Factors associated with in-hospital mortality and readmission in a cohort of patients treated with noninvasive ventilation during emergency department or out-of-hospital emergency care: the VentilaMadrid study. / Factores asociados a la mortalidad intrahospitalaria y reingreso en una cohorte tratada con ventilación no invasiva en urgencias extrahospitalarias y hospitalarias: estudio VentilaMadrid.

OBJECTIVES: To describe clinical, outcome, and risk factors in a cohort of patients treated with noninvasive ventilation (NIV) in a hospital emergency department (ED) or by out-of-hospital emergency medical services (OHEMSs). MATERIAL AND METHODS: Multicenter, prospective cohort study enrolling consecutive patients with acute pulmonary edema and/or exacerbated chronic obstructive pulmonary disease who were treated with NIV between November 2018 and November 2020 in a hospital ED or OHEMS setting in Madrid. We recorded baseline data, variables related to the acute episode, and outcome variables, including in-hospital mortality and 30-day readmission. RESULTS: A total of 317 patients were included; 132 (41.6%) were treated in an OHEMS setting and 185 (58.4%) in a hospital ED. Forty-seven (16.3%) in-hospital deaths occurred, and 78 patients (28.8%) were readmitted within 30 days. Mortality in the hospital ED and OHEMS subsamples did not differ, but the patients who received NIV in an OHEMS setting had a lower 30-day readmission rate. On multivariate analysis, in-hospital mortality was associated with prior dependence in activities of daily living in the multivariate analysis (odds ratio [OR], 2.4; 95% CI, 1.11-5.27) and a low-moderate score on the Simplified Acute Physiology Score II (SAPS II) versus a high-very high one (OR, 2.69; 95% CI, 1.26-5.77). Mortality after OHEMS ventilation was associated with discontinuance of NIV during transfer (OR, 8.57; 95% CI, 2.19-33.60). Readmission within 30 days was associated with group (in-hospital ED application of NIV) (OR, 3.24; 95% CI, 2.62-6.45) and prior dependence (OR, 2.08; 95% CI, 1.02-4.22). CONCLUSION: Patients treated in the hospital ED and OHEMS setting have similar baseline characteristics, although acute episodes were more serious in the OHEMS group. No significant differences were found related to in-hospital mortality. Higher mortality was associated with dependence, a SAPS II score greater than 52, and discontinuance of NIV. Readmission was associated with dependence and NIV treatment in the hospital ED setting.

OBJETIVO: Describir las características clínicas, evolutivas y los factores pronóstico de una cohorte de pacientes tratados con ventilación no invasiva (VNI) en servicios de urgencias extrahospitalarios (SUEH) y hospitalarios (SUH). METODO: Estudio de cohortes multicéntrico, prospectivo con inclusión consecutiva de pacientes con edema agudo de pulmón o agudización de enfermedad pulmonar obstructiva crónica tratados con VNI entre noviembre 2018 y noviembre de 2020 en SUEH y SUH de la Comunidad de Madrid. Se recogieron características basales, del episodio agudo, así como variables de resultado incluyendo la mortalidad hospitalaria y el reingreso a 30 días. RESULTADOS: Se incluyeron 317 pacientes, 132 (41,6%) en SUEH y 185 (58,4%) en SUH. Hubo 47 muertes intrahospitalarias (16,3%) y 78 reingresos a los 30 días (28,8%). No hubo diferencias en la mortalidad, pero el grupo VNI-SUEH tuvo menor reingreso a 30 días. En el análisis multivariado la mortalidad intrahospitalaria se asoció con la dependencia previa (OR = 2,4; IC 95%: 1,11-5,27) y el SAPS-II bajo-moderado frente al alto-muy alto (OR = 2,69; IC 95%: 1,26-5,77). En la cohorte extrahospitalaria, la mortalidad intrahospitalaria se asoció con la retirada de la VNI en la transferencia del paciente (OR = 8,57; IC 95%: 2,19-33,60). Los reingresos a los 30 días se asociaron con inicio de VNI en el hospital (OR = 3,24; IC 95%: 2,62-6,45) y dependencia previa (OR = 2,08; IC 95%: 1,02-4,22). CONCLUSIONES: Los pacientes de ambos grupos, SUH y SUEH, tienen un perfil clínico basal similar, aunque con mayor gravedad del episodio en el grupo SUEH. No se encontraron diferencias estadísticamente significativas en la mortalidad intrahospitalaria. Se asociaron a una mayor mortalidad la dependencia, la escala SAPS-II > 52 y la retirada de la VNI. El reingreso se asoció con la dependencia y pertenecer al grupo SUH.

