Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients

Crossbow Injuries: Predictors of Mortality

INTRODUCTION

Crossbow injuries are rare but carry significant morbidity and mortality, and there is limited evidence in the medical literature to guide care. This paper reviews the case reports and case series of crossbow injuries and looks for trends regarding morbidity and mortality based on the type of arrow, anatomic location of injury, and intent of injury.

METHODS

Multiple databases were searched for cases of crossbow injuries and data were abstracted into a spreadsheet. Statistics were done in SPSS.

RESULTS

358 manuscripts were returned in the search. After deduplication and removal of nonclinical articles, 101 manuscripts remained. Seventy-one articles describing 90 incidents met the inclusion criteria. The mean age was 36.5 years. There were 10 female and 79 male victims. Fatality was 36% for injuries by field tip arrows and 71% for broadhead arrows, p  =  .024. Assaults were fatal in 84% of cases, suicides in 29%, and accidental injuries in 17%, p < .001. Mortality was similar for wounds to the head and neck (41%), chest (42%), abdomen (33%), extremities (50%), and multiple regions, p  =  .618.

CONCLUSIONS

Crossbows are potentially lethal weapons sold with fewer restrictions than firearms. Injuries caused by broadhead arrows are more likely to be fatal than injuries from field tip arrows. The anatomic location of injury does not correlate with fatality. More than half of crossbow injuries are due to attempted suicide, with a high case-fatality rate.

Beyond drowning: Characteristics, trends, the impact of exposure on unintentional non-drowning coastal fatalities between 2012 and 22

OBJECTIVES

Drowning has been the focus of coastal safety, but a notable proportion of coastal mortality is due to other causes of death. This study describes that burden and quantifies the impact of exposure on Australian unintentional coastal fatalities not due to drowning.

METHODS

Analyses of Australian non-drowning coastal fatalities (NDCF) between July 2012 and June 2022 were conducted. Population and exposure-based rates were calculated for Australians 16+ years and compared to all-cause mortality rates. Time series analysis was performed using Joinpoint regression.

RESULTS

616 NDCFs were recorded (0.27/100,000 pop.), with a decreasing average annual percent change of -5.1% (95% CI:-9.5 to -0.4). Cardiac conditions were the primary causal factor, involved in 52% of deaths. Higher fatality rates were seen among men and for incidents occurring in rural and remote areas. Fatality rates were disproportionately high among young adults when compared to all-cause mortality.

CONCLUSIONS

Men, young adults, and those living in/visiting regional and remote areas represent high-risk populations. Proximity to emergency services and extended response times represent major determinants of NDCF.

IMPLICATIONS FOR PUBLIC HEALTH

Due to the high prevalence of NDCF, coastal safety practitioners should expand their attention beyond drowning to consider the broader range of coastal hazards and fatality types.

Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database

BACKGROUND

Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes.

METHODS

A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed.

RESULTS

In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality.

DISCUSSION

Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.

Outcomes by time-to-OR for penetrating abdominal trauma patients

INTRODUCTION

Time-To-OR is a critical process measure for trauma performance. However, this measure has not consistently demonstrated improvement in outcome.

STUDY DESIGN

Using TQIP, we identified facilities by 75th percentile time-to-OR to categorize slow, average, and fast hospitals. Using a GEE model, we calculated odds of mortality for all penetrating abdominal trauma patients, firearm injuries only, and patients with major complication by facility speed. We additionally estimated odds of mortality at the patient level.

RESULTS

Odds of mortality for patients at slow facilities was 1.095; 95% CI: 0.746, 1.608; p = 0.64 compared to average. Fast facility OR = 0.941; 95% CI: 0.780, 1.133; p = 0.52. At the patient-level each additional minute of time-to-OR was associated with 1.5% decreased odds of in-hospital mortality (OR 0.985; 95% CI:0.981, 0.989; p < 0.001). For firearm-only patients, facility speed was not associated with odds of in-hospital mortality (p-value = 0.61). Person-level time-to-OR was associated with 1.8% decreased odds of in-hospital mortality (OR 0.982; 95% CI: 0.977, 0.987; p < 0.001) with each additional minute of time-to-OR. Similarly, failure-to-rescue analysis showed no difference in in-hospital mortality at the patient level (p = 0.62) and 0.4% decreased odds of in-hospital mortality with each additional minute of time-to-OR at the patient level (OR 0.996; 95% CI: 0.993, 0.999; p = 0.004).

