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BMC Emergency Medicine Sep 2022Emergency medical services (EMS) are the first point of contact for most acute stroke patients. EMS call to hospital times have increased in recent years for stroke...
BACKGROUND
Emergency medical services (EMS) are the first point of contact for most acute stroke patients. EMS call to hospital times have increased in recent years for stroke patients in the UK which is undesirable due to the relationship between time and effectiveness of reperfusion treatment. This review aimed to identify and describe interventions devised to improve the efficiency of acute stroke care which reported an impact on ground-based EMS call to hospital times.
METHODS
A systematic review of published literature identified from five databases (Medline, EMBASE, CINAHL, the Cochrane library and the Database of Research in Stroke (DORIS)) from January 2000 to December 2020 with narrative synthesis was conducted. Inclusion criteria were primary studies of ground-based EMS, focused on stroke and aiming to improve EMS times. Papers published before 2000, focussing on mobile stroke units or in languages other than English were excluded. Two reviewers independently screened prospective titles. Cochrane ROB2 and ROBINS-I tools were used to assess for risk of bias. This review was funded by a Stroke Association fellowship.
RESULTS
From 3767 initial records, 11 studies were included in the review. Included studies were categorised into three groups: studies targeting EMS dispatch and EMS clinicians (n = 4); studies targeting EMS clinicians only (n = 4); and studies targeting whole system change (n = 3). Suspected stroke patients were the primary population studied and most (n = 10) interventions involved clinician education. Only one study (9%) reported a significant decrease in call to hospital time in one subgroup whereas two studies (18%) reported a significant increase in call to hospital time and all other studies (73%) reported no significant change.
CONCLUSIONS
Based on the included studies, interventions intended to improve the efficiency of the acute stroke pathway rarely improved EMS call to hospital times. Included studies were heterogenous and rarely focussed on the review topic which limits the usability of the findings. Further research is needed to explore the trade-off between changes to EMS stroke care and call to hospital times and subsequent impacts on in-hospital care and patient outcomes.
Topics: Critical Care; Emergency Medical Dispatch; Emergency Medical Services; Humans; Prospective Studies; Stroke
PubMed: 36057767
DOI: 10.1186/s12873-022-00713-6 -
Journal of Paramedic Practice : the... Sep 2022Effective triage is critical to ensure patients suffering major trauma are identified and access a pathway to definitive major trauma care, typically provided in a major...
Effective triage is critical to ensure patients suffering major trauma are identified and access a pathway to definitive major trauma care, typically provided in a major trauma centre as part of an established major trauma system. The pre-hospital triage of trauma patients often relies upon the use of major trauma triage tools; this commentary critically appraises a recent systematic review which sought to evaluate and compare the accuracy of pre-hospital triage tools for major trauma.
PubMed: 38828102
DOI: 10.12968/jpar.2022.14.9.CPD1 -
BMC Emergency Medicine Aug 2022Research examining paramedic care of back pain is limited. (Review)
Review
BACKGROUND
Research examining paramedic care of back pain is limited.
OBJECTIVE
To describe ambulance service use and usual paramedic care for back pain, the effectiveness and safety of paramedic care of back pain, and the characteristics of people with back pain who seek care from paramedics.
METHODS
We included published peer-reviewed studies of people with back pain who received any type of paramedic care on-scene and/or during transport to hospital. We searched MEDLINE, EMBASE, CINAHL, Web of Science and SciELO from inception to July 2022. Two authors independently screened and selected the studies, performed data extraction, and assessed the methodological quality using the PEDro, AMSTAR 2 and Hawker tools. This review followed the JBI methodological guidance for scoping reviews and PRISMA extension for scoping reviews.
RESULTS
From 1987 articles we included 26 articles (25 unique studies) consisting of 22 observational studies, three randomised controlled trials and one review. Back pain is frequently in the top 3 reasons for calls to an ambulance service with more than two thirds of cases receiving ambulance dispatch. It takes ~ 8 min from time of call to an ambulance being dispatched and 16% of calls for back pain receive transport to hospital. Pharmacological management of back pain includes benzodiazepines, NSAIDs, opioids, nitrous oxide, and paracetamol. Non-pharmacological care is poorly reported and includes referral to alternate health service, counselling and behavioural interventions and self-care advice. Only three trials have evaluated effectiveness of paramedic treatments (TENS, active warming, and administration of opioids) and no studies provided safety or costing data.
