Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

Prehospital management of chest injuries in severely injured patients-a systematic review and clinical practice guideline update.

PURPOSE: Our aim was to review and update the existing evidence-based and consensus-based recommendations for the management of chest injuries in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies were included if they compared interventions for the detection and management of chest injuries in severely injured patients in the prehospital setting. We considered patient-relevant clinical outcomes such as mortality and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS: Two new studies were identified, both investigating the accuracy of in-flight ultrasound in the detection of pneumothorax. Two new recommendations were developed, one recommendation was modified. One of the two new recommendations and the modified recommendation address the use of ultrasound for detecting traumatic pneumothorax. One new good (clinical) practice point (GPP) recommends the use of an appropriate vented dressing in the management of open pneumothorax. Eleven recommendations were confirmed as unchanged because no new high-level evidence was found to support a change. CONCLUSION: Some evidence suggests that ultrasound should be considered to identify pneumothorax in the prehospital setting. Otherwise, the recommendations from 2016 remained unchanged.

Ambulance deployment without transport: a retrospective difference analysis for the description of emergency interventions without patient transport in Bavaria.

BACKGROUND: Not all patients who call the ambulance service are subsequently transported to hospital. In 2018, a quarter of deployments of an emergency ambulance in Bavaria were not followed by patient transport. This study describes factors that influence patient transport rates. METHOD: This is a retrospective cross-sectional study based on data from all Integrated Dispatch Centres of the Free State of Bavaria in 2018. Included were ambulance deployments without emergency physician involvement, which were subdivided into ambulance deployments without transport and ambulance deployments with transport. The proportion of transported patients were determined for the primary reasons for deployment and for the different community types. On-scene time was compared for calls with and without patient transport. Differences were tested for statistical significance using Chi2 tests and the odds ratio was calculated to determine differences between groups. RESULTS: Of 510,145 deployments, 147,621 (28.9%) could be classified as ambulance deployments without transport and 362,524 (71.1%) as ambulance deployments with transport.The lowest proportion of patients transported was found for activations where the fire brigade was involved ("fire alarm system" 0.6%, "fire with emergency medical services" 5.4%) and "personal emergency response system active alarm" (18.6%). The highest transport rates were observed for emergencies involving "childbirth/delivery" (96.9%) and "trauma" (83.2%). A lower proportion of patients is transported in large cities as compared to smaller cities or rural communities; in large cities, the odds ratio for emergencies without transport is 2.02 [95% confidence interval 1.98-2.06] referenced to rural communites. The median on-scene time for emergencies without transport was 20.8 min (n = 141,052) as compared to 16.5 min for emergencies with transport (n = 362,524). The shortest on-scene times for emergencies without transport were identified for activations related to "fire alarm system" (9.0 min) and "personal emergency response system active alarm" (10.6 min). CONCLUSION: This study indicates that the proportion of patients transported depends on the reason for deployment and whether the emergency location is urban or rural. Particularly low transport rates are found if an ambulance was dispatched in connection with a fire department operation or a personal emergency medical alert button was activated. The on-scene-time of the rescue vehicle is increased for deployments without transport. The study could not provide a rationale for this and further research is needed. Trial registration This paper is part of the study "Rettungswageneinsatz ohne Transport" ["Ambulance deployment without transport"] (RoT), which was registered in the German Register of Clinical Studies under the number DRKS00017758.

A simulation-based randomized trial of ABCDE style cognitive aid for emergency medical services CHecklist In Prehospital Settings: the CHIPS-study.