CONCLUSION

Despite the use of time-to-OR as a metric of trauma performance, there is little evidence for improvement in mortality or complication rate with improved time-to-OR at the facility or patient level. Performance metrics for trauma should be developed that more appropriately approximate patient outcome.

Characteristics of traumatic major haemorrhage in a tertiary trauma center

BACKGROUND

Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma.

METHODS

This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission.

RESULTS

In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality.

RESULTS

Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.

Ambulance response times and 30-day mortality: a Copenhagen (Denmark) registry study

BACKGROUND AND IMPORTANCE

Ensuring prompt ambulance responses is complicated and costly. It is a general conception that short response times save lives, but the actual knowledge is limited.

OBJECTIVE

To examine the association between the response times of ambulances with lights and sirens and 30-day mortality.

DESIGN

A registry-based cohort study using data collected from 2014-2018.

SETTINGS AND PARTICIPANTS

This study included 182 895 individuals who, during 2014-2018, were dispatched 266 265 ambulances in the Capital Region of Denmark.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was 30-day mortality. Subgroup analyses were performed on out-of-hospital cardiac arrests, ambulance response priority subtypes, and caller-reported symptoms of chest pain, dyspnoea, unconsciousness, and traffic accidents. The relation between variables and 30-day mortality was examined with logistic regression.

RESULTS

Unadjusted, short response times were associated with higher 30-day mortality rates across unadjusted response time quartiles (0-6.39 min: 9%; 6.40-8.60 min: 7.5%, 8.61-11.80 min: 6.6%, >11.80 min: 5.5%). This inverse relationship was consistent across subgroups, including chest pain, dyspnoea, unconsciousness, and response priority subtypes. For traffic accidents, no significant results were found. In the case of out-of-hospital cardiac arrests, longer response times of up to 10 min correlated with increased 30-day mortality rates (0-6.39 min: 84.1%; 6.40-8.60 min: 86.7%, 8.61-11.8 min: 87.7%, >11.80 min: 85.5%). Multivariable-adjusted logistic regression analysis showed that age, sex, Charlson comorbidity score, and call-related symptoms were associated with 30-day mortality, but response time was not (OR: 1.00 (95% CI [0.99-1.00])).

CONCLUSION

Longer ambulance response times were not associated with increased mortality, except for out-of-hospital cardiac arrests.

Attempted Suicide Is Independently Associated with Increased In-Hospital Mortality and Hospital Length of Stay among Injured Patients at Community Tertiary Hospital in Japan: A Retrospective Study with Propensity Score Matching Analysis

Suicide is an increasingly important public healthcare concern worldwide. Studies examining the effect of attempted suicide on clinical outcomes among patients with trauma are scarce. We conducted a retrospective cohort study at a community emergency department in Japan. We included all severely injured patients with an Injury Severity Score > 15 from January 2002 to December 2021. The primary outcome measure was in-hospital mortality. The other outcome of interest was hospital length of stay. One-to-one propensity score matching was performed to compare these outcomes between suicide attempt and no suicide attempt groups. Of the 2714 eligible patients, 183 (6.7%) had trauma caused by a suicide attempt. In the propensity score-matched analysis with 139 pairs, the suicide attempt group showed a significant increase in-hospital mortality (20.9% vs. 37.4%; odds ratio 2.27; 95% confidence intervals 1.33-3.87) compared with the no suicide attempt group. Among survivors, the median hospital length of stay was significantly longer in the suicide attempt group than that in the no suicide attempt group (9 days vs. 12 days, p = 0.0076). Because of the unfavorable consequences and potential need for additional healthcare, increased attention should be paid to patients with trauma caused by a suicide attempt.

Factors associated with prolonged on-scene time in ambulance transportation among patients with minor diseases or injuries in Japan: a population-based observational study

BACKGROUND

Prolonged prehospital time is a major global problem in the emergency medical system (EMS). Although factors related to prolonged on-scene times (OSTs) have been reported in patients with trauma and critical medical conditions, those in patients with minor diseases or injuries remain unclear. We examined factors associated with prolonged OSTs in patients with minor diseases or injuries.