CONCLUSION
Paramedics are frequently responding to people with back pain. Use of pain medicines is common but varies according to the type of back pain and setting, while non-pharmacological care is poorly reported. There is a lack of research evaluating the effectiveness and safety of paramedic care for back pain.
Topics: Allied Health Personnel; Ambulances; Back Pain; Emergency Medical Services; Emergency Medical Technicians; Humans; Referral and Consultation
PubMed: 35945506
DOI: 10.1186/s12873-022-00699-1 -
BMC Health Services Research Jul 2022Heatwaves have been linked to increased levels of health service demand in Australia. This systematic literature review aimed to explore health service demand during...
OBJECTIVES
Heatwaves have been linked to increased levels of health service demand in Australia. This systematic literature review aimed to explore health service demand during Australian heatwaves for hospital admissions, emergency department presentations, ambulance call-outs, and risk of mortality.
STUDY DESIGN
A systematic review to explore peer-reviewed heatwave literature published from 2000 to 2020.
DATA SOURCES
Articles were reviewed from six databases (MEDLINE, Scopus, Web of Science, PsychINFO, ProQuest, Science Direct). Search terms included: heatwave, extreme heat, ambulance, emergency department, and hospital. Studies were included if they explored heat for a period of two or more consecutive days. Studies were excluded if they did not define a threshold for extreme heat or if they explored data only from workers compensation claims and major events.
DATA SYNTHESIS
This review was prospectively registered with PROSPERO (# CRD42021227395 ). Forty-five papers were included in the final review following full-text screening. Following a quality assessment using the GRADE approach, data were extracted to a spreadsheet and compared. Significant increases in mortality, as well as hospital, emergency, and ambulance demand, were found across Australia during heatwave periods. Admissions for cardiovascular, renal, respiratory, mental and behavioural conditions exhibited increases during heatwaves. The most vulnerable groups during heatwaves were children (< 18 years) and the elderly (60+).
CONCLUSIONS
Heatwaves in Australia will continue to increase in duration and frequency due to the effects of climate change. Health planning is essential at the community, state, and federal levels to mitigate the impacts of heatwaves on health and health service delivery especially for vulnerable populations. However, understanding the true impact of heatwaves on health service demand is complicated by differing definitions and methodology in the literature. The Excess Heat Factor (EHF) is the preferred approach to defining heatwaves given its consideration of local climate variability and acclimatisation. Future research should explore evidence-based and spatially relevant heatwave prevention programs. An enhanced understanding of heatwave health impacts including service demand will inform the development of such programs which are necessary to promote population and health system resilience.
Topics: Aged; Ambulances; Australia; Child; Emergency Service, Hospital; Extreme Heat; Hospitalization; Hot Temperature; Humans
PubMed: 35902847
DOI: 10.1186/s12913-022-08341-3 -
BMJ Open Jun 2022To examine the current knowledge and possibly identify gaps in the knowledge base for cost-benefit analysis and safety concerning community paramedicine in rural areas. (Review)
Review
OBJECTIVE
To examine the current knowledge and possibly identify gaps in the knowledge base for cost-benefit analysis and safety concerning community paramedicine in rural areas.
DESIGN
Scoping review.
DATA SOURCES
MEDLINE via PubMed, CINAHL, Cochrane and Embase up to December 2020.
STUDY SELECTION
All English studies involving community paramedicine in rural areas, which include cost-benefit analysis or safety evaluation.
DATA EXTRACTION
This scoping review follows the methodology developed by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We systematically searched for all types of studies in the databases and the reference lists of key studies to identify studies for inclusion. The selection process was in two steps. First, two reviewers independently screened 2309 identified articles for title and abstracts and second performed a full-text review of 24 eligible studies for inclusion.
RESULTS
Three articles met the inclusion criteria concerning cost-benefit analysis, two from Canada and one from USA. No articles met the inclusion criteria for safety evaluation.
CONCLUSION
There are knowledge gaps concerning safety evaluation of community paramedicine in rural areas. Three articles were included in this scoping review concerning cost-benefit analysis, two of them showing positive cost-effectiveness with community paramedicine in rural areas.
Topics: Canada; Cost-Benefit Analysis; Delivery of Health Care; Emergency Medical Services; Humans
PubMed: 35680256
DOI: 10.1136/bmjopen-2021-057752 -
European Stroke Journal Jun 2022Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients... (Review)
Review
BACKGROUND
Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS.