BACKGROUND: Checklists are a powerful tool for reduction of mortality and morbidity. Checklists structure complex processes in a reproducible manner, optimize team interaction, and prevent errors related to human factors. Despite wide dissemination of the checklist, effects of checklist use in the prehospital emergency medicine are currently unclear. The aim of the study was to demonstrate that participants achieve higher adherence to guideline-recommended actions, manage the scenario more time-efficient, and thirdly demonstrate better adherence to the ABCDE-compliant workflow in a simulated ROSC situation. METHODS: CHIPS was a prospective randomized case-control study. Professional emergency medical service teams were asked to perform cardiopulmonary resuscitation on an adult high-fidelity patient simulator achieving ROSC. The intervention group used a checklist which transferred the ERC guideline statements of ROSC into the structure of the 'ABCDE' mnemonic. Guideline adherence (performance score, PS), utilization of process time (items/minute) and workflow were measured by analyzing continuous A/V recordings of the simulation. Pre- and post-questionnaires addressing demographics and relevance of the checklist were recorded. Effect sizes were determined by calculating Cohen's d. The level of significance was defined at p < 0.05. RESULTS: Twenty scenarios in the intervention group (INT) and twenty-one in the control group (CON) were evaluated. The average time of use of the checklist (CU) in the INT was 6.32 min (2.39-9.18 min; SD = 2.08 min). Mean PS of INT was significantly higher than CON, with a strong effect size (p = 0.001, d = 0.935). In the INT, significantly more items were completed per minute of scenario duration (INT, 1.48 items/min; CON, 1.15 items/min, difference: 0.33/min (25%), p = 0.001), showing a large effect size (d = 1.11). The workflow did not significantly differ between the groups (p = 0.079), although a medium effect size was shown (d = 0.563) with the tendency of the CON group deviating stronger from the ABCDE than the INT. CONCLUSION: Checklists can have positive effects on outcome in the prehospital setting by significantly facilitates adherence to guidelines. Checklist use may be time-effective in the prehospital setting. Checklists based on the 'ABCDE' mnemonic can be used according to the 'do verify' approach. Team Time Outs are recommended to start and finish checklists.

[Pediatric emergency patients in the emergency departments of a German metropolitan region : A retrospective cross-sectional study over a one-year period]. / Pädiatrische Notfallpatienten in den Notaufnahmen einer deutschen Metropolregion : Eine retrospektive Querschnittsstudie über einen 1-Jahres-Zeitraum.

BACKGROUND: To date, no detailed analysis of pediatric emergencies treated in emergency departments (ED) exists. However, in the context of capacity planning and upcoming emergency care reform in Germany, these data are urgently needed. METHODS: Retrospective, multicenter cross-sectional study for the period 01 July 2013 to 01 June 2014 of pediatric cases in emergency departments in Munich. RESULTS: A total of 103,830 cases were analyzed (age: 6.9 ± 5.4 years, boys/girls 55%/45%). A total of 85.9% of cases were treated as outpatients, 12.4% (9.6 per 100,000 children) were admitted to normal and 1.7% (1.0 per 100,000 children) to intensive care. However, the real bed requirements exceeded these guideline numbers, with an absolute requirement of 4.9 ICU beds and 35.1 normal ward beds per day. Load peaks were seen on Wednesday and Friday afternoons and on weekends. Every 8th patient who presented to an ED as a self-referral was treated as an inpatient. CONCLUSION: Capacity planning for inpatient emergency care of pediatric patients requires planning for more beds than can be expected on a population basis. The availability of panel physician care influences patient volume in the EDs. Initial medical assessment tools for treatment need and urgency are needed to distribute patients. The pediatric emergency centers planned as part of the current reform of emergency care must be adequately staffed and financed in order to be able to handle-in close cooperation with statutory health insurance-accredited medical care-the expected demand for care.

Pre-Hospital Emergency Medical Services Utilization Amid COVID-19 in 2020: Descriptive Study Based on Routinely Collected Dispatch Data in Bavaria, Germany.

BACKGROUND AND IMPORTANCE: The COVID-19 pandemic affected the utilization of health care services and posed organizational challenges. While many previous studies focused on the misuse of pre-hospital EMS for low-urgency health problems, the pandemic has put more emphasis on the avoidance of medically necessary calls. OBJECTIVE: To compare the utilization of pre-hospital emergency medical services before and after specific pandemic periods. DESIGN, SETTING AND PARTICIPANTS: This was a retrospective, descriptive analysis of routine data from 26 dispatch centers in Bavaria, Germany. OUTCOMES MEASURE AND ANALYSIS: We investigated the number of emergencies per 100,000 population, as well as the relative change in the emergency rates and transport rates in 2020, compared to the two previous years. Boxplots showed the distributions across the Bavarian districts per calendar week. The mean rates and standard deviations as well as the relative changes were presented for the specific periods. A paired samples t-test was used to compare the rates. MAIN RESULTS: Compared to the average of the two previous years, the emergency rates in 2020 were lower in 35 out of 52 calendar weeks. The strongest reductions were observed during the first wave, where the average emergency rate declined by 12.9% (SD 6.8, p < 0.001). There was no statistically significant difference in the overall emergency rate during the summer holidays. Lower transport rates were observed throughout the year, especially during the first wave. CONCLUSIONS: Utilization of pre-hospital emergency medical services decreased in 2020, especially during the periods with strict measures. This could be due to the lower morbidity from the behavioral changes during the pandemic, but also to the avoidance of medical services for both less urgent and severe conditions. While a reduction in unnecessary care would be beneficial, patients must be encouraged to seek necessary urgent care, even during a pandemic.