METHODS

This population-based observational study used the ambulance transportation and request call record databases of the Higashihiroshima Fire Department, Japan, between January 1, 2016, and December 31, 2022. The participants were patients with minor diseases or injuries during the study period. We performed a multivariable logistic regression analysis with robust error variance to examine the association between patient age, sex, severity, accident type, date and time of ambulance call, and the coronavirus disease 2019 (COVID-19) pandemic with prolonged OSTs. Prolonged OST was defined as ≥ 30 min from the ambulance arrival at the scene to departure.

RESULTS

Of the 60,309 people transported by ambulance during the study period, 20,069 with minor diseases or injuries were included in the analysis. A total of 1,241 patients (6.2%) experienced prolonged OSTs. Fire accidents (adjusted odds ratio [aOR]: 7.77, 95% confidence interval [CI]: 3.82-15.79), natural disasters (aOR: 28.52, 95% CI: 2.09-389.76), motor vehicle accidents (aOR: 1.63, 95% CI: 1.30-2.06), assaults (aOR: 2.91, 95% CI: 1.86-4.53), self-injuries (aOR: 5.60, 95% CI: 3.37-9.32), number of hospital inquiries ≥ 4 (aOR: 77.34, 95% CI: 53.55-111.69), and the COVID-19 pandemic (aOR: 2.01, 95% CI: 1.62-2.50) were associated with prolonged OSTs. Moreover, older and female patients had prolonged OSTs (aOR: 1.18, 95% CI: 1.01-1.36 and aOR: 1.12, 95% CI: 1.08-1.18, respectively).

CONCLUSIONS

Older age, female sex, fire accidents, natural disasters, motor vehicle accidents, assaults, self-injuries, number of hospital inquiries ≥ 4, and the COVID-19 pandemic influenced prolonged OSTs among patients with minor diseases or injuries. To improve community EMS, we should reconsider how to intervene with potentially modifiable factors, such as EMS personnel performance, the impact of the presence of allied services, hospital patient acceptance systems, and cooperation between general emergency and psychiatric hospitals.

Challenges and opportunities to improve efficiency and quality of prehospital emergency care using an mHealth platform: Qualitative study in Rwanda

Introduction

Prompt, high-quality pre-hospital emergency medical services (EMS) can significantly reduce morbidity and mortality. The goal of this study was to identify factors that compromise efficiency and quality of pre-hospital emergency care in Rwanda, and explore the opportunities for a mobile health (mHealth) tool to address these challenges.

Methods

In-depth interviews were conducted with 21 individuals representing four stakeholder groups: EMS dispatch staff, ambulance staff, hospital staff, and policymakers. A semi-structured interview guide explored participants' perspectives on all aspects of the pre-hospital emergency care continuum, from receiving a call at dispatch to hospital handover. Participants were asked how the current system could be improved, and the potential utility of an mHealth tool to address existing challenges. Interviews were audio-recorded, and transcripts were thematically analyzed using NVivo.

Results

Stakeholders identified factors that compromise the efficiency and quality of care across the prehospital emergency care continuum: triage at dispatch, dispatching the ambulance, locating the emergency, coordinating patient care at scene, preparing the receiving hospital, and patient handover to the hospital. They identified four areas where an mHealth tool could improve care: efficient location of the emergency, streamline communication for decision making, documentation with real-time communication, and routine data for quality improvement. While stakeholders identified advantages of an mHealth tool, they also mentioned challenges that would need to be addressed, namely: limited internet bandwidth, capacity to maintain and update software, and risks of data security breaches that could lead to stolen or lost data.

Conclusion

Despite the success of Rwanda's EMS system, this study highlights factors across the care continuum that could compromise quality and efficiency of prehospital emergency care. Mobile health tools hold great promise to address these challenges, but contextual issues need to be considered to ensure sustainability of use.

Effect of urban vs. remote settings on prehospital time and mortality in trauma patients in Norway: a national population-based study

BACKGROUND

Norway has a diverse population pattern and often long transport distances from injury sites to hospitals. Also, previous studies have found an increased risk of trauma-related mortality in remote areas in Norway. Studies on urban vs. remote differences on trauma outcomes from other countries are sparse and they report conflicting results.The aim of the present study was to investigate differences in prehospital time intervals in urban and remote areas in Norway and assess how prehospital time and urban vs. remote settings were associated with mortality in the Norwegian trauma population.

