Emergency Department and Health Care System Factors Associated with Telehealth Innovation During the COVID-19 Pandemic

Objective: Telehealth capacity may be an important component of pandemic response infrastructure. We aimed to examine changes in the telehealth use by the US emergency departments (EDs) during COVID-19, and to determine whether existing telehealth infrastructure or increased system integration were associated with increased likelihood of use. Methods: We analyzed 2016-2020 National ED Inventory (NEDI)-USA data, including ED characteristics and nature of telehealth use for all US EDs. American Hospital Association data characterized EDs' system integration. An ordinary least-squares regression model obtained one-step-ahead forecast of the expected proportion of EDs using telehealth in 2020 based on growth observed from 2016 to 2019. Among EDs without telehealth in 2019, we used logistic regression models to examine whether system membership or existing telehealth infrastructure were associated with odds of innovation in telehealth use in 2020, accounting for ED characteristics. Results: Of 4,038 EDs responding to telehealth questions in 2019 and 2020 (73% response rate), 3,015 used telehealth in 2020. Telehealth use by US EDs increased more than expected in 2020 (2016: 58%, 2017: 61%, 2018: 65%, 2019: 67%, 2020: 74%, greater than predicted 71%, p = 0.004). Existing telehealth infrastructure was associated with increased telehealth innovation (OR = 1.88, 95% CI: 1.49-2.36), whereas hospital system membership was not (odds ratio [OR] = 1.00, 95% confidence interval [CI]: 0.80-1.25). Conclusions: Telehealth use by US EDs in 2020 grew more than expected and preexisting telehealth infrastructure was associated with increased innovation in its use. Preparation for future pandemic responses may benefit from considering strategies to invest in local infrastructure to facilitate technology adoption and innovation.

Ambulance and helicopter response time. Association with patient outcome and illness severity: Protocol of a systematic literature review and meta-analysis

BACKGROUND

Response time for emergency medical service units is a key performance indicator. Studies have shown reduced response time association with improved outcome for specific critical conditions. To achieve short response time, emergency vehicles utilize lights and sirens, and crews are allowed to be non-compliant with traffic rules, posing a risk for accident. The purpose of the systematic review and meta-analysis is to provide an overview of the current body of evidence regarding the association, if any, between ambulance and helicopter response time and major complications and mortality in patients conveyed by ambulance and/or helicopter. Our secondary aim will be to enhance knowledge in the field of criteria-based dispatch to provide decision makers with evidence to optimize dispatch of limited resources.

RESEARCH QUESTIONS

What is the association between overall emergency medical services unit response time and patient outcomes, major complications, and time-critical conditions? What is the internal and external validity of the included literature?

METHODS

We plan the systematic review and meta-analysis to be in accordance with the Cochrane Handbook and Joanna Briggs Institute Manual for Systematic Reviews. The methodology will include formulating the review questions using a Population, Exposure, and Outcome framework. Every study design is eligible, including qualitative, quantitative, and mixed-methods designs. We will include all articles in English, Scandinavian, German, French and Portuguese in this systematic review.

RESULTS

We will publish results from the systematic review and meta-analysis in a peer-reviewed journal and we will present the results at scientific conferences and meetings. Results will also be available at www.ahrtemis.dk.

CONCLUSION

We will base our conclusions on the findings of the review and meta-analysis.

Cardiac Arrest After Adenosine Administration in Compensatory Tachycardia: A Case Report

Compensatory tachycardia, an increased heart rate responding to stressors, requires careful consideration in treatment. This case report outlines a scenario where emergency medical services (EMS) misinterpreted a patient's electrocardiogram (EKG) as paroxysmal supraventricular tachycardia (PSVT) and administered adenosine, resulting in sudden cardiac arrest. Despite the rarity of deaths post-adenosine, this case highlights the potential risks of its use in inappropriate clinical scenarios. The patient, later diagnosed with a pulmonary embolism, had a compensatory heart rate that was disrupted after adenosine administration. While adenosine remains a safe and effective treatment for PSVT, this case report serves as a warning to EMS systems about the risks associated with its increased misuse, especially given the trends of prehospital EKG misinterpretation.