Systemic review of age brackets in pediatric emergency medicine literature and the development of a universal age classification for pediatric emergency patients - the Munich Age Classification System (MACS).

Currently arbitrary, inconsistent and non-evidence-based age cutoffs are used in the literature to classify pediatric emergencies. None of these classifications have valid medical rationale. This leads to confusion and poor comparability of the different study results. To clarify this problem, this paper presents a systematic review of the commonly used age limits from 115 relevant articles. In the literature search 6226 articles were screened. To be included, the articles had to address the following three topics: "health services research in emergency medicine", "pediatrics" and "age as a differentiator". Physiologic and anatomic principles with reference to emergency medicine were used to solve the problem to create a medically based age classification for the first time.The Munich Age Classification System (MACS) presented in this paper is thus consistent with previous literature and is based on medical evidence. In the future, MAC should lead to ensure that a uniform classification is used. This will allow a better comparability of study results and enable meta-analyses across studies.

Severe trauma in Germany and Israel: are we speaking the same language? A trauma registry comparison.

Background: Trauma registries are a crucial component of trauma systems, as they could be utilized to perform a benchmarking of quality of care and enable research in a critical but important area of health care. The aim of this study is to compare the performance of two national trauma systems: Germany (TraumaRegister DGU®, TR-DGU) and Israel (Israeli National Trauma Registry, INTR). Methods: The present study was a retrospective analysis of data from the described above trauma registries in Israel and Germany. Adult patients from both registries treated during 2015-2019 with an Injury Severity Score (ISS) ≥ 16 points were included. Patient demographics, type, distribution, mechanism, and severity of injury, treatment delivered and length of stay (LOS) in the ICU and in the hospital were included in the analysis. Results: Data were available from 12,585 Israeli patients and 55,660 German patients. Age and sex distribution were comparable, and road traffic collisions were the most prevalent cause of injuries. The ISS of German patients was higher (ISS 24 vs. 20), more patients were treated on an intensive care unit (92 vs. 32%), and mortality was higher (19.4 vs. 9.5%) as well. Conclusion: Despite similar inclusion criteria (ISS ≥ 16), remarkable differences between the two national datasets were observed. Most probably, this was caused by different recruitment strategies of both registries, like trauma team activation and need for intensive care in TR-DGU. More detailed analyses are needed to uncover similarities and differences of both trauma systems.

[Position of trauma surgery in emergency medicine]. / Stellung der Unfallchirurgie in der Notfallmedizin.

BACKGROUND: The decision of the Federal Joint Committee has resulted in the further development of in-hospital emergency medicine through the establishment of central emergency departments and staged emergency care. In addition, the additional training in clinical acute and emergency medicine was established. AIM: The aim of this work is on the one hand to make trauma surgeons aware of these structural changes. On the other hand, we would like to evaluate an opinion and discuss the position of trauma surgery in emergency medicine. METHODS: A web-based online survey was conducted at the Trauma Network and Trauma Registry Congress to collect participants' opinions on the position of trauma surgery in emergency medicine. RESULTS: Of 143 congress participants, 98 (67%) responded to the survey. The majority of participants were male (n = 78, 80%), over 40 years of age (n = 62, 63%), and in a professional position with staff responsibility (n = 73, 75%). Emergency medicine (mean: 84.8; SD: 18.7) and intensive care medicine (mean: 78.3; SD: 20.4) training appears important. On the other hand, subsequent work in these areas appears less important (prehospital emergency medicine: mean: 65.1; SD: 28.0; ICU: mean: 53.7, SD: 30.3); however, activity in an emergency department is rated higher (MW: 87.0; SD: 18.7). There is high agreement that the trauma leader should be a trauma surgeon (mean 87.9; SD: 19.7). DISCUSSION: A high volume of emergency trauma surgery patients and the care of severely injured patients in designated trauma centers show that trauma surgery expertise is mandatory in a central emergency department. Senior positions should also be sought to ensure high quality standards.