METHODS

We performed a population-based study of trauma cases included in the Norwegian Trauma Registry from 2015 to 2020. 28,988 patients met the inclusion criteria. Differences in study population characteristics and prehospital time intervals (response time, on-scene time and transport time) were analyzed. The Norwegian Centrality Index score was used for urban vs. remote classification. Descriptive statistics and relevant non-parametric tests with effect size measurements were used. A binary logistic regression model, adjusted for confounding factors, was performed.

RESULTS

The prehospital time intervals increased significantly from urban to remote areas.Adjusted for control variables we found a significant relationship between prolonged on-scene time and higher odds of mortality. Also, suburban areas compared with remote areas were associated with higher odds of mortality.

CONCLUSION

In this nationwide study comparing prehospital time intervals in urban and remote areas, we found that prehospital time intervals in remote areas exceeded those in urban areas. Prolonged on-scene time was found to be associated with higher odds of mortality, but remoteness itself was not.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Redefining trauma deserts: novel technique to accurately map prehospital transport time

Background

Prehospital transport time has been directly related to mortality for hemorrhaging trauma patients. 'Trauma deserts' were previously defined as being outside of a 5-mile radial distance of an urban trauma center. We postulated that the true 'desert' should be based on transport time rather than transport distance.

Methods

Using the Chicagoland area that was used to describe 'trauma deserts,' a sequential process to query a commercial travel optimization product to map transport times over coordinates that covered the entire urban area at a particular time of day. This produces a heat map representing prehospital transport times. Travel times were then limited to 15 minutes to represent a temporally based map of transport capabilities. This was repeated during high and low traffic times and for centers across the city.

Results

We demonstrated that the temporally based map for transport to a trauma center in an urban center differs significantly from the radial distance to the trauma center. Primary effects were proximity to highways and the downtown area. Transportation to centers were significantly different when time was considered instead of distance (p<0.001). We were further able to map variations in traffic patterns and thus transport times by time of day. The truly 'closest' trauma center by time changed based on time of day and was not always the closest hospital by distance.

Discussion

As the crow flies is not how the ambulance drives. This novel technique of dynamically mapping transport times can be used to create accurate trauma deserts in an urban setting with multiple trauma centers. Further, this technique can be used to quantify the potential benefit or detriment of adding or removing firehouses or trauma centers.

Factors associated with EMS on-scene time and its regional difference in road traffic injuries: a population-based observational study

Background

The outcome of road traffic injury (RTI) is determined by duration of prehospital time, patient’s demographics, and the type of injury and its mechanism. During the emergency medical service (EMS) prehospital time interval, on-scene time should be minimized for early treatment. This study aimed to examine the factors influencing on-scene EMS time among RTI patients.

Methods

We evaluated 19,141 cases of traffic trauma recorded between April 2014 and March 2020 in the EMS database of the Nara Wide Area Fire Department and the prehospital database of the emergency Medical Alliance for Total Coordination of Healthcare (e-MATCH). To examine the association of the number of EMS phone calls until hospital acceptance, age ≥65 years, high-risk injury, vital signs, holiday, and nighttime (0:00–8:00) with on-scene time, a generalized linear mixed model with random effects for four study regions was conducted.

Results

EMS phone calls were the biggest factor, accounting for 5.69 minutes per call, and high-risk injury accounted for an additional 2.78 minutes. Holiday, nighttime, and age ≥65 years were also associated with increased on-scene time, but there were no significant vital sign variables for on-scene time, except for the level of consciousness. Regional differences were also noted based on random effects, with a maximum difference of 2 minutes among regions.

Conclusions

The number of EMS phone calls until hospital acceptance was the most significant influencing factor in reducing on-scene time, and high-risk injury accounted for up to an additional 2.78 minutes. Considering these factors, including regional differences, can help improve the regional EMS policies and outcomes of RTI patients.

Emergency services utilization in Jakarta (Indonesia): a cross-sectional study of patients attending hospital emergency departments

BACKGROUND

Pre-hospital and emergency services in Indonesia are still developing. Despite recent improvements in the Indonesian healthcare system, issues with the provision of pre-hospital and emergency services persist. The demand for pre-hospital and emergency services has not been the subject of previous research and, therefore, has not been fully understood. Our research explored the utilization of emergency medical services by patients attending hospital emergency departments in Jakarta, Indonesia.