METHODS
We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS.
RESULTS
We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken.
CONCLUSION
Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.
PubMed: 35647316
DOI: 10.1177/23969873221078136 -
Frontiers in Neurology 2022The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized...
BACKGROUND
The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance.
METHODS
Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours ("per day"), mechanical thrombectomy (MT)/dispatch and MT/day.
RESULTS
Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150-0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074-0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8-9.5%, I = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215-0.502, I = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2-2.8%, I = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046-0.138, I = 91%).
CONCLUSIONS
In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.
PubMed: 35614916
DOI: 10.3389/fneur.2022.868051 -
Resuscitation Plus Jun 2022To determine the optimal first-shock energy level for biphasic defibrillation and whether fixed or escalating protocols for subsequent shocks are most effective. (Review)
Review
AIM
To determine the optimal first-shock energy level for biphasic defibrillation and whether fixed or escalating protocols for subsequent shocks are most effective.
METHODS
We searched Medline, Embase, Cochrane CENTRAL, CINAHL, the Web of Science and national and international trial registry databases for papers published from database inception to January 2022. We reviewed reference lists of key papers to identify additional references. The population included adults sustaining non traumatic out-of-hospital cardiac arrest subject to attempted defibrillation. Studies of internal or monophasic defibrillation and studies other than randomised controlled trials or prospective cohorts were excluded. Two reviewers assessed study relevance. Data extraction and risk of bias assessment, using the ROBINS-I tool, were conducted by one reviewer and checked by a second reviewer. Data underwent intention-to-treat analysis.
RESULTS
We identified no studies evaluating first shock energy. Only one study ( = 738) comparing fixed versus escalating energy met eligibility criteria: a prospective cohort analysis of a randomised controlled trial of manual versus mechanical CPR. High fixed (360 J) energy was compared with an escalating (200-200/300-360 J) strategy. Researchers found 27.5% (70/255) of patients in the escalating energy group and 27.61% (132/478) in the fixed high energy group survived to hospital discharge (unadjusted risk ratio 0.99, 95% CI 0.73, 1.23). Results were of very low certainty as the study was at serious risk of bias.
CONCLUSION
This systematic review did not identify an optimal first-shock energy for biphasic defibrillation. We identified no survival advantage at 30 days when comparing 360 J fixed with 200 J escalating strategy.
PubMed: 35602465
DOI: 10.1016/j.resplu.2022.100232 -
Resuscitation Plus Jun 2022To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in... (Review)
Review
AIM
To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning strategies.
METHODS
We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence.
RESULTS
Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses.
CONCLUSION
We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.
PubMed: 35515010
DOI: 10.1016/j.resplu.2022.100236 -
BMC Medical Ethics Mar 2022Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a...
BACKGROUND
Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a risk that the patient may be inflicted with moral harm or injury, while healthcare professionals are at risk of feeling moral distress. Therefore, it is essential to support the learning and development of ethical competencies among healthcare professionals and students. The aim of this study was to explore the available literature regarding ethics education that promotes ethical competence learning for healthcare professionals and students undergoing training in healthcare professions.
METHODS
In this integrative systematic review, literature was searched within the PubMed, CINAHL, and PsycInfo databases using the search terms 'health personnel', 'students', 'ethics', 'moral', 'simulation', and 'teaching'. In total, 40 articles were selected for review. These articles included professionals from various healthcare professions and students who trained in these professions as subjects. The articles described participation in various forms of ethics education. Data were extracted and synthesised using thematic analysis.
RESULTS
The review identified the need for support to make ethical competence learning possible, which in the long run was considered to promote the ability to manage ethical problems. Ethical competence learning was found to be helpful to healthcare professionals and students in drawing attention to ethical problems that they were not previously aware of. Dealing with ethical problems is primarily about reasoning about what is right and in the patient's best interests, along with making decisions about what needs to be done in a specific situation.
CONCLUSIONS
The review identified different designs and course content for ethics education to support ethical competence learning. The findings could be used to develop healthcare professionals' and students' readiness and capabilities to recognise as well as to respond appropriately to ethically problematic work situations.
Topics: Delivery of Health Care; Ethics, Nursing; Health Personnel; Humans; Morals
PubMed: 35305627
DOI: 10.1186/s12910-022-00766-z