Association between prehospital ROX index with 30-day mortality among septic shock.

PURPOSE: Respiratory dysfunction is one of the most frequent symptoms observed during sepsis reflecting hypoxemia and/or acidosis that may be assessed by the ROX index (ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate). This study aimed to describe the relationship between the prehospital ROX index and 30-day mortality rate among septic shock patients cared for in the prehospital setting by a mobile intensive care unit (MICU). METHODS: From May 2016 to December 2021, 530 septic shock patients cared for by a prehospital MICU were retrospectively analysed. Initial ROX index value was calculated at the first contact with MICU. A Cox regression analysis after propensity score matching was performed to assess the relationship between 30-day mortality rate and a ROX index ≤ 10. RESULTS: Pulmonary, digestive and urinary sepsis were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality reached 31%. Cox regression analysis showed a significant association between 30-day mortality and a ROX index ≤ 10: adjusted hazard ratio of 1.54 [1.08-2.31], p < 0.05. CONCLUSIONS: During the prehospital stage of septic shock patients cared for by a MICU, ROX index is significantly associated with 30-day mortality. A prehospital ROX ≤ 10 value is associated with a 1.5-fold 30-day mortality rate increase. Prospective studies are needed to confirm the ability of prehospital ROX to predict sepsis outcome since the prehospital setting.

Pediatric trauma patients in Swedish ambulance services -a retrospective observational study of assessments, interventions, and clinical outcomes.

BACKGROUND: Pediatric trauma patients constitute a significant portion of the trauma population treated by Swedish Emergency Medical Services (EMS), and trauma remains a notable cause of death among Swedish children. Previous research has identified potential challenges in prehospital assessments and interventions for pediatric patients. In Sweden, there is limited information available regarding pediatric trauma patients in the EMS. The aim of this study was to investigate the prevalence of pediatric trauma patients within the Swedish EMS and describe the prehospital assessments, interventions, and clinical outcomes. METHODS: This retrospective observational study was conducted in a region of Southwestern Sweden. A random sample from ambulance and hospital records from the year 2019 was selected. Inclusion criteria were children aged 0-16 years who were involved in trauma and assessed by EMS clinicians. RESULTS: A total of 440 children were included in the study, representing 8.4% of the overall trauma cases. The median age was 9 years (IQR 3-12), and 60.5% were male. The leading causes of injury were low (34.8%) and high energy falls (21%), followed by traffic accidents. The children were assessed as severely injured in 4.5% of cases. A quarter of the children remained at the scene after assessment. Complete vital signs were assessed in 29.3% of children, and 81.8% of children were assessed according to the ABCDE structure. The most common intervention performed by prehospital professionals was the administration of medication. The mortality rate was 0.2%. CONCLUSIONS: Pediatric trauma cases accounted for 8.4% of the overall trauma population with a variations in injury mechanisms and types. Vital sign assessments were incomplete for a significant proportion of children. The adherence to the ABCDE structure, however, was higher. The children remained at the scene after assessment requires further investigation for patient safety.

[Beware of labels]. / 5 minutes pour apprendre. Gare aux étiquettes.

A 50-year-old individual identified as a 'frequent user' of emergency services due to chronic abdominal pain was transported to the emergency department by ambulance during a new episode of abdominal pain. Despite being initially deemed stable by paramedics, the patient was not reassessed by the triage nurse upon arrival. Subsequently, the patient presented with severe pain, arterial hypotension, and tachycardia. Following a multidisciplinary protocol for pain management, analgesic treatment was initiated. Despite several hours of management and repeated assessments, an abdominal CT-scan was eventually conducted, revealing a perforated small intestine. The application of the 'frequent user' label may have contributed to a delay in the provision of timely care for this patient.

[Reduction in malaria case-fatality rate after implementation of an emergency plan for improved case management in the Bittou health district, Burkina Faso]. / Réduction de la létalité du paludisme après la mise en œuvre d'un plan d'urgence pour l'amélioration de la prise en charge des cas dans le district sanitaire de Bittou, Burkina Faso.