METHODS

The study used a cross-sectional survey design involving five general hospitals (four government-funded and one private). Each patient's demographic profile, medical conditions, time to treatment, and mode of transport to reach the hospital were analysed using descriptive statistics.

RESULTS

A total of 1964 (62%) patients were surveyed. The median age of patients was 44 years with an interquartile range (IQR) of 26 to 58 years. Life-threatening conditions such as trauma and cardiovascular disease were found in 8.6 and 6.6% of patients, respectively. The majority of patients with trauma travelled to the hospital using a motorcycle or car (59.8%). An ambulance was used by only 9.3% of all patients and 38% of patients reported that they were not aware of the availability of ambulances. Ambulance response time was longer as compared to other modes of transportation (median: 24 minutes and IQR: 12 to 54 minutes). The longest time to treatment was experienced by patients with neurological disease, with a median time of 120 minutes (IQR: 78 to 270 minutes). Patients who used ambulances incurred higher costs as compared to those patients who did not use ambulances.

CONCLUSION

The low utilization of emergency ambulances in Jakarta could be contributed to patients' lack of awareness of medical symptoms and the existence of ambulance services, and patients' disinclination to use ambulances due to high costs and long response times. The emergency ambulance services can be improved by increasing population awareness on symptoms that warrant the use of ambulances and reducing the cost burden related to ambulance use.

Does Every Minute Really Count? Road Time as an Indicator for the Economic Value of Emergency Medical Services

OBJECTIVES

This article builds on the literature regarding the association between emergency medical service (EMS) response times and patient outcomes (death and severe injury). Three issues are addressed in this article with respect to the empirical estimation of this relationship: the endogeneity of response time (systematically quicker response for higher degrees of urgency), the nonlinearity of this relationship, and the variation between such estimations for different patient outcomes.

METHODS

Binomial and multinomial logistic regression models are used to estimate the impact of response time on the probabilities of death and severe injury using data from French Fire and Rescue Services. These models are developed with response time as an explanatory variable and then with road time (dispatch to arrival) hypothesized as representing the exogenous variation within response time. Both models are also applied to data subsets based on response time intervals.

RESULTS

The results show that road time yields a higher estimate for the impact of response time on patient outcomes than (total) response time. The impact of road time on patient outcomes is also shown to be nonlinear. These results are of both statistical significance (model coefficients are significant at the 95% confidence level) and economical significance (when taking into account the number of annual interventions performed).

CONCLUSIONS

When using heterogeneous data on EMS interventions where endogeneity is a clear issue, road time is a more reliable indicator to estimate the impact of EMS response time on patient outcomes than (total) response time.

The impact of prehospital time intervals on mortality in moderately and severely injured patients

BACKGROUND

Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality.

METHODS

All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association.

RESULTS

We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality.

CONCLUSION

A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; level III.

OUP accepted manuscript

Background

Risk-adjusted mortality (RAM) analysis and comparisons of clinically relevant subsets of trauma patients allow hospitals to assess performance in different processes of care. The aim of the study was to develop a RAM model and compare RAM ratio (RAMR) in subsets of severely injured adult patients treated in university hospitals (UHs) and emergency hospitals (EHs) in Sweden.

Methods

This was a retrospective study of the Swedish trauma registry data (2013 to 2017) comparing RAMR in patients (aged 15 years or older and New Injury Severity Score (NISS) of more than 15) in the total population (TP) and in multisystem blunt (MB), truncal penetrating (PEN), and severe traumatic brain injury (STBI) subsets treated in UHs and EHs. The RAM model included the variables age, NISS, ASA Physical Status Classification System Score, and physiology on arrival.

Results

In total, 6690 patients were included in the study (4485 from UHs and 2205 from EHs). The logistic regression model showed a good fit. RAMR was 4.0, 3.8, 7.4, and 8.5 percentage points lower in UH versus EH for TP (P < 0.001), MB (P < 0.001), PEN (P = 0.096), and STBI (P = 0.005), respectively. The TP and MB subsets were subgrouped in with (+) and without (−) traumatic brain injury (TBI). RAMR was 7.5 and 7.0, respectively, percentage points lower in UHs than in EHs in TP + TBI and MB + TBI (both P < 0.001). In the TP–TBI (P = 0.027) and MB–TBI (P = 0.107) subsets the RAMR was 1.6 and 1.8 percentage points lower, respectively.

