Establishment of an Alternate Care Site (ACS) in Imperial County During COVID-19.

Imperial County is in southern California, one of the state's two counties at the international United States-Mexico border. The county is one of the most resource-limited in the state, with only two hospitals serving its 180,000 citizens, and no tertiary care centers. A significant portion of the population cared for at the local hospitals commutes from Mexicali, a large city of 1.2 million persons, just south of Imperial County's ports of entry. Since May 2020, following an outbreak in Mexicali, Imperial County has seen a significant increase in the number of COVID-19 patients, quickly outpacing its local resources. In response to this surge an alternate care site (ACS) was created as part of a collaboration between the California State Emergency Medical Service Authority (EMSA) and the county. In the first month of operations (May 26-June 26, 2020) the ACS received 106 patients with an average length of stay of 3.6 days. The average patient age was 55.5 years old with a range of 19-95 years. Disposition of patients included 25.5% sent to the emergency department for acute care needs, 1.8% who left against medical advice, and 72.7% who were discharged home or to a skilled nursing facility. There were no deaths on site. This study shares early experiences, challenges, and innovations created with the implementation of this ACS. Improving communication with local partners was the single most significant step in overcoming initial barriers.

Is Door-to-Needle Time Reduced for Emergency Medical Services Transported Stroke Patients Routed Directly to the Computed Tomography Scanner on Emergency Department Arrival?

BACKGROUND: A nationally recommended practice to accelerate thrombolytic therapy for acute ischemic stroke is to route emergency medical services (EMS)-transported stroke patients directly to the computed tomography (CT) scanner on arrival. We evaluated door-to-needle time with direct-to-CT routing versus emergency department (ED)-bed first routing. METHODS: This was a retrospective analysis from a large regionalized stroke system. Paramedics utilize the modified Los Angeles Prehospital Stroke Screen and transport acute stroke patients to Approved Stroke Centers. Individual stroke centers postarrival protocols vary, with some routing patients directly to CT. Stroke centers report treatment and outcomes to a registry, from which data were abstracted from May 2015 through April 2016. Adult patients transported by EMS and treated with thrombolytic therapy were included. The primary outcome was door-to-needle time. Secondary outcome was door-to-imaging time. RESULTS: EMS transported 6315 patients for suspected stroke and 789 (13%) were treated with thrombolysis at 41 stroke centers, 171 (22%) at hospitals with direct-to-CT routing and 618 (78%) at hospitals with ED-bed routing. Patient characteristics were similar between groups. Door-to-needle time was not different in the 2 groups, median 57 minutes (interquartile range [IQR] 44-76) for CT routing versus 54 minutes (IQR 40-74) for ED routing, median difference 3 (95% CI -1, 7), P == .2. Door-to-imaging time was shorter with CT routing compared to ED routing, median 13 minutes (IQR 8-21) and 16 minutes (IQR 10-24), respectively. CONCLUSIONS: In this regional stroke system, hospitals with protocols for routing EMS-transported stroke patients directly to CT did not have reduced door-to-needle compared to hospitals without such protocols.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field.

BACKGROUND: Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%). CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Patient preferences and acceptable risk for computed tomography in trauma.

BACKGROUND: Rising use of computed tomography (CT) to evaluate patients with trauma has increased both patient costs and risk of cancer from ionizing radiation, without demonstrable improvements in outcome. Patient-centred care mandates disclosure of the potential risks, costs and benefits of diagnostic testing whenever possible. OBJECTIVE: We sought to determine (1) patient preferences regarding emergency department (ED) real-time discussions of risks and costs of CT during their trauma evaluations; and (2) whether varying levels of odds of detection of life-threatening injury (LTI) were associated with changes in patient preferences for CT. METHODS: Excluding patients already receiving CT and patients with altered mental status, we surveyed adult, English-speaking patients at four Level I verified trauma centres. After informing subjects of cancer risks associated with chest CT, we used hypothetical scenarios with varying LTIs to assess patients' preferences regarding CT. RESULTS: Of 941 patients enrolled, 50% were male and their mean age was 42 years. Most patients stated they would prefer to discuss CT radiation risks (73.5%, 95% CI [66.1-80.8]) and costs (53.2%, 95% CI [46.1-60.4]) with physicians. As the odds of detecting LTI decreased, preferences for receiving CT decreased accordingly: LTI 25% (desire 91.2%, 95% CI [89.4-93.1]), LTI 10% (desire 79.3%, 95% CI [76.7-81.9]), LTI 5% (desire 69.1%, 95% CI [66.1-72.1]) and LTI <2% (desire 53.8%, 95% CI [50.6-57.0]). If the LTI was <2% and subjects were required to pay $1000 out-of-pocket, only 34.5% (95% CI 31.4-37.5) would opt for CT. CONCLUSION: Most non-critically injured patients prefer to discuss radiation risks and costs of CT prior to receiving imaging. As the odds of detecting LTI decrease, fewer patients prefer to have CT; at an LTI threshold of 2%, approximately half of patients would prefer to forego CT. Adding out-of-pocket costs reduced this proportion to one-third of patients.

Risk factors for venous thromboembolism in critically ill trauma patients who cannot receive chemical prophylaxis.

BACKGROUND: Standard venous thromboembolism (VTE) prevention for critically ill trauma patients includes sequential compression devices and chemical prophylaxis. When contraindications to anticoagulation are present, prophylactic inferior vena cava filters (IVCF) may be used to prevent pulmonary emboli (PE) in high-risk patients, but specific indications are lacking. We sought to identify independent predictors of VTE in critically-ill trauma patients who cannot receive chemical prophylaxis in order to identify a subset of patients who may benefit from aggressive screening and/or prophylactic IVCF placement. METHODS: All trauma patients in the surgical ICU from 2008 to 2009 were prospectively followed. Patients with an ICU length of stay ≥2 days who had contraindications to prophylactic anticoagulation were included. Screening duplex exams were obtained within 48 h of admission and then weekly. CT-angiography for PE was obtained if clinically indicated. Patients were excluded if they did not receive a duplex or if they had a post-injury VTE prior to ICU admission. Data regarding VTE rates (lower extremity [LE] DVT or PE), demographics, past medical history (PMH), injuries, and surgeries were collected. Univariate and multivariable analyses were performed to identify independent predictors of VTE with a p<0.05. RESULTS: 411 trauma patients with a mean age of 48 (SD 22) years and 8 (SD 9) ICU days were included. 72% were male and the mean ISS was 22 (SD 13). 30 (7.3%) patients developed VTE: 28 (6.8%) with LEDVT and 2 (0.5%) with PE. Risk factors for VTE with a p<0.2 on univariate analysis included: PMH of DVT, injury severity score (ISS), extremity fractures (Fx), and a pelvis or LE extremity Fx repair. After logistic regression, only PMH of DVT (OR=22.6) and any extremity Fx (OR=2.4) remained as independent predictors. CONCLUSION: VTE occur in 7% of critically injured trauma patients who cannot receive chemical prophylaxis. Aggressive screening and/or prophylactic IVCF placement may be considered in patients with a PMH of DVT or extremity fractures when anticoagulation is prohibited.