Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

Operationalising routinely collected patient data in research to further the pursuit of social justice and health equity: a team-based scoping review

BACKGROUND

Vast volumes of routinely collected data (RCD) about patients are collated by health professionals. Leveraging this data - a form of real-world data - can be valuable for quality improvement and contributing to the evidence-base to inform practice. Examining routine data may be especially useful for examining issues related to social justice such as health inequities. However, little is known about the extent to which RCD is utilised in health fields and published for wider dissemination.

OBJECTIVES

The objective of this scoping review is to document the peer-reviewed published research in allied health fields which utilise RCD and evaluate the extent to which these studies have addressed issues pertaining to social justice.

METHODS

An enhanced version of the Arksey and O'Malley's framework, put forth by Westphalm et al. guided the scoping review. A comprehensive literature search of three databases identified 1584 articles. Application of inclusion and exclusion criteria was piloted on 5% of the papers by three researchers. All titles and abstracts were screened independently by 2 team members, as were full texts. A data charting framework, developed to address the research questions, was piloted by three researchers with data extraction being completed by the lead researcher. A sample of papers were independently charted by a second researcher for reliability checking.

RESULTS

One hundred and ninety papers were included in the review. The literature was diverse in terms of the professions that were represented: physiotherapy (33.7%) and psychology/mental health professions (15.8%) predominated. Many studies were first authored by clinicians (44.2%), often with clinical-academic teams. Some (33.25%) directly referenced the use of their studies to examine translation of research to practice. Few studies (14.2%) specifically tackled issues pertaining to social justice, though many collected variables that could have been utilised for this purpose.

CONCLUSION

Studies operationalising RCD can meaningfully address research to practice gaps and provide new evidence about issues related to social justice. However, RCD is underutilised for these purposes. Given that vast volumes of relevant data are routinely collected, more needs to be done to leverage it, which would be supported by greater acknowledgement of the value of RCD studies.

Impact of emergency physician-staffed ambulances on preoperative time course and survival among injured patients requiring emergency surgery or transarterial embolization: A retrospective cohort study at a community emergency department in Japan

Injured patients requiring definitive intervention, such as surgery or transarterial embolization (TAE), are an extremely time-sensitive population. The effect of an emergency physician (EP) patient care delivery system in this important trauma subset remains unclear. We aimed to clarify whether the preoperative time course and mortality among injured patients differ between ambulances staffed by EPs and those staffed by emergency life-saving technicians (ELST). This was a retrospective cohort study at a community emergency department (ED) in Japan. We included all injured patients requiring emergency surgery or TAE who were transported directly from the ED to the operating room from January 2002 to December 2019. The primary exposure was dispatch of an EP-staffed ambulance to the prehospital scene. The primary outcome measures were preoperative time course including prehospital length of stay (LOS), ED LOS, and total time to definitive intervention. The other outcome of interest was in-hospital mortality. One-to-one propensity score matching was performed to compare these outcomes between the groups. Of the 1,020 eligible patients, 353 (34.6%) were transported to the ED by an EP-staffed ambulance. In the propensity score-matched analysis with 295 pairs, the EP group showed a significant increase in median prehospital LOS (71.0 min vs. 41.0 min, P < 0.001) and total time to definitive intervention (189.0 min vs. 177.0 min, P = 0.002) in comparison with the ELST group. Conversely, ED LOS was significantly shorter in the EP group than in the ELST group (120.0 min vs. 131.0 min, P = 0.043). There was no significant difference in mortality between the two groups (8.8% vs.9.8%, P = 0.671). At a community hospital in Japan, EP-staffed ambulances were found to be associated with prolonged prehospital time, delay in definitive treatment, and did not improve survival among injured patients needing definitive hemostatic procedures compared with ELST-staffed ambulances.

Physician-staffed ambulance and increased in-hospital mortality of hypotensive trauma patients following prolonged prehospital stay: A nationwide study

BACKGROUND

The benefits of physician-staffed emergency medical services (EMS) for trauma patients remain unclear because of the conflicting results on survival. Some studies suggested potential delays in definitive hemostasis due to prolonged prehospital stay when physicians are dispatched to the scene. We examined hypotensive trauma patients who were transported by ambulance, with the hypothesis that physician-staffed ambulances would be associated with increased in-hospital mortality, compared with EMS personnel-staffed ambulances.

