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Scandinavian Journal of Trauma,... May 2024Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who...
BACKGROUND
Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.
METHODS
A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.
RESULTS
The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.
CONCLUSIONS
Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.
Topics: Humans; Triage; England; Female; Male; Emergency Medical Services; Middle Aged; Adult; Trauma Centers; Wounds and Injuries; Aged; Cohort Studies; Injury Severity Score
PubMed: 38773613
DOI: 10.1186/s13049-024-01219-9 -
Scandinavian Journal of Trauma,... May 2024Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be...
BACKGROUNDS
Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia.
METHODS
Physicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians.
RESULTS
In total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores.
CONCLUSIONS
Ongoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes.
TRIAL REGISTRATION
Not applicable.
Topics: Humans; Leadership; Prospective Studies; Cross-Sectional Studies; Male; Female; Surveys and Questionnaires; Patient Care Team; Adult; Clinical Competence; Emergency Medical Services; Middle Aged; Emergency Medicine; Air Ambulances; United States; Europe
PubMed: 38773532
DOI: 10.1186/s13049-024-01221-1 -
BMJ Open Quality May 2024BackgroundAn evaluation report for a pilot project on the use of video in medical emergency calls between the caller and medical operator indicates that video is only...
UNLABELLED
BackgroundAn evaluation report for a pilot project on the use of video in medical emergency calls between the caller and medical operator indicates that video is only used in 4% of phone calls to the emergency medical communication centre (EMCC). Furthermore, the report found that in half of these cases, the use of video did not alter the assessment made by the medical operator at the EMCC.We aimed to describe the reasons for when and why medical operators choose to use or not use video in emergency calls.
METHOD
The study was conducted in a Norwegian EMCC, employing a thematic analysis of notes from medical operators responding to emergency calls regarding the use of video.
RESULT
Informants reported 19 cases where video was used and 46 cases where it was not used. When video was used, three main themes appeared: 'unclear situation or patient condition', 'visible problem' and 'children'. When video was not used the following themes emerged: 'cannot be executed/technical problems', 'does not follow instructions', 'perceived as unnecessary'. Video was mostly used in cases where the medical operators were uncertain about the situation or the patients' conditions.
CONCLUSION
The results indicate that medical operators were selective in choosing when to use video. In cases where operators employed video, it provided a better understanding of the situation, potentially enhancing the basis for decision-making.
Topics: Humans; Norway; Video Recording; Male; Female; Pilot Projects; Adult; Emergency Medical Services; Qualitative Research
PubMed: 38772882
DOI: 10.1136/bmjoq-2024-002751 -
Resuscitation Plus Jun 2024Limited data exists regarding cardiovascular diseases (CVDs) and related emergencies such as out-of-hospital cardiac arrest (OHCA) in low- and middle-income countries... (Review)
Review
INTRODUCTION
Limited data exists regarding cardiovascular diseases (CVDs) and related emergencies such as out-of-hospital cardiac arrest (OHCA) in low- and middle-income countries (LMICs). The recent burden of disease report indicates a rising prevalence of CVDs in these settings like the Democratic Republic of Congo (DRC), likely associated with acute complications. Achieving improved outcomes necessitates resilient healthcare systems, including adequate emergency care and resuscitation systems. This study aims to characterize the current state of resuscitation systems in the DRC, contributing to the discourse on the burden of CVDs in LMICs and advocating for context-appropriate interventions to develop and reinforce these systems.
METHODS
A narrative review utilizing the modified survival framework of the Global Resuscitation Alliance was conducted. It encompassed the country's CVD epidemiological data, healthcare components, and emergency care system.
RESULTS
Analysis of limited available data revealed an underdeveloped and inadequately resourced healthcare system in the country, particularly its early-stage emergency care component. While specific data on out-of-hospital cardiac arrests were lacking, crucial components of the survival chain necessary for improved post-arrest outcomes were found to be largely deficient. Community-based first aid knowledge and practice were inadequate, the availability of automated external defibrillators (AEDs) and integrated ambulance services were either absent or insufficiently developed, and facility-based resuscitation capacity was predominantly in its infancy. Nonetheless, optimism is warranted due to recent government decisions to increase total health expenditure and progressively implement Universal Health Coverage.