[Differences between emergency medical services operations with and without patient transport : A retrospective analysis of dispatch center data in a territorial state]. / Unterschiede zwischen Rettungsdiensteinsätzen mit und ohne Patiententransport : Eine retrospektive Analyse der Leitstellendaten in einem Flächenstaat.

BACKGROUND: The use of the emergency medical services (EMS) in Bavaria has been increasing for years. We hypothesized that emergency response without patient transport (RoT) is often an expression of inadequate alert planning. The aim of the study was to describe the differences between the integrated dispatch centers (ILSs) for such operations with regard to the characteristics of transport quotas and ranges according to the reason for deployment as well as times and days of the week. METHOD: Retrospective cross-sectional study of data from all 26 ILSs in the Free State of Bavaria in 2018. Transport quotas for emergency operations for essential reasons without emergency physician involvement were analyzed comparatively in relation to dispatch center area, time of day, and day of the week. Deployments were categorized as RoT or ambulance deployment with transport (TP). RESULTS: Of 510,145 call-outs, 147,621 (28.9%) were RoT and 362,524 (71.1%) were TP. There were significant regional differences in the transport quotas for all deployment reasons investigated. The highest range among the ILSs was found for the deployment reasons "fire alarm system" (16.8 percentage points), "personal emergency response system" (16.1%), and "heart/circulation" (14.6%). In the morning hours, the number of calls decreases with increasing TP. The fewest RoT took place between 8 and 10 am. The days of the week analysis revealed small differences in the frequency of RoT on Mondays as well as on weekends without planning relevance. CONCLUSION: We found significant differences in the ranges. This could indicate locally different alert planning specifications or dispatching decisions by the ILS. The control centers probably have considerable potential for controlling and improving resource allocation.

Evaluation of a standardized instrument for post hoc analysis of trauma-team-activation-criteria in 75,613 injured patients an analysis of the TraumaRegister DGU®.

INTRODUCTION: To improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently. The objective was to examine whether the catalogue can identify patients that died after admission to the hospital and therefore can benefit from a specialized trauma team mostly. MATERIALS AND METHODS: The catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum abbreviated injury score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care. RESULTS: The TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%. DISCUSSION: The consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria. Our instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury.

Optimizing Emergency Medical Service Structures Using a Rule-Based Discrete Event Simulation-A Practitioner's Point of View.

Many studies in research deal with optimizing emergency medical services (EMS) on both the operational and the strategic level. It is the purpose of this method-oriented article to explain the major features of "rule-based discrete event simulation" (rule-based DES), which we developed independently in Germany and Switzerland. Our rule-based DES addresses questions concerning the location and relocation of ambulances, dispatching and routing policies, and EMS interplay with other players in prehospital care. We highlight three typical use cases from a practitioner's perspective and go into different countries' peculiarities. We show how research results are applied to EMS and healthcare organizations to simulate and optimize specific regions in Germany and Switzerland with their strong federal structures. The rule-based DES serves as basis for decision support to improve regional emergency services' efficiency without increasing cost. Finally, all simulation-based methods suggest normative solutions and optimize EMS' performance within given healthcare system structures. We argue that interactions between EMS, emergency departments, and public healthcare agencies are crucial to further improving effectiveness, efficiency, and quality.

Testing mechanical chest compression devices of different design for their suitability for prehospital patient transport - a simulator-based study.