METHODS

A retrospective cohort study that included hypotensive trauma patients (systolic blood pressure ≤ 90 mm Hg at the scene) transported by ambulance was conducted using the Japan Trauma Data Bank (2004-2019). Physician-staffed ambulances are capable of resuscitative procedures, such as thoracotomy and surgical airway management, while EMS personnel-staffed ambulances could only provide advanced life support. In-hospital mortality and prehospital time until the hospital arrival were compared between patients who were classified based on the type of ambulance. Inverse probability weighting was conducted to adjust baseline characteristics including age, sex, comorbidities, mechanism of injury, vital signs at the scene, injury severity, and ambulance dispatch time.

RESULTS

Among 14,652 patients eligible for the study, 738 were transported by a physician-staffed ambulance. In-hospital mortality was higher in the physician-staffed ambulance than in the EMS personnel-staffed ambulance (201/699 [28.8%] vs. 2287/13,090 [17.5%]; odds ratio, 1.90 [1.61-2.26]; adjusted odds ratio, 1.22 [1.14-1.30]; p < 0.01), and the physician-staffed ambulance showed longer prehospital time (50 [36-66] vs. 37 [29-48] min, difference = 12 [11-12] min, p < 0.01). Such potential harm of the physician-staffed ambulance was only observed among patients who arrived at the hospital with persistent hypotension (systolic blood pressure < 90 mm Hg on hospital arrival) in subgroup analyses.

CONCLUSION

Physician-staffed ambulances were associated with prolonged prehospital stay and increased in-hospital mortality among hypotensive trauma patients compared with EMS personnel-staffed ambulance.

LEVEL OF EVIDENCE

Therapeutic, level IV.

[Implications of prehospital estimation of trauma patients for the treatment pathway-An evaluation of the TraumaRegister DGU®]

BACKGROUND

In the prehospital acute treatment phase of severely injured patients, the stabilization of the vital parameters is paramount. The rapid and precise assessment of the injuries by the emergency physician is crucial for the initial treatment and the selection of the receiving hospital.

OBJECTIVE

The aim of this study was to determine whether the prehospital emergency medical assessment has an influence on prehospital and emergency room treatment.

MATERIAL AND METHODS

Data from the TraumaRegister DGU® between 2015 and 2019 in Germany were evaluated. The prehospital emergency medical assessment of the injury pattern and severity was recorded using the emergency physician protocol and compared with the in-hospital documented diagnoses using the abbreviated injury scale.

RESULTS

A total of 47,838 patients with an average injury severity score (ISS) of 18,7 points (SD 12.3) were included. In summary, 127,739 injured body regions were documented in the hospitals. Of these, a total of 87,921 were correctly suspected by the emergency physician Thus, 39,818 injured body regions were not properly documented. In 42,530 cases a region of the body was suspected to be injured without the suspicion being confirmed in the hospital. Traumatic brain injuries and facial injuries were mostly overdiagnosed (13.5% and 14.7%, respectively documented by an emergency physician while the diagnosis was not confirmed in-hospital). Chest injuries were underdocumented (17.3% missed by an emergency physician while the diagnosis was finally confirmed in-hospital). The total mortality of all groups was very close to the expected mortality calculated with the revised injury severity classification II(RISC II)-score (12.0% vs. 11.3%).

CONCLUSION

In the prehospital care of severely injured patients, the overall injury severity is often correctly recorded by the emergency physician and correlates well with the derived treatment, the selection of the receiving hospital as well as the clinical course and the patient outcome; however, the assessment of injuries of individual body regions seems to be challenging in the prehospital setting.

Physician-led prehospital management is associated with reduced mortality in severe blunt trauma patients: a retrospective analysis of the Japanese nationwide trauma registry

BACKGROUND

Although the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.

METHODS

This retrospective cohort study analyzed the data of Japan's nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.

RESULTS

A total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78-1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.

CONCLUSIONS

Physician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.

The Effect of Physician-Led Enhanced Care Teams in Prehospital Trauma Resuscitation

Trauma is the leading cause of morbidity and mortality for those under 45 years of age in the United States with half of the deaths in trauma being attributed to hemorrhagic shock. The use of enhanced care teams (ECTs) that include physicians in selective prehospital settings has allowed the delivery of advanced critical care interventions in the field. We present a unique case where a young driver involved in a motor vehicle accident was trapped under the weight of his vehicle, causing extended extrication time. An ECT from the closest trauma center was able to deliver massive transfusion and definitive airway care while the patient was being extricated. While previous literature regarding the benefit of ECTs has been debated, this case suggests a unique niche where rapid deployment of an ECT to the scene made a pronounced difference in survival of the patient.