Point-of-care ultrasound use in COVID-19: a narrative review

Background and Objective

The coronavirus disease 2019 (COVID-19) pandemic that began in early 2020 resulted in significant mortality from respiratory tract infections. Existing imaging modalities such as chest X-ray (CXR) lacks sensitivity in its diagnosis while computed tomography (CT) scan carries risks of radiation and contamination. Point-of-care ultrasound (POCUS) has the advantage of bedside testing with higher diagnostic accuracy. We aim to describe the various applications of POCUS for patients with suspected severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in the emergency department (ED) and intensive care unit (ICU).

Methods

We performed literature search on the use of POCUS in the diagnosis and management of COVID-19 in MEDLINE, Embase and Scopus databases using the following search terms: "ultrasonography", "ultrasound", "COVID-19", "SARS-CoV-2", "SARS-CoV-2 variants", "emergency services", "emergency department" and "intensive care units". Search was performed independently by two reviewers with any discrepancy adjudicated by a third member.

Key Content and Findings

Lung POCUS in patients with COVID-19 shows different ultrasonographic features from pulmonary oedema, bacterial pneumonia, and other viral pneumonia, thus useful in differentiating between these conditions. It is more sensitive than CXR, and more accessible and widely available than CT scan. POCUS can be used to diagnose COVID-19 pneumonia, screen for COVID-19-related pulmonary and extrapulmonary complications, and guide management of ICU patients, such as timing of ventilator weaning based on lung POCUS findings.

Conclusions

POCUS is a useful and rapid point-of-care modality that can be used to aid in diagnosis, management, and risk stratification of COVID-19 patients in different healthcare settings.

Artificial Intelligence Model Predicts Sudden Cardiac Arrest Manifesting With Pulseless Electric Activity Versus Ventricular Fibrillation

BACKGROUND

There is no specific treatment for sudden cardiac arrest (SCA) manifesting as pulseless electric activity (PEA) and survival rates are low; unlike ventricular fibrillation (VF), which is treatable by defibrillation. Development of novel treatments requires fundamental clinical studies, but access to the true initial rhythm has been a limiting factor.

METHODS

Using demographics and detailed clinical variables, we trained and tested an AI model (extreme gradient boosting) to differentiate PEA-SCA versus VF-SCA in a novel setting that provided the true initial rhythm. A subgroup of SCAs are witnessed by emergency medical services personnel, and because the response time is zero, the true SCA initial rhythm is recorded. The internal cohort consisted of 421 emergency medical services-witnessed out-of-hospital SCAs with PEA or VF as the initial rhythm in the Portland, Oregon metropolitan area. External validation was performed in 220 emergency medical services-witnessed SCAs from Ventura, CA.

RESULTS

In the internal cohort, the artificial intelligence model achieved an area under the receiver operating characteristic curve of 0.68 (95% CI, 0.61-0.76). Model performance was similar in the external cohort, achieving an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.59-0.84). Anemia, older age, increased weight, and dyspnea as a warning symptom were the most important features of PEA-SCA; younger age, chest pain as a warning symptom and established coronary artery disease were important features associated with VF.

CONCLUSIONS

The artificial intelligence model identified novel features of PEA-SCA, differentiated from VF-SCA and was successfully replicated in an external cohort. These findings enhance the mechanistic understanding of PEA-SCA with potential implications for developing novel management strategies.

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

Background

Socioeconomic factors and the COVID-19 pandemic influence children's physical and mental health. We aimed to investigate the association between a census tract's median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified.

Methods

This study is a retrospective analysis of ambulance calls for pediatric (<18 years) intoxication in Rhode Island between March 1st, 2018, and February 28th, 2022. March 1st, 2020 was considered the beginning of the COVID-19 pandemic. Prehospital data were joined with information from the United States Census Bureau. The census tracts' case counts and MHI were examined using Poisson regression. Geographical clusters were identified with the Global Moran's I and local indicators of spatial association tests in ArcGIS Pro (Esri Corporation, Redlands, CA).

Results

Inclusion criteria were met by 208 incidents (48% female, median age 16 (IQR 15 to 17) years). The regression model showed a 0.6% increase (IRR 1.006, 95% CI [1.002, 1.01], p = 0.003) in pediatric intoxications for every $ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic.