CONCLUSION
Resuscitation systems in the DRC are largely non-existent, reflecting the country's underdeveloped healthcare system, particularly in emergency care. Urgent action is needed to develop and reinforce context-appropriate resuscitation systems to address the growing burden of CVD-related emergencies in LMICs.
PubMed: 38764760
DOI: 10.1016/j.resplu.2024.100656 -
BMC Medical Ethics May 2024Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress...
BACKGROUND
Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine.
METHODS
We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach.
RESULTS
We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope.
CONCLUSION
Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.
Topics: Humans; Trust; Focus Groups; Emergency Medical Services; Emergency Medical Technicians; Female; Male; Adult; Attitude of Health Personnel; Decision Making; Morals; Middle Aged; Allied Health Personnel; Burnout, Professional
PubMed: 38762457
DOI: 10.1186/s12910-024-01061-9 -
Acute Medicine & Surgery 2024To analyze characteristics and investigate prognostic indicators of out-of-hospital cardiac arrest (OHCA) in a hilly area in Japan.
AIM
To analyze characteristics and investigate prognostic indicators of out-of-hospital cardiac arrest (OHCA) in a hilly area in Japan.
METHODS
A retrospective population-based study was conducted using the Utstein Registry for 4280 OHCA patients in the Nagasaki Medical Region (NMR) registered over the 10-year period from 2011 to 2020. The main outcome measure was a favorable cerebral performance category (CPC 1-2). Sites at which OHCA occurred were classified into "sloped places (SPs)" (not easily accessible by emergency medical services [EMS] personnel due to slopes) and "accessible places (APs)" (EMS personnel could park an ambulance close to the site). The characteristics and prognosis based on CPC were compared between SPs and APs, and multivariable analysis was performed.
RESULTS
No significant improvement in prognosis occurred in the NMR from 2011 to 2020. Prognosis in SPs was significantly worse than that in APs. However, multivariable analysis did not identify SP as a prognostic indicator. The following factors were associated with survival and CPC 1-2: age group, witness status, first documented rhythm, bystander-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, use of mechanical CPR (m-CPR) device or esophageal obturator airway (EOA), and year. Both m-CPR and EOA use were associated with a poor prognosis.
CONCLUSION
In a hilly area, OHCA patients in SPs had a worse prognosis than those in APs, but SPs was not significantly associated with prognosis by multivariable analysis. Interventions to increase bystander-initiated CPR and AED use could potentially improve outcomes of OHCA in the NMR.
PubMed: 38756720
DOI: 10.1002/ams2.966 -
Frontiers in Neurology 2024As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition,...
As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.
PubMed: 38756217
DOI: 10.3389/fneur.2024.1389056 -
BMJ Open May 2024The objective of this study is to determine research priorities for the management of major trauma, representing the shared priorities of patients, their families,...
OBJECTIVE
The objective of this study is to determine research priorities for the management of major trauma, representing the shared priorities of patients, their families, carers and healthcare professionals.
DESIGN/SETTING
An international research priority-setting partnership.
PARTICIPANTS
People who have experienced major trauma, their carers and relatives, and healthcare professionals involved in treating patients after major trauma. The scope included chest, abdominal and pelvic injuries as well as major bleeding, multiple injuries and those that threaten life or limb.
METHODS
A multiphase priority-setting exercise was conducted in partnership with the James Lind Alliance over 24 months (November 2021-October 2023). An international survey asked respondents to submit their research uncertainties which were then combined into several indicative questions. The existing evidence was searched to ensure that the questions had not already been sufficiently answered. A second international survey asked respondents to prioritise the research questions. A final shortlist of 19 questions was taken to a stakeholder workshop, where consensus was reached on the top 10 priorities.
RESULTS
A total of 1572 uncertainties, submitted by 417 respondents (including 132 patients and carers), were received during the initial survey. These were refined into 53 unique indicative questions, of which all 53 were judged to be true uncertainties after reviewing the existing evidence. 373 people (including 115 patients and carers) responded to the interim prioritisation survey and 19 questions were taken to a final consensus workshop between patients, carers and healthcare professionals. At the final workshop, a consensus was reached for the ranking of the top 10 questions.