Conclusion

The lower RAMR in UHs versus EH were due to differences in TBI-related mortality. No evidence supported that Swedish EHs provide inferior quality of care for trauma patients without TBI or for patients with penetrating injuries.

Selective Prehospital Advanced Resuscitative Care - Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage

Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.

Impact of Using Drones in Emergency Medicine: What Does the Future Hold?

The use of unmanned aerial vehicles or "drones" has expanded in the last decade, as their technology has become more sophisticated, and costs have decreased. They are now used routinely in farming, environmental surveillance, public safety, commercial product delivery, recreation, and other applications. Health-related applications are only recently becoming more widely explored and accepted. The use of drone technology in emergency medicine is especially promising given the need for a rapid response to enhance patient outcomes. The purpose of this paper is to describe some of the main current and expanding applications of drone technology in emergency medicine and to describe challenges and future opportunities. Current applications being studied include delivery of defibrillators in response to out-of-hospital cardiac arrest, blood and blood products in response to trauma, and rescue medications. Drones are also being studied and actively used in emergency response to search and rescue operations as well as disaster and mass casualty events. Current challenges to expanding their use in emergency medicine and emergency medical system (EMS) include regulation, safety, flying conditions, concerns about privacy, consent, and confidentiality, and details surrounding the development, operation, and maintenance of a medical drone network. Future research is needed to better understand end user perceptions and acceptance. Continued technical advances are needed to increase payload capacities, increase flying distances, and integrate drone networks into existing 9-1-1 and EMS systems. Drones are a promising technology for improving patient survival, outcomes, and quality of life, particularly for those in areas that are remote or that lack funds or infrastructure. Their cost savings compared with ground transportation alone, speed, and convenience make them particularly applicable in the field of emergency medicine. Research to date suggests that use of drones in emergency medicine is feasible, will be accepted by the public, is cost-effective, and has broad application.

Effects of mode and time of EMS transport on the rate and distribution of dead on arrival among trauma population transported to ACSCOT-verified trauma centers in the United States

BACKGROUND

Unintentional injury remains the leading cause of death for adults worldwide. We aimed to investigate the rates and distribution of dead on arrival (DOA) patients according to emergency medical services (EMS) mode of transport (MoT), EMS transport time (TT), injury severity score (ISS), and type of injury.

METHODS

This retrospective study utilized de-identified incident-based data from the American College of Surgeons Trauma Quality Improvement Program Participant Use File (ACS-TQIP PUF) dataset (2013-2018) to study Adult DOA patients. DOA was defined according to the data point, "arrived with no signs of life and did not recover". Patients with unknown vitals and patients with no EMS vitals at the scene (HR = 0, RR = 0, and SBP = 0) were excluded to identify DOAs who died during transport. The DOAs included for analysis were sorted into three groups based on injury severity score [low (ISS < 15), intermediate (ISS = 15-24), and severe (ISS ≥ 25)] and subdivided according to injury type (blunt vs. penetrating), EMS Mode of transport and transport times. Statistical significance was defined as p < 0.05.

RESULTS

The majority of the evaluated 6030 adult DOA patients were male (73.3%) and 18-64 years of age (79.6%). Most patients sustained blunt injuries (58.2%), and the most common mechanism of injury was motor vehicle collisions (MVCs). Patients who traveled by helicopter EMS (HEMS) experienced less deaths than those traveling by ground EMS (GEMS) despite transporting more severely injured patients over longer time intervals. Median HEMS TTs were greater than their GEMS counterparts for blunt and penetrating injuries across all ISS groups but were associated with fewer deaths.

CONCLUSION

Helicopter emergency medical service use with intermediate and severely injured patients with penetrating injuries is associated with a reduced number of DOAs. Future studies should prospectively investigate EMS performance to confirm the findings identified in this retrospective analysis. Additionally, other factors affecting pre-hospital EMS performance (e.g., geographic variations, weather-related characteristics, in-flight interventions/procedures) should be investigated. Finally, the results of this study highlight the need for standardized HEMS utilization triage criteria.

Police transport of firearm-injured patients-more often and more injured

BACKGROUND

Police transport (PT) of penetrating trauma patients decreases the time between injury and trauma center arrival. Our study objective was to characterize trends in the rate of PT and its impact on mortality. We hypothesized that PT is increasing and that these patients are more injured.