Conclusion

Higher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.

Unscheduled Emergency Department Revisits Within 48 Hours of Discharge

This study aimed to analyze early revisits (within 48 hours of discharge) in an Emergency Department. Among the 178,295 visits, 11,686 were revisits, resulting in a rate of 6.55% (95%CI 6.43-6.67). A total of 1,410 revisits required hospitalization, and 252 were due to preventable errors (17.87%). These errors were mainly related to an inadequate therapeutic plan at discharge (47.22%), an incomplete diagnostic process (29.37%), and misdiagnoses (13.10%). These findings represent a technology-enabled clinical audit tool. Electronic Healthcare Records have the potential to: provide quality metrics of hospital performance, help to keep revisit rates updated (assessment through a real-time dashboard), and improve clinical management (by transparency initiatives about errors, and a supportive learning environment regarding lessons learned).

Effectiveness of a Doctor Dispatch System Activated by an Advanced Automatic Collision Notification after a Single-Vehicle Accident: A Case Report

A 79-year-old woman collided with a cliff in a passenger automobile. The fire department acknowledged an automated collision notification from the D-Call Net (DCN) at 1 min after the accident and called for doctors by helicopter ( "Doctor-Heli" [DH] in Japan) 9 min after the injury. The DH reached the victim 28 min after the injury, and examination revealed pain in the right side of her chest, tachypnea, and a weak radial artery pulse (indicating shock). The DH arrived at the hospital 49 min after the injury. Thoracic drainage was performed for right-sided tension pneumothorax. She recovered from shock but was diagnosed with flail chest and placed on a respirator. She was extubated on postoperative day 6 and transferred to a rehabilitation hospital on postoperative day 57. Because of the DCN, the patient received treatment 15 min earlier than she would have with the conventional system. Emergency response task forces must develop strategies for connecting DCN warnings to rapid medical response systems.

Expanding access to substance misuse services through emergency medical services: envisioning a novel partnership for addiction medicine clinicians

Emergency medical services (EMS) can be an invaluable ally of addiction medicine clinicians, but the potential role of EMS in combating the opioid epidemic has been under-realized. EMS has historically focused on emergency response and resuscitation in cases of overdose; however, EMS is also well-positioned to build rapport with persons who use drugs (PWUD), provide harm reduction services, and connect PWUD with additional treatment services and resources. A select number of EMS organizations have begun to offer substance-related programming that extends beyond resuscitation, but these offerings remain limited in scope and impact. This perspective argues that addiction medicine clinicians can bolster the ability of EMS to provide high quality substance-related services by engaging in prehospital care education, program development and research, and clinical care. This perspective shares practical strategies for addiction medicine clinicians to partner with EMS and considers several potential barriers that must be overcome, including bureaucratic challenges, variability in the scope of practice of EMS providers across different locations, and limited funding.

Access to Trauma Care in a Rural State: A Descriptive Geographic and Demographic Analysis

BACKGROUND

Montana is a rural state with limited access to higher-level trauma care; it also has higher injury fatality rates compared with the rest of the country.

OBJECTIVES

The purpose of this study was to utilize Geographic Information System methodology to assess proximity to trauma care and identify the demographic characteristics of regions without trauma access.

METHODS

Maptitude® Geographic Information System software (Caliper Corporation, Newton, MA) was used to identify regions in Montana within 60 min of trauma care; this included access to a Level II or Level III trauma center with general surgery capabilities and access to any level of trauma care. Demographic characteristics are reported to identify population groups lacking access to trauma care.

RESULTS

Of the 1.1 million residents of Montana, 63% of residents live within 60 driving min of a higher-level trauma center, and 83% of residents live within 60 driving min of any level of trauma center. Elderly residents over age 65 years of age and American Indians had reduced access to both higher-level trauma care and any level trauma care.

CONCLUSIONS

Prompt access to trauma care is significantly lower in Montana than in other parts of the country, with dramatic disparities for American Indians. In a rural state, it is important to ensure that all hospitals are equipped to provide some level of trauma care to reduce these disparities.

Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI-AS-ODT)

BACKGROUND

In the emergency department (ED), prompt administration of systemic corticosteroids for pediatric asthma exacerbations decreases hospital admission rates. However, there is sparse evidence for whether earlier administration of systemic corticosteroids by emergency medical services (EMS) clinicians, prior to ED arrival, further improves pediatric asthma outcomes.

METHODS

Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial is a multicenter, observational, nonrandomized stepped-wedge design study with seven participating EMS agencies who adopted an oral systemic corticosteroid (OCS) into their protocols for pediatric asthma treatment. Using univariate analyses and multivariable mixed-effects models, we compared hospital admission rates for pediatric asthma patients ages 2-18 years before and after the introduction of a prehospital OCS and for those who did and did not receive a systemic corticosteroid from EMS.

RESULTS

A total of 834 patients were included, 21% of whom received a systemic corticosteroid from EMS. EMS administration of systemic corticosteroids increased after the introduction of an OCS from 14.7% to 28.1% (p < 0.001). However, there was no significant difference between hospital admission rates and ED length of stay before and after the introduction of OCS or between patients who did and did not receive a systemic corticosteroid from EMS. Mixed-effects models revealed that age 14-18 years (coefficient -0.83, p = 0.002), EMS administration of magnesium (coefficient 1.22, p = 0.04), and initial EMS respiratory severity score (coefficient 0.40, p < 0.001) were significantly associated with hospital admission.

CONCLUSIONS

In this multicenter study, the addition of an OCS into EMS agency protocols for pediatric asthma exacerbations significantly increased systemic corticosteroid administration but did not significantly decrease hospital admission rates. As overall EMS systemic corticosteroid administration rates were low, further work is required to understand optimal implementation of EMS protocol changes to better assess potential benefits to patients.

Compliance with CPR quality guidelines and survival after 30 days following out-of-hospital cardiac arrest. A retrospective study

BACKGROUND

Our study assessed the quality of cardiopulmonary resuscitation (CPR) given by emergency medical services in Southern Ostrobothnia Finland, as is advised in the international guidelines. The goal was to evaluate the current quality of CPR given to patients who suffered an out-of-hospital cardiac arrest and to examine possible measures for improving emergency medical services.

METHODS

A retrospective study was conducted on out-of-hospital cardiac arrest patients in Southern Ostrobothnia, Finland, during a three-year period. Confounding caused by each patient's individual medical history was addressed by calculating Charlson Comorbidity Index (CCI), a score describing individual's risk for death in 10 years. The Utstein analysis and the CPR metrics were acquired from the medical records hospital district in question and analysed in an orderly manner using SPSS. Descriptive statistics are presented as mean (SD) and median [IQR].

RESULTS

We found that of the 349 patients, 144 (41%) received ROSC, 96 (28%) survived to the hospital and 51 (15%) survived for at least 30 days. CPR metrics data were available for 181 patients. CCIs were 3.0 versus 5.0 (p = .157) for the ones who did and those who did not survive at least 30 days. Correspondingly, following metrics were as follows: Mean compression depth was 5.1 (1.3) versus 5.6 (0.8) cm (p = .088), median 28 [18;40] versus 40 [26;54]% of the compressions were in target depth (p = .015) and median compression rate was 113 [109;119] versus 112 [108;120] min-1 (p = .757). The median no-flow fraction was 5.1 [2.8;7.1] versus 3.7 [2.5;5.5] s (p = .073). Ventricular fibrillation (OR 8.74, 95% CI 2.89-26.43, p < .001), public location (OR 3.163, 95% CI 1.03-9.69, p = .044) and compression rate of 100-110/min (OR 7.923, 95% CI 2.11-29.82, p = .002) were related to survival.

CONCLUSION

Patients who suffered out-of-hospital cardiac arrest in Southern Ostrobothnia received CPR that met the international CPR quality target values. The proportion of unintentional pauses during CPR was low and the 30-day survival rate exceeded the international average.

Prior Emergency Medical Services Utilization Among People Who Had an Accidental Opioid-Involved Fatal Drug Overdose-Rhode Island, 2018-2020

OBJECTIVE

To help understand whether decreased emergency medical services (EMS) utilization due to the COVID-19 pandemic contributed to increased accidental fatal drug overdoses, we characterized recent EMS utilization history among people who had an accidental opioid-involved fatal drug overdose in Rhode Island.