Objective: To observe the evolution in malaria case-fatality rate among children under 5 years of age receiving care at the Bittou district hospital (CMA) after an improvement of the care practices. The management team implemented an emergency plan in 2016 with 5 components: i) health facilities staff sensitization to enable rapid referral of severe malaria cases to CMA; ii) reorganization of CMA paediatric emergencies to make a physician as the mainpoint of contact; iii) ensuring availability of supplies for severe malaria case management, including the availability of blood; iv) daily medical check-ups of hospitalized patients; v) reinforcement of clinical staff skills at all peripheral health facilities. At the same time were introduced i) free care for children under 5 years; ii) municipality involvement to finance ambulance fuel for the referrals of patients; iii) free blood collection in professional schools and soldiers; iv) a free telephone line between the health structures; v) presence of 5 medical doctors at the CMA. Material and methods: Analysis of data collected from the statistical yearbooks of the Ministry of Health of Burkina Faso from 2014 to 2021. Results: The malaria case-fatality rate (CFR) in under-five in the Bittou health district (1.39% and 1.52% in 2014 and 2015) was higher than the average for all districts in this region (1.08%). After implementation of the emergency plan, the malaria CFR in Bittou declined to 0% in 2016 and 2017, 0.2% in 2018, 0% in 2019, 0.07% in 2020 and 0.05% in 2021. The same trend was observed at the CMA level with 2.94% and 2.59% in 2014 and 2015, 0% in 2016 and 2017, 0.38% in 2018, 0% in 2019, then 0.17% and 0.47% in 2020 and 2021. Conclusion: Malaria control remains a challenge in Burkina Faso. However, the improved malaria CFRs observed in Bittou show that effective involvement of health district teams could potentially contribute to substantial reductions in malaria case-fatality risk.

Role identities of emergency medical services personnel and their associations with intention to leave the profession.

BACKGROUND: The scope of emergency medical services (EMS) has expanded from the urgent care of emergency patients to on-call healthcare services provided in the field with a holistic view of the patient's wellbeing. This challenges EMS to find solutions to cover all demands, while simultaneously setting high skill requirements for EMS personnel. Understanding personnel is a critical element in developing functional and resistant EMS. The aim of this study was to investigate how Finnish EMS personnel emphasize the Emergency Medical Services Role Identity Scale aspects of caregiving, thrill-seeking, duty, and capacity; and if these role identities are associated with intention to leave the profession. METHODS: We conducted a cross-sectional survey (N = 616, 52% women, mean age 32.9 years). Data were collected through social media platforms and analyzed with means, standard deviations, Mann-Whitney U-tests, Kruskal-Wallis H-tests, and binary logistic regression analyses. RESULTS: Our results indicate that capacity is the most emphasized aspect among EMS personnel, and at the same time, it increases intention to leave EMS. Capacity was followed by caregiving, with no association with intention to leave. Duty and thrill-seeking were the least emphasized and were negatively associated with intention to leave. Additionally, there were also other factors that were associated with emphasizing EMS-RIS aspect and intention to leave. CONCLUSION: Capacity stands out most strongly in analysis being at the core of the role identity of EMS personnel and was associated with a higher likelihood of leaving intentions. Several other factors were also associated with the intention to leave. Future studies should examine the exact dimensions of capacity that are considered important among EMS personnel and why factors such as work experience are associated with intentions to leave.

Implementation of a point-of-care ultrasound archiving system and governance framework in a UK physician-paramedic staffed helicopter emergency medical service.