BACKGROUND: Mechanical chest compression (mCPR) offers advantages during transport under cardiopulmonary resuscitation. Little is known how devices of different design perform en-route. Aim of the study was to measure performance of mCPR devices of different construction-design during ground-based pre-hospital transport. METHODS: We tested animax mono (AM), autopulse (AP), corpuls cpr (CC) and LUCAS2 (L2). The route had 6 stages (transport on soft stretcher or gurney involving a stairwell, trips with turntable ladder, rescue basket and ambulance including loading/unloading). Stationary mCPR with the respective device served as control. A four-person team carried an intubated and bag-ventilated mannequin under mCPR to assess device-stability (displacement, pressure point correctness), compliance with 2015 ERC guideline criteria for high-quality chest compressions (frequency, proportion of recommended pressure depth and compression-ventilation ratio) and user satisfaction (by standardized questionnaire). RESULTS: All devices performed comparable to stationary use. Displacement rates ranged from 83% (AM) to 11% (L2). Two incorrect pressure points occurred over 15,962 compressions (0.013%). Guideline-compliant pressure depth was > 90% in all devices. Electrically powered devices showed constant frequencies while muscle-powered AM showed more variability (median 100/min, interquartile range 9). Although physical effort of AM use was comparable (median 4.0 vs. 4.5 on visual scale up to 10), participants preferred electrical devices. CONCLUSION: All devices showed good to very good performance although device-stability, guideline compliance and user satisfaction varied by design. Our results underline the importance to check stability and connection to patient under transport.

Is there any benefit in the pre-hospital application of pelvic binders in patients with suspected pelvic injuries?

BACKGROUND: Massive hemorrhage is a common cause of death in patients sustaining instable pelvic ring fractures. Pelvic binders have been propagated for rapid, non-invasive pelvic ring stabilization and control of severe pelvic hemorrhage. There is a recommendation to applicate a pelvic binder due to the trauma mechanism alone. However, there is little evidence to support this advice. The aim of this study was to evaluate effects of an early pelvic binder application on transfusion requirements and hospital mortality. METHODS: This was a subgroup analysis of a study investigating clinical examination for pelvic stability. We included 64 patients who showed radiologically proven pelvic ring fracture (Tile type B or C). Study data were complemented by retrospective chart review to assess transfusion requirements. We used descriptive statistical analysis. RESULTS: 37 patients had a pelvic binder applied during prehospital treatment (pb), 27 received no binder (npb). Both showed no statistically significant difference in terms of injury severity or probability of survival. We found a trend towards higher ISS (29.7 vs. 24.4) and a lower probability of survival (RISC-II Prognosis 81% vs. 89%) in the pb group. Risk for massive transfusion according to TASH-Scores (10% vs. 6%), and average number of RPBC transfused (10.5 vs. 7.5) was higher in the pb group, without statistically significance. 20 patients (54%) in the pb group and 15 patients (55%) in the npb group showed a need of RPBC within the first 72 h. There was no significant difference in hospital mortality (20% vs. 13.3%). CONCLUSION: We were unable to identify blood-saving effects with application of a pelvic binder to patients with instable pelvic ring fractures in terms of RPBC requirements. Nevertheless, some salutary effect of prehospital pb application may be assumed. Better studies are needed to elucidate the value of this intervention.

Survey on worldwide trauma team activation requirement.

PURPOSE: Trauma team activation (TTA) is thought to be essential for advanced and specialized care of very severely injured patients. However, non-specific TTA criteria may result in overtriage that consumes valuable resources or endanger patients in need of TTA secondary to undertriage. Consequently, criterion standard definitions to calculate the accuracy of the various TTA protocols are required for research and quality assurance purposes. Recently, several groups suggested a list of conditions when a trauma team is considered to be essential in the initial care in the emergency room. The objective of the survey was to post hoc identify trauma-related conditions that are thought to require a specialized trauma team that may be widely accepted, independent from the country's income level. METHODS: A set of questions was developed, centered around the level of agreement with the proposed post hoc criteria to define adequate trauma team activation. The participants gave feedback before they answered the survey to improve the quality of the questions. The finalized survey was conducted using an online tool and a word form. The income per capita of a country was rated according to the World Bank Country and Lending groups. RESULTS: The return rate was 76% with a total of 37 countries participating. The agreement with the proposed criteria to define post hoc correct requirements for trauma team activation was more than 75% for 12 of the 20 criteria. The rate of disagreement was low and varied between zero and 13%. The level of agreement was independent from the country's level of income. CONCLUSIONS: The agreement on criteria to post hoc define correct requirements for trauma team activation appears high and it may be concluded that the proposed criteria could be useful for most countries, independent from their level of income. Nevertheless, more discussions on an international level appear to be warranted to achieve a full consensus to define a universal set of criteria that will allow for quality assessment of over- and undertriage of trauma team activation as well as for the validation of field triage criteria for the most severely injured patients worldwide.