METHODS

We conducted a single-center, retrospective cohort study of adult (≥18 years) patients presenting with gunshot wounds (GSWs) to a level 1 center from 2012 to 2018. Patients transported by police or ambulance (emergency medical service [EMS]) were included. The association between mode of transport (PT vs. EMS) and mortality was evaluated using χ2, t tests, Mann-Whitney U tests, and logistic regression.

RESULTS

Of 2,007 patients, there were 1,357 PT patients and 650 EMS patients. Overall in-hospital mortality was 23.7%. The rate of GSW patients arriving by PT increased from 48.9% to 78.5% over the study period (p < 0.001). Compared with EMS patients, PT patients were sicker on presentation with lower initial systolic blood pressure (98 vs. 110, p < 0.001), higher Injury Severity Score (median [interquartile range], 10 [2-75] vs. 9 [1-17]; p < 0.001) and more bullet wounds (3.5 vs. 2.9, p < 0.001). Police-transported patients more frequently underwent resuscitative thoracotomy (19.2% vs. 10.0%, p < 0.001) and immediate surgical exploration (31.3% vs. 22.6%, p < 0.001). There was no difference in adjusted in-hospital mortality between transport groups. Of patients surviving to discharge, PT patients had higher Injury Severity Score (9.6 vs. 8.3, p = 0.004) and lower systolic blood pressure on arrival (126 vs. 130, p = 0.013) than EMS patients.

CONCLUSION

Police transport of GSW patients is increasing at our urban level 1 center. Compared with EMS patients, PT patients are more severely injured but have similar in-hospital mortality. Further study is necessary to understand the impact of PT on outcomes in specific subsets in penetrating trauma patients.

LEVEL OF EVIDENCE

Epidemiological, level III.

Prolonged Prehospital Time is a Risk Factor for Pneumonia in Trauma (the PRE-TRIP study): A Retrospective Analysis of the United States National Trauma Data Bank

BACKGROUND

Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown.

RESEARCH QUESTION

Is prolonged prehospital time an independent risk factor for pneumonia?

STUDY DESIGN AND METHODS

We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016.

RESULTS

Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (p < 0.001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (p < 0.001, 4.3% mortality without pneumonia vs. 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns.

INTERPRETATION

Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important as prolonged prehospital time may need to be considered in subsequent decision making.

CLINICAL TRIAL REGISTRATION

Not applicable.

Dispatch, Prehospital time, Interventions and Outcomes in a Norwegian Trauma population – assessing initial trauma management in urban and rural areas. The DIONT-project: a national registry-based research protocol (Preprint)

Background

Time is considered an essential determinant in the initial care of trauma patients. In Norway, response time (ie, time from dispatch center call to ambulance arrival at scene) is a controversial national quality indicator. However, no national requirements for response times have been established. There is an ongoing debate regarding the optimal configuration of the Norwegian trauma system. The recent centralization of trauma services and closure of emergency hospitals have increased prehospital transport distances, predominantly for rural trauma patients. However, the impact of trauma system configuration on early trauma management in urban and rural areas is inadequately described.

Objective

The project will assess injured patients’ initial pathways through the trauma system and explore differences between central and rural areas in a Norwegian trauma cohort. This field is unexplored at the national level, and existing evidence for an optimal organization of trauma care is still inconclusive regarding the impact of prehospital time.

Methods

Three quantitative registry-based retrospective cohort studies are planned. The studies are based on data from the Norwegian Trauma Registry (NTR; studies 1, 2, and 3) and the local Emergency Medical Communications Center (study 2). All injured patients admitted to a Norwegian hospital and registered in the NTR in the period between January 1, 2015, and December 31, 2020, will be included in the analysis. Trauma registry data will be analyzed using descriptive and relevant statistical methods to compare prehospital time in rural and central areas, including regression analyses and adjusting for confounders.

Results

The project received funding in fall 2020 and was approved by the Oslo University Hospital data protection officer, case number 18/02592. Registry data including approximately 40,000 trauma patients will be extracted during the first quarter of 2022, and analysis will begin immediately thereafter. Results are expected to be ready for publication from the third quarter of 2022.