METHODS

We identified accidental opioid-involved fatal drug overdoses among Rhode Island residents that occurred from January 1, 2018, through December 31, 2020. We linked decedents by name and date of birth to the Rhode Island EMS Information System to obtain EMS utilization history.

RESULTS

Among 763 people who had an accidental opioid-involved fatal overdose, 51% had any EMS run and 16% had any opioid overdose-related EMS run in the 2 years before death. Non-Hispanic White decedents were significantly more likely than decedents of other races and ethnicities to have any EMS run (P < .001) and any opioid overdose-related EMS run (P = .05) in the 2 years before death. Despite a 31% increase in fatal overdoses from 2019 through 2020, corresponding with the onset of the COVID-19 pandemic, EMS utilization in the prior 2 years, prior 180 days, or prior 90 days did not vary by time frame of death.

CONCLUSION

In Rhode Island, decreased EMS utilization because of the COVID-19 pandemic was not a driving force behind the increase in overdose fatalities observed in 2020. However, with half of people who had an accidental opioid-involved fatal drug overdose having an EMS run in the 2 years before death, emergency care is a potential opportunity to link people to health care and social services.

Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment

BACKGROUND

Emergency medical services (EMS) is an important link in the stroke chain of recovery. Various prehospital quality metrics have been proposed for prehospital stroke care, but their individual impact is uncertain. We sought to measure associations between EMS quality metrics and downstream stroke care.

METHODS

This is a retrospective analysis of a cohort of EMS-transported stroke patients assembled through a linkage between Michigan's EMS and stroke registries. We used multivariable regression to quantify the independent associations between EMS quality metric compliance (dispatch within 90 seconds of 911 call, prehospital stroke screen documentation [Prehospital stroke scale], glucose check, last known well time, maintenance of scene times ≤15 minutes, hospital prenotification, and intravenous line placement) and shorter door-to-CT times (door-to-CT ≤25), accounting for EMS recognition, age, sex, race, stroke subtype, severity, and duration of symptoms. We then developed a simple EMS quality score based on metrics associated with early CT and examined its associations with hospital stroke evaluation times, treatment, and patient outcomes.

RESULTS

Five thousand seven hundred seven EMS-transported stroke cases were linked to prehospital records from January 2018 through June 2019. In multivariable analysis, prehospital stroke scale documentation (adjusted odds ratio, 1.4 [1.2-1.6]), glucose check (1.3 [1.1-1.6]), on-scene time ≤15 minutes (1.6 [1.4-1.9]), hospital prenotification ([2.0 [1.4-2.9]), and intravenous line placement (1.8 [1.5-2.1]) were independently associated with a door-to-CT ≤25 minutes. A 5-point quality score (1 point for each element) was therefore developed. In multivariable analysis, a 1-point higher EMS quality score was associated with a shorter time from EMS contact to CT (-9.2 [-10.6 to -7.8] minutes; P<0.001) and thrombolysis (-4.3 [-6.4 to -2.2] minutes; P<0.001), and higher odds of discharge to home (adjusted odds ratio, 1.1 [1.0-1.2]; P=0.002).

CONCLUSIONS

Five EMS actions recommended by national guidelines were associated with rapid CT imaging. A simple quality score derived from these measures was also associated with faster stroke evaluation, greater odds of reperfusion treatment, and discharge to home.

Regional Variation in Opioid-Related Emergency Medical Services Transfers During the COVID-19 Pandemic: An Interrupted Time Series Analysis

BACKGROUND

The COVID-19 pandemic has impacted public infrastructure and healthcare utilization. However, regional variation in opioid-related harm secondary to COVID-19 remains poorly understood. This study aimed to measure the regional variation in the association between stay-at-home orders (SAHOs) and nonfatal opioid-related emergency medical services (EMS) transfers in the United States.

METHODS

In this interrupted time series design, counts of nonfatal opioid overdoses were identified in each week between July 29, 2019 and December 27, 2020 from the National Emergency Medical Services Information System Dataset. A longitudinal, interrupted time series model was used to compare the change in the number of nonfatal opioid overdose transfers between the pre-pandemic period (July 29, 2019-January 6, 2020) and the pandemic period (June 1, 2020-December 27, 2020). The time period between January 7, 2020 and May 31, 2020 was treated as a washout period to account for state-level variation in the timing of SAHO implementation.