Terror and disaster surgical care: training experienced trauma surgeons in decision making for a MASCAL situation with a tabletop simulation game.

BACKGROUND: Mass-casualty incidents, especially in connection with a terrorist attack, can quickly overwhelm the capacities of receiving hospitals. After a mass-casualty terrorist incident, patients often arrive at hospitals in an uncoordinated manner on account of the chaotic situation. Many patients leave the incident site and refer themselves to hospitals independently. Hospital decision makers must, therefore, be able to make quick decisions on diagnostic procedures and treatment for every individual patient and, at the same time, take into consideration available resources. They require decision criteria and aids to properly manage such scenarios. MATERIALS AND METHODS: As part of the preparation of the Terror and Disaster Surgical Care (TDSC®) course, we developed a tabletop simulation game based on a comprehensive and structured review of the literature, the opinions of renowned experts, and the results of specialised conferences. This tabletop simulation game is played four times during each TDSC® course. RESULTS: Our analysis involved 264 of 465 course-participants from 2017 to 2019 and showed that the overall evaluation was very good and that participants grew more positive about the tabletop simulation game during the course. The tabletop simulation game received an average rating of 1.53 (1 = very good, 6 = insufficient). This rating remained consistently high over 19 courses. DISCUSSION: Hospital decision makers must respond to mass-casualty terrorist situations in a defined tactical and strategic approach. Rapid decisions must be made that take into account the special situation and available capacities and resources to maximise the number of survivors even though individual patients may have a poorer functional outcome. As part of the TDSC® course, the tabletop simulation game teaches high-level decision-making algorithms and prepares key hospital personnel for such situations.

Applying Principles From Aviation Safety Investigations to Root Cause Analysis of a Critical Incident During a Simulated Emergency.

STATEMENT: Safety investigations in aviation aim to identify potential root causes. They use structured techniques to analyze information from flight data and cockpit voice recorders. Full-scale medical simulations using audiovisual recordings provide similar possibilities. During a simulated cardiac arrest, an incident related to use of the defibrillator (automated external defibrillator) occurred with emergency medical services (EMS) providers. Treatment interventions and dialogs during the incident were extracted from audiovisual recordings and transferred into a transcript of events.Knowing indicated treatment measures, the team adhered to automated external defibrillator voice prompts rather than follow their own assessment. Cardiopulmonary resuscitation was on hold for 72% of the time. Time to first defibrillation was delayed by 2:17 minutes. Transcript allowed us to identify faulty decision-making, loss of leadership, and automation bias as possible root causes. Use of RCA methodology during medical simulation improves understanding of critical incidents and can contribute to training of EMS personnel and education of instructors.

[Analysis of Treatment Figures in the Munich Emergency Rooms 2013-2014]. / Analyse der Behandlungszahlen in den Münchener Notaufnahmen des Jahres 2013/2014.

Medical care provided at the hospital emergency rooms in Germany has hardly been explored. On the occasion of restructuring the Municipal Hospital, the Munich City Council initiated the "Round Table Emergency Care" in order to determine reference figures for capacity planning. The present study was designed to analyze treatment data from 14 emergency departments which mainly carry the city's hospital emergency service. For inpatient cases, data were used in accordance with §21 Hospital Charges Act, for outpatient cases - as far as available - similar data were used, anonymized and combined with data from prehospital emergency medical services (EMS). In order to describe the domains treatment urgency, diagnostic/therapeutic effort and bed requirements, data were categorized in a 4-stage system. Over 12 months, 524,716 treatment cases were recorded: 34% were admitted to hospital, 80% came without EMS. One in 7 patients who independently went to an emergency room needed a bed in the intensive care or intermediate care unit (ICU/IMC). There were 64 cases per day and per 100,000 inhabitants requiring 7 ICU/IMC and 15 regular ward beds. Most cases (66%) were treated as outpatients and presented to the hospital's emergency department at times when facilities of the ambulatory care system would have been available. Urgency of these cases was usually low (50.9%), but effort was often high, due to diagnostics and surgical procedures. This study offers fundamental knowledge for planning emergency care. A large proportion of the presentations, especially those with injuries and those with diagnosis that require a more differentiated work-up, seem to be medically justified, which is why appropriate capacities have to be planned in. The study also shows that capacity planning on the basis of EMS cases alone is an inappropriate, one-sided approach.

