effective for cardiac arrest from cardiac origin. This review highlights the need to modify this approach in special circumstances. Potentially reversible causes of cardiac arrest are clustered into four Hs and four Ts (Hypoxia, Hypovolaemia, Hyperkalaemia/other electrolyte disorders, Hypothermia, Thrombosis, Tamponade, Tension pneumothorax, Toxic agents). Point-of-care ultrasound has its role in identification of the cause and targeting treatment. Time-critical interventions may even prevent cardiac arrest if applied early. The extracorporeal CPR (eCPR) or mechanical CPR should be considered for bridging the period needed to reverse the precipitating cause(s). There is low quality of evidence available to guide the treatment in the majority of situations. Some topics (pulmonary embolism, eCPR, drowning, pregnancy and opioid toxicity) were included in recent ILCOR reviews and evidence updates but majority of recommendations is based on individual systematic reviews, scoping reviews, evidence updates and expert consensus. Cardiac arrests from reversible causes happen with lower incidence. Return of spontaneous circulation and neurologically intact survival can hardly be achieved without a modified approach focusing on immediate treatment of the underlying cause(s) of cardiac arrest.