Do pre-hospital physicians improve mortality in major trauma patients? A systematic review

Background

Optimal pre-hospital care systems contribute to improvements in trauma survival. The presence of pre-hospital physicians (PHPs) is reported to increase survival in traumatic brain injury, yet the effects of PHPs on outcomes for all trauma patients is currently unreported. The objective of this systematic review was to compare trauma mortality for patients treated by a PHP with those treated by a non-medical pre-hospital practitioner (NMPHP).

Methods

A systematic literature search (Medline, Embase, and CINAHL) was performed, on 10th March 2020, to identify original studies comparing the mortality for trauma patients treated by a PHP with those treated by a NMPHP published between 1st January 2010 and 31st December 2019. Methodological quality of studies was assessed using Grade of Recommendations, Assessment, Development and Evaluation (GRADE).

Results

The search revealed 6,296 studies and 14 met the inclusion criteria, comprising a total of 42,479 patients. Unadjusted mortality suggested a higher mortality for the physician cohort in four studies and no difference in six. However, patients treated by physicians had higher Injury Severity Scores and where adjusted mortality was provided several studies showed a mortality benefit for physicians.

Conclusion

This systematic review did not demonstrate a mortality benefit from pre-hospital physicians attending major trauma patients. However, those with higher Injury Severity Scores may benefit from the presence of a PHP. Identifying this patient cohort in the pre-hospital setting to ensure appropriate resource use requires further evaluation.

Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review

BACKGROUND

Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene.

METHODS

A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables.

RESULTS

We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers.

CONCLUSIONS

Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

Purpose

Swiss and German (pre-)hospital systems, distribution and organization of trauma centres differ from each other. It is unclear if outcome in trauma patients differs as well. Therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both German-speaking countries.

Methods

The TraumaRegister DGU^® (TR-DGU) was used. Patients with Injury Severity Score ≥ 9 admitted to a level 1 trauma centre between 01/2009 and 12/2017 were included if they required ICU care or died. Trauma pattern, pre-hospital procedures and outcome were compared between Swiss (CH, n = 4768) and German (DE, n = 66,908) groups.

Results

Swiss patients were older than German patients (53 vs. 50 years). ISS did not differ between groups (CH 23.8 vs. DE 23.0 points). There were more low falls < 3 m (34% vs. 21%) at the expense of less traffic accidents (37% vs. 52%) in the Swiss population. In Switzerland 30% of allocations were done without physician involvement, whereas this occurred in 4% of German cases. Despite a comparable number of patients with a GCS ≤ 8 (CH 29.6%; DE 26.4%), differences in pre-hospital intubation rates occurred (CH 31% vs. DE 40%). Severe traumatic brain injuries were diagnosed most frequently in Switzerland (CH 62% vs. DE 49%). Admission vital signs were similar, and standardized mortality ratios were close to one in both countries.

Conclusion

This study demonstrates that patients’ age, trauma patterns and pre-hospital care differ between Germany and Switzerland. However, adjusted mortality was almost similar. Further benchmarking studies are indicated to optimize trauma care in both German-speaking countries.

Observed versus expected mortality in pediatric patients intubated in the field with Glasgow Coma Scale scores < 9

PURPOSE

A Glasgow Coma Scale (GCS) score of 8 or less in patients suffering from severe traumatic brain injury (TBI) represents a decision-making marker in terms of intubation. This study evaluated the impact of prehospital intubation on the mortality of these TBI cases among different age groups.

METHODS

This study included the data from patients predominantly suffering from severe TBI [Abbreviated Injury Scale (AIS) of the head ≥ 3, GCS score < 9, Injury Severity Score (ISS) > 9] who were registered in TraumaRegister DGU^® from 2002 to 2013. An age-related analysis of five subgroups was performed (1-6, 7-15, 16-55, 56-79, and ≥ 80 years old). The observed and expected mortality were matched according to the Revised Injury Severity Classification, version II.

RESULTS

A total of 21,242 patients were included. More often, the intubated patients were severely injured when compared to the non-intubated patients (median ISS 29, IQR 22-41 vs. 24, IQR 16-29, respectively), with an associated higher mortality (42.2% vs. 30.0%, respectively). When compared to the calculated expected mortality, the observed mortality was significantly higher among the intubated patients within the youngest subgroup (42.2% vs. 33.4%, respectively; p = 0.03).

CONCLUSIONS

The observed mortality in the intubated children 1-6 years old suffering from severe TBI seemed to be higher than expected. Whether or not a GCS score of 8 or less is the only reliable criterion for intubation in this age group should be investigated in further trials.