Factores asociados a la mortalidad intrahospitalaria y reingreso en una cohorte tratada con ventilación no invasiva en urgencias extrahospitalarias y hospitalarias: estudio VentilaMadrid / Factors associated with in-hospital mortality and readmission in a cohort of patients treated with noninvasive ventilation during emergency department or out-of-hospital emergency care: the VentilaMadrid study

Objetivo. Describir las características clínicas, evolutivas y los factores pronóstico de una cohorte de pacientes trata- dos con ventilación no invasiva (VNI) en servicios de urgencias extrahospitalarios (SUEH) y hospitalarios (SUH). Método. Estudio de cohortes multicéntrico, prospectivo con inclusión consecutiva de pacientes con edema agudo de pulmón o agudización de enfermedad pulmonar obstructiva crónica tratados con VNI entre noviembre 2018 y noviembre de 2020 en SUEH y SUH de la Comunidad de Madrid. Se recogieron características basales, del episodio agudo, así como variables de resultado incluyendo la mortalidad hospitalaria y el reingreso a 30 días. Resultados. Se incluyeron 317 pacientes, 132 (41,6%) en SUEH y 185 (58,4%) en SUH. Hubo 47 muertes intrahospi talarias (16,3%) y 78 reingresos a los 30 días (28,8%). No hubo diferencias en la mortalidad, pero el grupo VNI-SUEH tuvo menor reingreso a 30 días. En el análisis multivariado la mortalidad intrahospitalaria se asoció con la dependen- cia previa (OR = 2,4; IC 95%: 1,11-5,27) y el SAPS-II bajo-moderado frente al alto-muy alto (OR = 2,69; IC 95%: 1,26- 5,77). En la cohorte extrahospitalaria, la mortalidad intrahospitalaria se asoció con la retirada de la VNI en la transferencia del paciente (OR = 8,57; IC 95%: 2,19-33,60). Los reingresos a los 30 días se asociaron con inicio de VNI en el hospital (OR = 3,24; IC 95%: 2,62-6,45) y dependencia previa (OR = 2,08; IC 95%: 1,02-4,22). Conclusiones. Los pacientes de ambos grupos, SUH y SUEH, tienen un perfil clínico basal similar, aunque con mayor gravedad del episodio en el grupo SUEH. No se encontraron diferencias estadísticamente significativas en la mortalidad intrahospitalaria. Se asociaron a una mayor mortalidad la dependencia, la escala SAPS-II > 52 y la retirada de la VNI. El reingreso se asoció con la dependencia y pertenecer al grupo SUH.

Objective. To describe clinical, outcome, and risk factors in a cohort of patients treated with noninvasive ventilation (NIV) in a hospital emergency department (ED) or by out-of-hospital emergency medical services (OHEMSs). Methods. Multicenter, prospective cohort study enrolling consecutive patients with acute pulmonary edema and/or exacerbated chronic obstructive pulmonary disease who were treated with NIV between November 2018 and November 2020 in a hospital ED or OHEMS setting in Madrid. We recorded baseline data, variables related to the acute episode, and outcome variables, including in-hospital mortality and 30-day readmission. Results. A total of 317 patients were included; 132 (41.6%) were treated in an OHEMS setting and 185 (58.4%) in a hospital ED. Forty-seven (16.3%) in-hospital deaths occurred, and 78 patients (28.8%) were readmitted within 30 days. Mortality in the hospital ED and OHEMS subsamples did not differ, but the patients who received NIV in an OHEMS setting had a lower 30-day readmission rate. On multivariate analysis, in-hospital mortality was associated with prior dependence in activities of daily living in the multivariate analysis (odds ratio [OR], 2.4; 95% CI, 1.11– 5.27) and a low-moderate score on the Simplified Acute Physiology Score II (SAPS II) versus a high-very high one (OR, 2.69; 95% CI, 1.26–5.77). Mortality after OHEMS ventilation was associated with discontinuance of NIV during transfer (OR, 8.57; 95% CI, 2.19–33.60). Readmission within 30 days was associated with group (in-hospital ED application of NIV) (OR, 3.24; 95% CI, 2.62–6.45) and prior dependence (OR, 2.08; 95% CI, 1.02–4.22). [...]

Role of oxytocin in prevention of postpartum hemorrhage in unplanned out-of-hospital deliveries treated by emergency medical services.