RESULTS

We identified 277 141 adult nonfatal opioid-related overdose EMS transfers in the United States across all census regions. After implementation of the SAHO, EMS transfers significantly increased in all regions, with an increase most notable in the Southern United States (2161, 95% CI: 1699-2623 transfers per week). In the post-SAHO period between June 1 and December 27, 2020, EMS transfers declined from this regional peak in the Southern, Midwestern, and Northeastern United States. No change in trend was observed in the Western United States.

CONCLUSION

These findings underscore the importance of tailoring public health policies regionally. While most regions saw a modest decline in opioid-related EMS transfers after an initial increase, the COVID-19 pandemic led to notable increases in opioid-related EMS transfers nationwide. Future research should focus on identifying public health strategies to counteract the deleterious effects of the COVID-19 pandemic on opioid-related morbidity.

Relaxation and strain among emergency medical service personnel and emergency control center dispatchers during the first two waves of the SARS-CoV-2 pandemic

BACKGROUND

Workloads of emergency medical service personnel (EMP) and emergency control center dispatchers (CCDs) were manifold. The SARS-CoV-2 pandemic presented new challenges for the prehospital emergency medical service. The purpose of this study was to compare the status of stress/strain and recovery of Recovery-Stress Questionnaire among EMP and CCDs in Germany during the first 2 waves of the SARS-CoV-2 pandemic both between occupational groups and over time.

MATERIAL AND METHODS

A total of 2426 emergency medical service personnel and control center dispatchers were questioned with the Recovery-Stress Questionnaire based on Kallus. The results from the first 2 waves of the pandemic (June-August 2020 and January-February 2021) were compared.

RESULTS

During the first and second wave of SARS-CoV-2 pandemic, the subjectively perceived stress of emergency medical service personnel and control center dispatchers increased, but recovery decreased. The CCDs showed more unfavorable values compared to EMP.

CONCLUSIONS

Health promotion interventions are necessary to counteract possible career changes or mental or other diseases due to insufficient management. Med Pr Work Health Saf. 2023;74(5):353-62.

Potential Use of Artificial Intelligence (AI) in Disaster Risk and Emergency Health Management: A Critical Appraisal on Environmental Health

The risk evaluation of natural disasters is an obstacle to ensuring healthcare services during catastrophic events worldwide. Therefore, timely and appropriate environmental health risk evaluation is essential. In this study, we incorporated the information from databases such as PubMed, Google Scholar, and Scopus. We performed this study to explore the feasibility of using artificial intelligence (AI) in disaster risk and emergency health management. Natural disasters have some phenomenon that is bound to happen. So, we can use AI to inform healthcare authorities about environmental health risks and emergency medical management. The recent innovations in technology have created novel opportunities for improving healthcare services across the world. AI technology would be the backbone of the fourth industrial revolution because we are entering an AI-based world this decade. Therefore, we suggest the authorities consider this positive aspect of AI technology to minimize the disastrous outcomes of any catastrophic events.

Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study

BACKGROUND

Prehospital tracheal intubation is a potentially lifesaving intervention, but is associated with prolonged time on-scene. Some services strongly advocate performing the procedure outside of the ambulance or aircraft, while others also perform the procedure inside the vehicle. This study was designed as a non-inferiority trial registering the rate of successful tracheal intubation and incidence of complications performed by a critical care team either inside or outside an ambulance or helicopter.

METHODS

This observational multicentre study was performed between March 2020 and September 2021 and involved 12 anaesthetist-staffed critical care teams providing emergency medical services by helicopter in Denmark, Norway, and Sweden. The primary outcome was first-pass successful tracheal intubations.