INTRODUCTION: There has been a rapid expansion in the use of point-of-care ultrasonography (POCUS) by emergency medical services (EMS). However, less than a third of UK EMS utilise imaging archiving for POCUS, and fewer review saved images as part of a clinical governance structure. This paper describes the implementation of a novel image archiving system and a robust clinical governance framework in our UK physician-paramedic staffed helicopter emergency medical service (HEMS). METHODS: A retrospective database review was conducted of all patients attended by East Anglian Air Ambulance (EAAA) between the introduction of a new POCUS device and image archiving system on 1 December 2020 to 31 January 2024. All patients with recorded POCUS examinations were included. Images from POCUS examinations at EAAA are archived on a cloud-based server, and retrospectively reviewed within 24 h by an EAAA POCUS supervisor. Image quality is graded using a 5-point Likert-type scale, agreement between reviewer and clinician is recorded and feedback is provided on scanning technique. T-tests were used to assess the difference in image quality between physicians and paramedics. Inter-rater reliability between reviewers and clinicians was assessed using Cohen's kappa (κ). RESULTS: During the study period, 5913 patients were attended by EAAA. Of these, 1097 patients had POCUS images recorded. The prevalence of POCUS during the study period was 18.6%. 1061 patient examinations underwent quality assurance (96.7%). The most common POCUS examination was echocardiography (60%), predominantly during cardiac arrest. The primary scanning clinician was a paramedic in 25.4% of POCUS examinations. Across all examination types; image quality was not significantly different between physicians and paramedics and agreement between reviewers and clinicians was strong (κ > 0.85). CONCLUSIONS: In this service evaluation study, we have described outcomes following the introduction of a new POCUS device, image archiving system and governance framework in our HEMS. Paramedics were the primary scanning clinician in a quarter of scans, with image quality comparable to physicians. Almost all scans underwent quality assurance and inter-rater reliability was strong between clinicians and reviewers. Further research is required to investigate the diagnostic accuracy of POCUS and to demonstrate the effect of utilising prehospital POCUS to refine diagnosis on clinical outcomes.

Development of practical emergency simulation training in primary health care: Lessons learnt.

Emergency care in the primary health care setting is often sub-optimal leading to physician stress and adverse patient outcomes. Formal training opportunities in the management of emergency management are limited in public-sector facilities. Two family physicians conducted emergency simulation drills at primary health care facilities to address this need. The multi-disciplinary team at these facilities were involved, and each drill was followed by reflection and feedback. The drill evolved over an 18 month period, and the simulations as well as the feedback process were reviewed and improved. Reported benefits included improved skills and confidence, teamwork and sharing of information. Staff appreciated the support and the opportunity to review emergency equipment and drugs. Recommendations based on the experience gained and the outcomes of the simulation training include that the feedback is just as important as the simulations and that clinicians need to be trained in order to facilitate simulations successfully.

A context-driven approach through stakeholder engagement to introduce a digital emergency obstetric and newborn care register into routine obstetric health care services in Bangladesh.

Background: Emergency obstetric and newborn care (EmONC) in Bangladesh focusses on maternal health, whereby it addresses childbirth and postpartum complications to ensure women's health and well-being. It was transitioned to a digital platform to overcome challenges with the paper-based EmONC register and we conducted implementation research to assess the outcome. Here we outline the stakeholder engagement process integral to the implementation research process. Methods: We adopted a four-step stakeholder engagement model based on the identification, sensitisation, involvement, and engagement of stakeholders. The approach was informed by previous experience, desk reviews, and expert consultations to ensure comprehensive engagement with stakeholders at multiple levels. Led by the Maternal Health Programme of the Government of Bangladesh, we involved high-power and high-interest stakeholders in developing a joint action plan for digitisation of the paper-based EmONC register. Finally, we demonstrated this digital EmONC register in real-life settings to stakeholders at different levels. Results: The successful demonstration process fostered government ownership and collaboration with multiple stakeholders, while laying the foundation for scalability and sustainability. Nevertheless, our experience highlighted that the stakeholder engagement process is context-driven, time-consuming, resource-intensive, iterative, and dynamic, and it requires involving stakeholders with varied expertise. Effective strategic planning, facilitation, and the allocation of sufficient time and resources are essential components for successful stakeholder engagement. Conclusions: Our experience demonstrates the potential of adopting the 'identification, sensitisation, involvement, and engagement' stakeholder engagement model. Success in implementing this model in diverse settings depends on leveraging knowledge gained during implementation, maintaining robust communication with stakeholders, and harnessing the patience and determination of the facilitating organisation.

Introducing a digital emergency obstetric and newborn care register for indoor obstetric patient management: An implementation research in selected public health care facilities of Bangladesh.