Conclusions

Findings from the study will contribute to new knowledge regarding existing quality indicators and with an increasing centralization of hospitals and residents, the study will contribute to further development of the Norwegian trauma system. A high generalizability to other trauma systems is expected, given the similarities between demographical changes and trauma systems in many high-income countries.

International Registered Report Identifier (IRRID)

PRR1-10.2196/30656

Outcomes after Prehospital Traumatic Cardiac Arrest in the Netherlands: a Retrospective Cohort Study

BACKGROUND

Traumatic cardiac arrest (TCA) is a severe and life-threatening situation that mandates urgent action. Outcomes after on-scene treatment of TCA in the Netherlands are currently unknown. The aim of the current study was to investigate the rate of survival to discharge in patients who suffered from traumatic cardiac arrest and who were subsequently treated on-scene by the Dutch Helicopter Emergency Medical Services (HEMS).

METHODS

A retrospective cohort study was performed including patients ≥ 18 years with TCA for which the Dutch HEMS were dispatched between January 1^st 2014 and December 31^st 2018. Patients with TCA after hanging, submersion, conflagration or electrocution were excluded. The primary outcome measure was survival to discharge after prehospital TCA. Secondary outcome measures were return of spontaneous circulation (ROSC) on-scene and neurological status at hospital discharge.

RESULTS

Nine-hundred-fifteen patients with confirmed TCA were included. ROSC was achieved on-scene in 261 patients (28.5%). Thirty-six (3.9%) patients survived to hospital discharge of which 17 (47.2%) had a good neurological outcome. Age < 70 years (0.7% vs. 5.2%; p=0.041) and a shockable rhythm on first ECG (OR 0.65 95%CI 0.02-0.28; p<0.001) were associated with increased odds of survival.

CONCLUSION

Neurologic intact survival is possible after prehospital traumatic cardiac arrest. Younger patients and patients with a shockable ECG rhythm have higher survival rates after TCA.

LEVEL OF EVIDENCE

prognostic study, level III.

Do EMS times associate with injury severity?

In this study, emergency medical services times, along with other crash-related explanatory variables, have been used to investigate influential factors on injury severity. To overcome the complexity of emergency medical services times impact on crash outcome, the interaction effects of EMS times and injury location on the body were also investigated in a separate model. This study utilized the linked data of police-reported crash data and emergency medical services runs, including 2192 crash injuries that transferred to hospital. A random-effects ordered probit approach was implemented to identify effective factors on crash injury severity. Three models of (1) crash-related variables, (2) crash-related and emergency medical services times and (3) crash-related, emergency medical services times and interaction effects of EMS times and injury location on the body were developed. Although the outcome could not find the impact of faster emergency medical services times on injury severity in the second model, in the third model, faster response time and slower on-scene time were associated with decreasing the severity of entire-body injuries. We discuss why this may be the case.

The Impact of Prehospital Transport Mode on Mortality of Penetrating Trauma Patients

OBJECTIVE

The optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality.

METHODS

Using the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates.

RESULTS

A total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P < .0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P < .0001).

CONCLUSION

Helicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.

Most of the Variation in Prehospital Scene Time Is Not Related to Patient Factors, Injury Characteristics, or Geography

OBJECTIVE

The time spent on scene by emergency medical services remains highly variable. We sought to investigate how much of the prehospital scene time variation in penetrating trauma patients could be explained by prehospital factors.

METHODS

Using the 2010 to 2016 Trauma Quality and Improvement database, all adult penetrating trauma patients were included. The prehospital scene time was defined as the time from emergency medical service scene arrival to departure. Using all Trauma Quality and Improvement database variables including patient, injury (eg, Injury Severity Score), geography, and logistical (eg, transport mode) factors, multivariable linear regression models were created to predict the prehospital scene time. The prehospital scene time was treated as a continuous variable, and the degree to which the models could explain the variation in scene time was measured using the coefficient of determination (R).

RESULTS

A total of 45,560 patients were included. The median prehospital scene time was 6 minutes (interquartile range, 3-10 minutes). The R for factors in the multivariable regression model was 0.06, suggesting that 94% of the prehospital scene time variation cannot be explained by the wide range of prehospital factors.

CONCLUSION

Most of the variation in prehospital scene time cannot be explained by injury characteristics. The variation may be caused by logistical delays or system-related factors.