RESULTS

Of the 422 drug-assisted tracheal intubations examined, 240 (57%) took place in the cabin of the ambulance or helicopter. The rate of first-pass success was 89.2% for intubations in-cabin vs 86.3% outside. This difference of 2.9% (confidence interval -2.4% to 8.2%) (two sided 10%, including 0, but not the non-inferiority limit Δ=-4.5) fulfils our criteria for non-inferiority, but not significant superiority. These results withstand after performing a propensity score analysis. The mean on-scene time associated with the helicopter in-cabin procedures (27 min) was significantly shorter than for outside the cabin (32 min, P=0.004).

CONCLUSIONS

Both in-cabin and outside the cabin, prehospital tracheal intubation by anaesthetists was performed with a high success rate. The mean on-scene time was shorter in the in-cabin helicopter cohort.

CLINICAL TRIAL REGISTRATION

NCT04206566.

Older Adult Frequent 9-1-1 Callers for Emergency Medical Services in a Large Metropolitan City: Individual- and System-Level Considerations

BACKGROUND

High utilizers of 9-1-1 place a substantial burden on emergency medical services (EMS). Results of a retrospective review of records data of the City of Los Angeles Fire Department (LAFD) showed a significant increase in older adult high utilizers of 9-1-1.

OBJECTIVE

The objective of this study was to explore individual- and system-level factors implicated in EMS use among older adults, and to provide system recommendations to mitigate overuse.

METHODS

A phenomenological study was conducted, drawing from LAFD EMS records between 2012 and 2016 to identify and contact high-utilizing patients older than 50 years, their family, agency representatives, and LAFD personnel. Interviews were recorded, transcribed, and coded and a thematic analysis was completed.

RESULTS

We conducted in-depth interviews with 27 participants, including patients (n = 8), their families (n = 6), social service agency representatives (n = 3), and LAFD personnel (n = 10). The following cross-cutting themes emerged: nature of 9-1-1 calls, barriers to access, and changing the system. In addition, LAFD and social service agency representatives identified the role of EMS responders and social agency representatives. Patients and their families agreed that previous encounters and interactions with emergency care responders were relevant factors.

CONCLUSIONS

This study described reasons for 9-1-1 calls related to medical and social service needs, including mental health care. Our analysis offers insight from different stakeholders' perspectives on access to medical care and types of barriers that interfere with medical care. All groups shared recommendations to advance access to medical and mental health care.

The views, opinions and decision-making of UK-based paramedics on the use of pre-hospital 12-lead electrocardiograms in acute stroke patients: a qualitative interview study

Introduction

A qualitative exploration into the views, opinions and decision-making of paramedics involved in undertaking pre-hospital 12-lead electrocardiograms (PHECGs) for stroke patients was undertaken, in order to gain a deeper understanding of the clinical and occupational context that the paramedics work within, the acceptability of the paramedics in using PHECGs for stroke patients and the consequences and influences of their decision-making.

Methods

Data were collected via semi-structured interviews and analysed using the framework method, with the underpinning theoretical framework of cognitive continuum theory. A purposive sample of 14 paramedics was recruited and interviewed.

Results

Five themes were generated from the analysis of the interviews: (1) 'time is brain': minimising delays and rapid transport to definitive care; (2) barriers and facilitators to undertaking PHECGs for stroke patients; (3) recognising and gaining cues; (4) maintaining patient dignity, self-protection and fully informed consent; and (5) education, experience and engagement with evidence.

Conclusion

The study showed mixed views on the usefulness of PHECGs, but all participants agreed that PHECGs should not cause additional delays. Paramedic decision-making on recording PHECGs relies on intuitive and quasi-rational cognitive modes, and requires a number of clinical, logistical and ethical considerations. The findings suggest careful consideration is needed of the benefits and potential drawbacks of incorporating PHECGs into pre-hospital stroke care.