Background: Digital health records have emerged as vital tools for improving health care delivery and patient data management. Acknowledging the gaps in data recording by a paper-based register, the emergency obstetric and newborn care (EmONC) register used in the labour ward was digitised. In this study, we aimed to assess the implementation outcome of the digital register in selected public health care facilities in Bangladesh. Methods: Extensive collaboration with stakeholders facilitated the development of an android-based electronic register from the paper-based register in the labour rooms of the selected district and sub-district level public health facilities of Bangladesh. We conducted a study to assess the implementation outcome of introducing the digital EmONC register in the labour ward. Results: The digital register demonstrated high usability with a score of 83.7 according to the system usability scale, and health care providers found it highly acceptable, with an average score exceeding 95% using the technology acceptance model. The adoption rate reached an impressive 98% (95% confidence interval (CI) = 98-99), and fidelity stood at 90% (95% CI = 88-91) in the digital register, encompassing more than 80% of data elements. Notably, fidelity increased significantly over the implementation period of six months. The digital system proved a high utility rate of 89% (95% CI = 88-91), and all outcome variables exceeded the predefined benchmark. Conclusions: The implementation outcome assessment underscores the potential of the digital register to enhance maternal and newborn health care in Bangladesh. Its user-friendliness, improved data completeness, and high adoption rates indicate its capacity to streamline health care data management and improve the quality of care.

Characteristics of consecutive versus non-consecutive frequent emergency medical services transport to a single emergency department.

OBJECTIVE: This study was to examine characteristics concerning frequent users of emergency medical services (EMS) transport by comparing patients who used EMS transport frequently for one year and those who used EMS transport for more than two years consecutively. METHODS: A retrospective review for frequent use of EMS transport was conducted. The patients from the fire stations that transported more than 70% of all EMS transport to the study hospital emergency department (ED) were included. The study subjects were divided into consecutive group (frequent EMS transport for ≥ two years consecutively) and non-consecutive group (frequent EMS transport for only one year). Characteristics of patients who were frequent users of EMS transport and those of all cases with EMS transport were examined. RESULTS: Of the total 205 patients and 1204 cases of frequent EMS transport, 85 (42%) patients and 755 (63%) cases were in the consecutive group. Patients in the consecutive group were more likely to have risky alcohol use, unemployed state, and medical aid type of payment for ED treatment than those in the non-consecutive group. More patients had previous experience of EMS transport to the study hospital ED in the consecutive group and the number of cases with alcohol ingestion was higher in the consecutive group. Elapsed time from EMS call to ED arrival was longer for the consecutive group. CONCLUSION: Risky alcohol use, unemployed state, and previous experience of EMS transport were associated with consecutive and frequent use of EMS transport in frequent users of EMS transport.

The way back home: The invisible burden of the emergency healthcare services.

Ambulance services around the world vary according to regional, cultural and socioeconomic conditions. Many countries apply different health policies locally. In Turkey, transportation from hospital to home has started to form an important part of ambulance services in recent years. The increase in the number of patients whose treatment has been completed and waiting to be referred may hinder the work of the emergency services. The aim of this study was to examine the costs, indications, and impact on workload of patients sent home by ambulance. Patients were divided into two groups according to the reasons for referral. The distance to home, transport time and cost were calculated according to the reasons for transport. Patients who were transferred to other clinics or hospitals by ambulance were excluded from the study. The findings showed that the hospital-to-home transfer rate during the study period was 11.4%. Although 9.7% of all cases transferred from our hospital to home were due to social indications, these cases accounted for 16.26% of the total costs. These results suggest that providing home transport services to selected patient groups for medical reasons should be seen as part of the treatment. However, the indications for home transport should not be exceeded and an additional burden should not be placed on the fragile health service.

Integrating the six C's of disaster response: Lessons from the mega terrorist attack on October 7, 2023.

On October 7, 2023, over 2,500 Hamas terrorists infiltrated Israel from Gaza and killed over 1,400 people and injured 2,800, resulting in the largest terrorist attack in Israel's history. Several models describe the principles of managing a mass casualty event. One of them is an Australian construct known as the six C's. While command, control, and coordination are familiar concepts, the six C's emphasize the importance of communication and community (consequences and community connection). We describe how two emergency departments in Israel-Assuta Ashdod and the Hadassah Medical Center-Ein Kerem-responded to this disaster in the context of the six C's.