CONCLUSIONS
The top 10 research priorities for major trauma include patient-centred questions regarding pain relief and prehospital management, multidisciplinary working, novel technologies, rehabilitation and holistic support. These shared priorities will now be used to guide funders and teams wishing to research major trauma around the globe.
Topics: Humans; Health Priorities; Surveys and Questionnaires; Research; Multiple Trauma; Wounds and Injuries; Caregivers; Health Personnel; Female; Male
PubMed: 38754886
DOI: 10.1136/bmjopen-2023-083450 -
PloS One 2024Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced...
Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced paramedics (APs), however little is known about how APs make restraint decisions. The aim of this research is to explore the decisions made by APs when managing restraint in the context of ABD, in the UK pre-hospital ambulance setting. Seven semi-structured interviews were undertaken with APs. All participants were experienced APs with post-registration, post-graduate advanced practice education and qualifications. The resulting data were analysed using reflexive thematic analysis, informed by critical realism. We identified four interconnected themes from the interview data. Firstly, managing complexity and ambiguity in relation to identifying ABD patients and determining appropriate treatment plans. Secondly, feeling vulnerable to professional consequences from patients deteriorating whilst in the care of APs. Thirdly, negotiating with other professionals who have different roles and priorities. Finally, establishing primacy of care in relation to incidents which involve police officers and other professionals. A key influence was the need to characterise incidents as medical, as an enabler to establishing clinical leadership and decision-making control. APs focused on de-escalation techniques and sought to reduce physical restraint, intervening with pharmacological interventions if necessary to achieve this. The social relationships and interactions with patients and other professionals at the scene were key to success. Decisions are a source of anxiety, with fears of professional detriment accompanying poor patient outcomes. Our results indicate that APs would benefit from education and development specifically in relation to making ABD decisions, acknowledging the context of inter-professional relationships and the potential for competing and conflicting priorities. A focus on joint, high-fidelity training with the police may be a helpful intervention.
Topics: Humans; Ambulances; United Kingdom; Restraint, Physical; Emergency Medical Services; Qualitative Research; Decision Making; Male; Allied Health Personnel; Female; Emergency Medical Technicians; Adult; Paramedics
PubMed: 38753728
DOI: 10.1371/journal.pone.0302524 -
Annals of Indian Academy of Neurology 2024Only a small percentage of patients with acute stroke are currently eligible for thrombolysis, partly due to severe delays in hospital arrival. We had previously...
BACKGROUND
Only a small percentage of patients with acute stroke are currently eligible for thrombolysis, partly due to severe delays in hospital arrival. We had previously conducted the first regional study to assess the factors delaying acute stroke care in India. The present study aims to understand and describe in depth the variables associated with prehospital delay among patients admitted with an acute ischemic stroke.
METHODS
Data were prospectively collected by conducting an in-depth interview of 470 acute ischemic stroke patients and their bystanders, aged above 18 years, presenting to the Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur. Patients who arrived within 4.5 h of symptom onset were considered as "early arrival" and those who arrived after 4.5 h were considered as "delayed arrival." Univariate and multivariate analyses were undertaken to determine associations between variables of interest and delays to hospital presentation.
RESULTS
Of the 470 patients who met the inclusion criteria, 73 patients reached within 4.5 h (15.5%), whereas 397 patients arrived after 4.5 h. The mean age of acute stroke patients who reached within 4.5 h was 63 ± 13.7 years, whereas the mean age of those who reached after 4.5 h was 63 ± 12.1 years. Binary logistic regression performed to quantify the associations of prehospital factors showed an increased risk of prehospital delay among individuals with lack of awareness (odds ratio [OR] = 5.16 [3.040-8.757], < 0.001), followed by those for whom a vehicle was not available at the site of event (OR = 3.745 [1.864-7.522], < 0.001). Within the predefined socioeconomic strata, compared to lower class, upper middle class had less risk (OR = 0.135 [0.018-1.035], = 0.054), whereas the distance from first medical contact to emergency department contributed moderate risk (OR = 1.071 [1.028-1.116], < 0.001) for prehospital delay.
CONCLUSIONS
Health promotion techniques that increase public knowledge about the early signs of stroke, transferring patients directly to hospitals with thrombolysis capabilities, and making ambulance services more widely available are appropriate measures to reduce prehospital delay.
PubMed: 38751933
DOI: 10.4103/aian.aian_1091_23