Differences between cases admitted to hospital and discharged from the emergency department after emergency medical services transport.

OBJECTIVE: Rising emergency medical services (EMS) utilisation increases transport to hospital emergency departments (ED). However, some patients receive outpatient treatment (discharged) while others are hospitalised (admitted). The aims of this analysis were to compare admitted and discharged cases, to assess whether cases that were discharged from the ED could be identified using dispatch data and to compare dispatch keyword categories and hospital diagnoses. DESIGN: Retrospective observational study using linked secondary data. SETTING AND PARTICIPANTS: 78 303 cases brought to 1 of 14 ED in the city of Munich, Germany, by EMS between 1 July 2013 and 30 June 2014. MAIN OUTCOME MEASURES: Characteristics of admitted and discharged cases were assessed. Logistic regression was used to estimate the association between discharge and age, sex, time of day, ambulance type and dispatch keyword category. Keyword categories were compared to hospital diagnoses. RESULTS: 39.4% of cases were discharged. They were especially likely to be young (OR 10.53 (CI 9.31 to 11.92), comparing <15-year-olds to >70-year-olds) and to fall under the categories 'accidents/trauma' (OR 2.87 (CI 2.74 to 3.01)) or 'other emergencies (unspecified)' (OR 1.23 (CI 1.12 to 1.34) (compared with 'cardiovascular'). Most frequent diagnoses came from chapter 'injury and poisoning' (30.1%) of the 10th revision of the international statistical classification of disease and related health problems (ICD-10), yet these diagnoses were more frequent at discharge (42.7 vs 22.0%) whereas circulatory system disease was less frequent (2.6 vs 21.8%). Except for accidents/trauma and intoxication/poisoning many underlying diagnoses were observed for the same dispatch keyword. CONCLUSION: Young age and dispatch for accidents or trauma were the strongest predictors of discharge. Even within the same dispatch keyword category the distribution of diagnoses differed between admitted and discharged cases. Discharge from the ED does not indicate that urgent response was unnecessary. However, these cases could be suitable for allocation to hospitals with low inpatient bed capacities and are of particular interest for future studies regarding the urgency of their condition.

Use of pre-hospital emergency medical services in urban and rural municipalities over a 10 year period: an observational study based on routinely collected dispatch data.

BACKGROUND: Pre-hospital emergency medical services (EMS) are an integral part of emergency medical care. EMS planning can be achieved by analyzing patterns of use. However, long-term time trends of EMS use have rarely been studied. The objective of this retrospective study was to investigate utilization patterns over a ten year period, and to compare utilization trends between urban and rural municipalities and between events with and without prehospital emergency physician (PEP) dispatch. METHODS: Routine data collected by 26 dispatch centers in the federal state of Bavaria, Germany, from 2007 to 2016 was analyzed. Emergency locations were classified into five levels of rurality. Negative binomial mixed effects regression models were fitted to predict emergency rates and to investigate differences in rates and utilization trends. Graphical representation methods were used to compare distribution of transport rates and distribution across daytime and weekday. RESULTS: Twelve million two hundred thousand one hundred fifty-five dispatches assigned to 7,725,636 single emergencies were included. The mean number of emergencies per year and 1000 population (emergency rate) was 42.8 (±16.0) in rural municipalities and 80.7 (±9.3) in large cities. Compared to rural municipalities, cities had higher emergency rates without (IRR = 3.0, CI 2.2-4.0) and with pre-hospital physicians (IRR = 1.5, CI 1.2-2.0). Between 2007 and 2016, the absolute number of emergencies increased by 49.1%. Estimated annual percent change of emergency rates without physician activation ranged from 5.7% (CI 4.3-7.1) in cities to 7.8% (CI 7.6-7.9) in rural areas. Changes in emergency rates with physician attendance were lower, with estimated increases between 1.3 and 2.4%. The average proportion of patients transported to a hospital was lower in cities and remained unchanged. There were no considerable differences or changes in the distribution across daytime and weekdays. CONCLUSION: Differences between cities and other areas suggest that the planning of EMS should be targeted to regional characteristics. A substantial increase in emergency rates was observed across all areas of Bavaria, but did not impact transport rates or temporal distributions. Further research is needed to better understand the urgency of emergency events and reasons behind increasing EMS utilization.