Predictive modelling of transport decisions and resources optimisation in pre-hospital setting using machine learning techniques.

BACKGROUND: The global evolution of pre-hospital care systems faces dynamic challenges, particularly in multinational settings. Machine learning (ML) techniques enable the exploration of deeply embedded data patterns for improved patient care and resource optimisation. This study's objective was to accurately predict cases that necessitated transportation versus those that did not, using ML techniques, thereby facilitating efficient resource allocation. METHODS: ML algorithms were utilised to predict patient transport decisions in a Middle Eastern national pre-hospital emergency medical care provider. A comprehensive dataset comprising 93,712 emergency calls from the 999-call centre was analysed using R programming language. Demographic and clinical variables were incorporated to enhance predictive accuracy. Random Forest (RF), Support Vector Machine (SVM), Extreme Gradient Boosting (XGBoost), and Adaptive Boosting (AdaBoost) algorithms were trained and validated. RESULTS: All the trained algorithm models, particularly XGBoost (Accuracy = 83.1%), correctly predicted patients' transportation decisions. Further, they indicated statistically significant patterns that could be leveraged for targeted resource deployment. Moreover, the specificity rates were high; 97.96% in RF and 95.39% in XGBoost, minimising the incidence of incorrectly identified "Transported" cases (False Positive). CONCLUSION: The study identified the transformative potential of ML algorithms in enhancing the quality of pre-hospital care in Qatar. The high predictive accuracy of the employed models suggested actionable avenues for day and time-specific resource planning and patient triaging, thereby having potential to contribute to pre-hospital quality, safety, and value improvement. These findings pave the way for more nuanced, data-driven quality improvement interventions with significant implications for future operational strategies.

Impact of intravenous accessibility and prehospital epinephrine use on survival outcomes of adult nontraumatic out-of-hospital cardiac arrest patients.

BACKGROUND: This study compared out-of-hospital cardiac arrest (OHCA) patient outcomes based on intravenous (IV) access and prehospital epinephrine use. METHODS: A retrospective study in Ulsan, South Korea, from January 2017 to December 2022, analyzed adult nontraumatic OHCA cases. Patients were grouped: Group 1 (no IV attempts), Group 2 (failed IV access), Group 3 (successful IV access without epinephrine), and Group 4 (successful IV access with epinephrine), with comparisons using logistic regression analysis. RESULTS: Among 2,656 patients, Group 4 had significantly lower survival to hospital discharge (adjusted OR 0.520, 95% CI 0.346-0.782, p = 0.002) and favorable neurological outcomes (adjusted OR 0.292, 95% CI 0.140-0.611, p = 0.001) than Group 1. Groups 2 and 3 showed insignificant survival to hospital discharge (adjusted OR 0.814, 95% CI 0.566-1.171, p = 0.268) and (adjusted OR 1.069, 95% CI 0.810-1.412, p = 0.636) and favorable neurological outcomes (adjusted OR 0.585, 95% CI 0.299-1.144, p = 0.117) and (adjusted OR 1.075, 95% CI 0.689-1.677, p = 0.751). In the shockable rhythm group, Group 3 had better survival to hospital discharge (adjusted OR 1.700, 95% CI 1.044-2.770, p = 0.033). CONCLUSIONS: Successful IV access with epinephrine showed worse outcomes in both rhythm groups than no IV attempts. Outcomes for failed IV and successful IV access without epinephrine were inconclusive. Importantly, successful IV access without epinephrine showed favorable survival to hospital discharge in the shockable rhythm group, warranting further research into IV access for fluid resuscitation in shockable rhythm OHCA patients.

[The psychotrauma prevention algorithm, a paramedical pilot study]. / L'algorithme de prévention du psychotraumatisme, une étude pilote paramédicale.

The aim of the psychotrauma prevention algorithm is to limit the occurrence of psychotrauma in a subject who has experienced a serious life event, by carrying out an initial assessment to define the severity criterion and the monitoring modality best suited to his or her clinical condition. This approach is in line with the philosophy of outreach and the ethics of concern. Recontacting the patient during the course of treatment helps to maintain the therapeutic link and prevent any deterioration in his condition, thus limiting the risk of his traumatic state becoming chronic.