Review article: Scoping review of the characteristics and outcomes of adults presenting to the emergency department during heatwaves

As a result of climate change heatwaves are expected to increase in frequency and intensity and will have detrimental impacts on human health globally. EDs are often the critical point of care for acute heat illnesses and other conditions associated with heat exposure. Existing literature has focused on heatwave-related hospitalisation and mortality. This scoping review aimed to identify, evaluate and summarise current literature regarding patient characteristics and outcomes of ED admissions from heatwaves. A scoping review of the literature was conducted using six databases: Medline, EMBASE, EMCARE, CINAHL, PsycINFO, and Scopus, using MeSH terms and keywords related to 'heatwave' and 'Emergency Department'. Articles were included if they were: published in English from January 2000 to August 2021, related to ED, and examined high temperature periods consistent with heatwave criteria. Articles were appraised using the Mixed Methods Appraisal Tool (MMAT). Thirty-one studies were included, mostly from the United States, Australia, and France. The study designs include retrospective case analysis, case-control, and time-series analysis. Eight studies examined known heatwaves, 21 used different criteria to identify heatwave occurrence, and two focused on heat-related illness. The selected articles display a moderate-high quality on MMAT. ED admissions for both heat-related illnesses and other conditions increased during heatwaves, with up to 18.5 times risk increase. The risk was elevated for all population groups, and substantially in the elderly, male patients with certain comorbidities, medications, or lower socioeconomic status. Outcomes including hospitalisation and mortality rates after ED admissions showed positive associations with heatwaves. The heatwaves resulting from climate change will place increasing demands on EDs providing care for increasingly susceptible populations. Significant public heatwave planning across multiple sectors is required to reduce the risk of overwhelming EDs with these patients.

A two-year retrospective study of the neonatal emergency transport service in Northeast Italy

BACKGROUND

Some newborns require acute transport to a Neonatal Intensive Care Unit (NICU) due to unpredicted or unpredictable reasons.

OBJECTIVE

To describe the activity of the Neonatal Emergency Transport Service (NETS) in Northeast Italy.

METHODS

An observational retrospective study was performed between 1 January 2018, and 31 December , 2019.

RESULTS

A total of 133 transports were collected, with a neonatal transport index of 1.4%. Infants ≤2500 grams were more frequently transferred by NETS than those in the normal group (n = 34/563, 6.0% vs. n = 99/8,437, 1.2%; p < .001). The incidence of preterm birth among transferred newborns was 42/133 (31.6%). For the newborns with >2500 grams, there was a low incidence of a cesarean birth compared to vaginal delivery (23.2% versus 63.5%; p = .001), while the percentages were reversed in the group of infants ≤2500 grams (67.7% versus 20.6%) (p = .001). Infant stabilization time was higher in the underweight group compared to those weighed >2500 grams (31.5 versus 23.0 min; p < .001), as well as the median length of stay in NICU (18.0 versus 8.0 days, respectively, p < .001). The group of infants ≤2500 grams received more intravenous therapy (47.1% vs. 26.2%) and invasive ventilation (26.5% vs. 8.1%), compared to the group of infants who weighed >2500 grams.

CONCLUSIONS

This study described a local reality by showing the characteristics of the neonatal transports that took place in a metropolitan area in Northeast Italy. Wider database is necessary to achieve a better knowledge in the field of perinatal outcomes.

Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians

INTRODUCTION

Glenohumeral dislocations present a challenging management dilemma in austere settings where patient transport time may be prolonged. Expeditious reduction is preferable, but treatment is commonly expected to take place within a hospital or comparable facility. Through a novel shoulder injury program, professional ski patrollers trained as emergency medical technicians (EMTs) have diagnosed and reduced anterior shoulder dislocations using biomechanical techniques without sedation or analgesia for over 20 y. Summary records have been maintained to track the performance and safety of this program.

METHODS

Five hundred forty-six records of winter sports-related shoulder injuries from 2009-10 to 2019-20 were retrospectively analyzed to determine the assessment performance and dislocation reduction efficacy of EMTs, with the intent of ascertaining whether EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations without premedication in a remote and resource-limited setting.

RESULTS

EMTs identified anterior shoulder dislocations with 98% sensitivity and 96% diagnostic accuracy. The overall success rate of reduction attempts was 86%, or 88% when limited to confirmed anterior dislocations. Two fracture-dislocations and 4 misdiagnoses were manipulated. No instances of iatrogenic harm were identified, and no patients who underwent successful reductions required ambulance transportation.

CONCLUSIONS

With appropriate education and within a structured program, EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations using biomechanical techniques without premedication in remote and resource-limited environments. Implementation of similar programs in austere settings has the potential to improve patient care. Further, using biomechanical reduction techniques may reduce reliance on procedural sedation irrespective of care setting.