Implementation of a prehospital whole blood program: Lessons learned.

Early blood administration by Emergency Medical Services (EMS) to patients suffering from hemorrhagic shock improves outcomes. Prehospital blood programs represent an invaluable resuscitation capability that directly addresses hemorrhagic shock and mitigates subsequent multiple organ dysfunction syndrome. Prehospital blood programs must be thoughtfully planned, have multiple safeguards, ensure adequate training and credentialing processes, and be responsible stewards of blood resources. According to the 2022 best practices model by Yazer et al, the four key pillars of a successful prehospital program include the following: (1) the rationale for the use and a description of blood products that can be transfused in the prehospital setting, (2) storage of blood products outside the hospital blood bank and how to move them to the patient in the prehospital setting, (3) prehospital transfusion criteria and administration personnel, and (4) documentation of prehospital transfusion and handover to the hospital team.  This concepts paper describes our operational experience using these four pillars to make Maryland's inaugural prehospital ground-based low-titer O-positive whole blood program successful. These lessons learned may inform other EMS systems as they establish prehospital blood programs to help improve outcomes and enhance mass casualty response.

Do prehospital sepsis alerts decrease time to complete CMS sepsis measures?

INTRODUCTION: In an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures. METHODS: This study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L. RESULTS: Median time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61-153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75-189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert. CONCLUSION: This study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.

Safety of Nurse-Managed Inhaled Nitric Oxide During Critical Care Interfacility Transport.

Inhaled nitric oxide (iNO) is an advanced therapy typically managed by physicians and respiratory therapists in order to increase arterial oxygenation and decrease pulmonary arterial pressure. The Johns Hopkins Lifeline Critical Care Transportation Program (Lifeline) initiated a novel nurse-managed iNO protocol in order to optimize the oxygenation of critically ill patients during interfacility transport. This study was a retrospective chart review of adverse events associated with iNO initiation or continuation by Lifeline on patients transported from March 1, 2020, to August 1, 2022. Basic demographic data and adverse events were recorded. Recorded adverse events included hypotension defined as a mean arterial pressure (MAP) < 65 mm Hg, hypoxemia defined as a decrease of ≥ 10% arterial oxygenation saturation measured by pulse oximetry, new bradycardia or tachyarrhythmia, nitrogen dioxide (NO2) levels greater than 1.0 ppm, methemoglobinemia, and cardiac arrest. Fifteen patients were diagnosed with SARS-CoV-2 infection, of which one also had pulmonary emboli, 2 had bacterial pneumonia, 1 suffered cardiogenic shock from occlusive myocardial infarction and were on VA-ECMO, and 2 had significant thoracic trauma resulting in pulmonary contusions and hemopneumothorax. iNO was continued on 10 patients and initiated on 8 patients, 2 of whom were transitioned from inhaled epoprostenol. Hypotension occurred in 3 (16.7%) patients and one (5.56%) of the hypotensive patients subsequently went on to experience new atrial fibrillation with vasopressor titration. No patients developed worsening hypoxemia, elevated NO2 levels, methemoglobinemia, or suffered cardiac arrest. All 3 patients who experienced hypotension were already on vasopressor support and the hypotension resolved with medication titration. This study shows that iNO administration can be safely managed by appropriately trained nurses.

Impacts of an EMS Hospital Liaison Program on Ambulance Offload Times: A Preliminary Analysis.

INTRODUCTION: Ambulance patients who are unable to be quickly transferred to an emergency department (ED) bed represent a key contributing factor to ambulance offload delay (AOD). Emergency department crowding and associated AOD are exacerbated by multiple factors, including infectious disease outbreaks such as the coronavirus disease 2019 (COVID-19) pandemic. Initiatives to address AOD present an opportunity to streamline ambulance offload procedures while improving patient outcomes. STUDY OBJECTIVE: The goal of this study was to evaluate the initial outcomes and impact of a novel Emergency Medical Service (EMS)-based Hospital Liaison Program (HLP) on ambulance offload times (AOTs). METHODS: Ambulance offload times associated with EMS patients transported to a community hospital six months before and after HLP implementation were retrospectively analyzed using proportional significance tests, t-tests, and multiple regression analysis. RESULTS: A proportional increase in incidents in the zero to <30 minutes time category after program implementation (+2.96%; P <.01) and a commensurate decrease in the proportion of incidents in the 30 to <60 minutes category (-2.65%; P <.01) were seen. The fully adjusted regression model showed AOT was 16.31% lower (P <.001) after HLP program implementation, holding all other variables constant. CONCLUSION: The HLP is an innovative initiative that constitutes a novel pathway for EMS and hospital systems to synergistically enhance ambulance offload procedures. The greatest effect was demonstrated in patients exhibiting potentially life-threatening symptoms, with a reduction of approximately three minutes. While small, this outcome was a statistically significant decrease from the pre-intervention period. Ultimately, the HLP represents an additional strategy to complement existing approaches to mitigate AOD.

Decision Making and Interventions During Interfacility Transport of High-Acuity Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

OBJECTIVE: There are limited data regarding the typical characteristics of coronavirus disease 2019 (COVID-19) patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision making needed to transport critically ill COVID-19 patients. METHODS: A retrospective chart review of persons under investigation for COVID-19 transported during the first 6 months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction assay were included in the analysis. RESULTS: Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and 1 (0.75%) received an inhaled pulmonary vasodilator. At least 1 ventilator setting change occurred for 59 patients (22.0%), and ventilation mode was changed for 11 patients (4.10%) during transport. CONCLUSION: The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking, and decision making.