Efficacy of the presence of an emergency physician in prehospital major trauma care: A nationwide cohort study in Japan

PURPOSE

The beneficial effect of the presence of an emergency physician in prehospital major trauma care is controversial. The aim in this study is to assess whether an emergency physician on scene can improve survival outcome of critical trauma patients.

METHODS

This retrospective cohort study was conducted by using nationwide trauma registry data between 2004 and 2013 in Japan. Severe trauma patients (injury severity score (ISS) ≥ 16) who were transported directly to the hospital from the injury site were included in our analysis. Patients who were predicted to be untreatable (abbreviated injury score (AIS) = 6 and/or cardiopulmonary arrest at least one time before hospital arrival) were excluded. Participants were divided into either a physician or paramedics group based on the prehospital practitioner. The primary outcome was survival rate at discharge. Multivariable logistic regression analysis was performed to compare the outcome with adjustment for age, gender, ISS, cause of injury, and pre-hospital vital signs.

RESULTS

A total of 30,283 patients were eligible for the selection criteria (physician: 1222, paramedics: 29,061). Overall, 172 patients (14.1%) died in the physician group compared to 3508 patients (12.1%) in the paramedics group. Patients in the physician group had higher ISSs than those in the paramedics group. In multivariable logistic regression, the physician group had an odds ratio (OR) of 1.16 (95% confidence interval (CI) = 0.97 to 1.40, p = 0.11) for in-hospital survival.

CONCLUSIONS

Our results failed to show a difference in survival at discharge between non-physician-staffed ambulances and physician-staffed ambulances.

Outcomes after cancelled helicopter emergency medical service missions due to concurrencies: a retrospective cohort study

BACKGROUND

Appropriate dispatch criteria and helicopter emergency medical service (HEMS) crew decisions are crucial for avoiding over-triage and reducing the number of concurrencies. The aim of the present study was to compare patient outcomes after completed HEMS missions and missions cancelled by the HEMS due to concurrencies.

METHODS

Missions cancelled due to concurrencies (AMB group) and completed HEMS missions (HEMS group) in Western Norway from 2004 to 2013 were assessed. Outcomes were survival to hospital discharge, physiology score in the emergency department, emergency interventions in the hospital, type of department for patient admittance, and length of hospital stay.

RESULTS

Survival to discharge was similar in the two groups. One-third of the primary missions in the HEMS group and 13% in the AMB group were patients with pre-hospital conditions posing an acute threat to life. In a sub group analysis of these patients, HEMS patients were younger, more often admitted to an intensive care unit, and had an increased survival to discharge. In addition, the HEMS group had a greater proportion of patients with deranged physiology in the emergency department according to an early warning score.

CONCLUSION

Patients in the HEMS group seemed to be critically ill more often and received more emergency interventions, but the two groups had similar in-hospital mortality. Patients with pre-hospital signs of acute threat to life were younger and presented increased survival in the HEMS group.

Does prehospital management by doctors affect outcome in major trauma? A systematic review

BACKGROUND

There is substantial variation worldwide in prehospital management of trauma and the role of doctors is controversial. The objective of this review was to determine whether prehospital management by doctors affects outcomes in major trauma, including the prespecified subgroup of severe traumatic brain injuries when compared with management by other advanced life support providers.

METHODS

EMBASE, MEDLINE(R), PubMed, SciELO, Trip, Web of Science, and Zetoc were searched for published articles. HSRProj, OpenGrey, and the World Health Organization International Clinical Trials Registry Platform were searched for unpublished data. Relevant reference lists were hand-searched. There were no limits on publication year, but articles were limited to the English language. Authors were contacted for further information as required. Quality was assessed using the Downs and Black criteria. Mortality was the primary outcome, and disability was the secondary outcome of interest. Studies were subjected to a descriptive analysis alone without a meta-analysis due to significant study heterogeneity. All searches, quality assessment, data abstraction, and data analysis was performed by two reviewers independently.

RESULTS

Two thousand thirty-seven articles were identified, 49 full-text articles assessed and eight studies included. The included studies consisted of one randomized controlled trial with 375 participants and seven observational studies with over 4,451 participants. All included studies were at a moderate to high risk of bias. Six of the eight included studies showed an improved outcome with prehospital management by doctors, five in terms of mortality and one in terms of disability. Two studies found no significant difference.

CONCLUSION

There appears to be an association between prehospital management by doctors and improved survival in major trauma. There may also be an association with improved survival and better functional outcomes in severe traumatic brain injury. Further high-quality evidence is needed to confirm these findings.

LEVEL OF EVIDENCE

Systematic review, level III.