INTRODUCTION: Intramuscular or intravenous oxytocin is used in out-of-hospital emergency care in Finland to prevent postpartum hemorrhage after unplanned out-of-hospital deliveries. However, the use of oxytocin by emergency medical services is based on in-hospital studies. The aim of this study was to determine whether the use of oxytocin is associated with diminished postpartum hemorrhage after unplanned out-of-hospital deliveries. MATERIAL AND METHODS: We studied patient records covering all unplanned out-of-hospital deliveries in the Helsinki University Hospital area between 1 January 2013 and 31 December 2017 inclusive. Oxytocin was available in ambulances responsible for half of the population of the study area and was not available in ambulances responsible for the other half. The study area corresponded to 25% of all deliveries in Finland. The primary outcome was the estimated total bleeding (mL). Secondary outcomes were (1) the first blood hemoglobin value measured in hospital (g/L), (2) whether blood hemoglobin was measured during the first 24 hours after delivery, (3) the need for red blood cell concentrate, (4) the need for uterotonic or prothrombotic medication in-hospital during the first 24 hours, (5) the need for any postpartum operation during the first 24 hours and (6) composite outcome combining the secondary outcomes 2-5. RESULTS: Of all ambulance responses in the study area, .04% concerned out-of-hospital deliveries. There were 216 analyzed out-of-hospital deliveries. Altogether, 111 of these occurred in the area with oxytocin available in ambulances and 105 in the area without. Oxytocin was administered in 57 of the 111 deliveries (51%) where it was available. No differences in the primary outcome (P = .548 for oxytocin available vs not available and P = .381 for oxytocin used vs not used) or secondary outcomes were detected between those deliveries where oxytocin was available vs not available or between those where it was used vs not used. CONCLUSIONS: Out-of-hospital oxytocin was not associated with diminished postpartum hemorrhage in this study setting. Oxytocin does not seem to be an essential drug for all ambulance units. The in-hospital use of oxytocin was not evaluated and thus is not disputed by this study.

Emergency medical services targeting opioid user disorder: An exploration of current out-of-hospital post-overdose interventions.

OBJECTIVE: The opioid epidemic continues to escalate, and out-of-hospital emergency medical services (EMS) play a vital role in acute overdose reversal, but could serve a broader role post-incident for follow-up, outreach, and referrals. Our objective is to identify the scope and prevalence of community-based, post-opioid overdose EMS programs across the United States. METHODS: We used a narrative review of prior studies in PubMed and Scopus for the last 20 years (1999-2020) to identify relevant medical literature and a web search to identify gray literature of EMS interventions involving opioids. RESULTS: Out of nearly 22,000 EMS agencies across the United States, we found evidence of only 27 programs published in medical or gray literature involving post-overdose interventions. They were most commonly found in the north and eastern region of the country. Although most of these programs incorporate harm reduction and education, other more innovative aspects such as linkage to outpatient addiction treatment or peer support services, are much less common. The most comprehensive programs involved combinations of innovative outreach, specialized referrals, integration with police and criminal justice, peer support, and even treatment initiation. CONCLUSIONS: Out-of-hospital emergency care has the potential to provide more comprehensive care after drug overdose, but many programs either do not currently have such an intervention in place, or are not disseminating their practices for other agencies to assimilate. EMS protocols and policies that encourage greater adoption of active community paramedicine practices for opioids should be encouraged.

Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review.

BACKGROUND: Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery. METHODS: We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary. RESULTS: A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation. CONCLUSIONS: Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

Counseling patients and family members in out-of-hospital emergency situations: a survey for emergency staff.

BACKGROUND: Not much is known about emergency care delivered in patients' homes or other out-of-hospital settings. This study aims to describe out-of-hospital emergency staff's experiences of encountering and counseling patients and their family members. METHODS: A descriptive cross-sectional design was applied. Data were collected from a hospital district in Finland from emergency care staff via an electronic survey questionnaire specifically developed for this purpose (N = 125, N = 142 reponse rate 59%, response rate 53%) and analyzed using descriptive statistics. RESULTS: Respondents succeeded in encountering (up to 3.88/4) and counseling (up to 3.89/4) patients and family members. Challenges were related to introducing themselves to family members (3.20/4), to interacting with patients from different cultures (3.38/4) and to allowing family members to be present in care situations (2.29/4). Providing emotional support (2.56/4), especially to family members, and confirming (3.16/4) and ensuring continuity of care instructions (3.00/4) were found to be challenging. CONCLUSIONS: High-level counseling in acute out-of-hospital situations demands that care providers can put themselves into the patient's and family's situation, ensure follow-up care and provide care instructions to both patients and families. The presence and participation of family members is essential in acute care situations outside hospital contexts. Ensuring that these contents are included and practiced during basic and continuing emergency care education for nurses and other emergency staff is crucial for developing counseling practices.