Rapid Ground Transport of Trauma Patients: A Moderate Distance From Trauma Center Improves Survival

Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan

PURPOSE

In Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a "doctor car". Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan.

METHODS

A nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations.

RESULTS

This study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065-1.415]).

CONCLUSION

Using nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Factors Associated With Delayed Pre-Hospital Times During Trauma-Related Mass Casualty Incidents: A Systematic Review

OBJECTIVE

Critically injured patients have experienced delays in being transported to hospitals during Mass Casualty Incidents (MCIs). Extended pre-hospital times (PHTs) are associated with increased mortality. It is not clear which factors affect overall PHT during an MCI. This systematic review aimed to investigate PHTs in trauma-related MCIs and identify factors associated with delays for triaged patients at incident scenes.

METHODS

This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, CINAHL, MEDLINE, and EMBASE were searched between January and February 2022 for evidence. Research studies of any methodology, and grey literature in English, were eligible for inclusion. Studies were narratively synthesized according to Cochrane guidance.

RESULTS

Of the 2025 publications identified from the initial search, 12 papers met the inclusion criteria. 6 observational cohort studies and 6 case reports described a diverse range of MCIs. PHTs were reported variably across incidents, from a median of 35 minutes to 8 hours, 8 minutes. Factors associated with prolonged PHT included: challenging incident locations, concerns about scene safety, and adverse decision-making in MCI triage responses. Casualty numbers did not consistently influence PHTs. Study quality was rated moderate to high.

CONCLUSION

PHT delays of more than 2 hours were common. Future MCI planning should consider responses within challenging environments and enhanced timely triage decision-making.

Effects of the establishment of trauma centres on the mortality rate among seriously injured patients: a propensity score matching retrospective study

BACKGROUND

Little evidence suggests that trauma centres are associated with a lower risk of mortality in severely injured patients (Injury Severity Score (ISS) ≥16) with multiple injuries in China. The objective of this study was to determine the association between the establishment of trauma centres and mortality among severely injured patients with multiple injuries and to identify some risk factors associated with mortality.

METHODS

A retrospective single-centre study was performed including trauma patients admitted to the First Affiliated Hospital of Nanchang University (FAHNU) between January 2016 and December 2021. To determine whether the establishment of a trauma centre was an independent predictor of mortality, logistic regression analysis and propensity score matching (PSM) were performed.

RESULTS

Among 431 trauma patients, 172 were enrolled before the trauma centre was built, while 259 were included after the trauma centre was built. A higher frequency of older age and traffic accident injury was found in patients diagnosed after the trauma centre was built. The times for the completion of CT examinations, emergency operations and blood transfusions in the "after trauma centre" group were shorter than those in the "before trauma centre" group. However, the total expenditure of patients was increased. In the overall group, univariate and multivariate logistic regression analyses showed that a higher ISS was an independent predictor for worse mortality (OR = 17.859, 95% CI, 8.207-38.86, P < 0.001), while the establishment of a trauma centre was favourable for patient survival (OR = 0.492), which was also demonstrated by PSM. After determining the cut-off value of time for the completion of CT examination, emergency operation and blood transfusion, we found that the values were within the "golden one hour", and it was better for patients when the time was less than the cut-off value.

CONCLUSION

Our study showed that for severely injured patients, the establishment of a trauma centre was favourable for a lower mortality rate. Furthermore, the completion of a CT examination, emergency surgery and blood transfusion in a timely manner and a lower ISS were associated with a decreased mortality rate.

A Statistical Overview of Fixed Wing Air Medical Transportation Operations in the United States (2019-2020)

Air medical transportation (AMT) services provide the transportation of patients, medical teams, and organs for the US health care system. Interfacility transfers account for 54% of air medical transports, and delivering specialty care and organs accounts for 13% of air medical transports. Interfacility transfer, specialty care, and organ delivery are predominantly conducted using fixed wing aircraft. The AMT fixed wing fleet has grown 2.2% per year over the last decade along with a 3.6% per year expansion in the number of AMT base airports with fixed wing operations. This article aims to characterize the operations of fixed wing AMT in the United States for the period of 2019 to 2020. This information can be used for aircraft design, airport and air traffic control infrastructure assessment and funding, and AMT industry sector analysis and strategic planning. Data from 12 databases were combined to identify AMT flights and generate operational statistics including the number of vehicles; ownership; flight distances; flight frequency; geographic distribution; and the types of airports, air traffic control, and navigation systems used.

Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States

Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police.Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police.Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13-15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321-2.333); p = 0.776).Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.

Is more better? Do statewide increases in trauma centers reduce injury-related mortality?

OBJECTIVES

Trauma centers are inconsistently distributed throughout the United States. It is unclear if new trauma centers improve care and decrease mortality. We tested the hypothesis that increases in trauma centers are associated with decreases in injury-related mortality (IRM) at the state level.

METHODS

We used data from the American Trauma Society to geolocate every state-designated or American College of Surgeons-verified trauma center in all 50 states and the District of Columbia from 2014 to 2018. These data were merged with publicly available IRM data from the Centers for Disease Control and Prevention. We used geographic information systems methods to map and study the relationships between trauma center locations and state-level IRM over time. Regression analysis, accounting for state-level fixed effects, was used to calculate the effect of total statewide number of trauma center on IRM and year-to-year changes in statewide trauma center with the IRM (shown as deaths per additional trauma center per 100,000 population, p value).

RESULTS

Nationwide between 2014 and 2018, the number of trauma center increased from 2,039 to 2,153. Injury-related mortality also increased over time. There was notable interstate variation, from 1 to 284 trauma centers. Four patterns in statewide trauma center changes emerged: static (12), increased (29), decreased (5), or variable (4). Of states with trauma center increases, 26 (90%) had increased IRM between 2014 and 2017, while the remaining 3 saw a decline. Regression analysis demonstrated that having more trauma centers in a state was associated with a significantly higher IRM rate (0.38, p = 0.03); adding new trauma centers was not associated with changes in IRM (0.02, p = 0.8).

CONCLUSION

Having more trauma centers and increasing the number of trauma center within a state are not associated with decreases in state-level IRM. In this case, more is not better. However, more work is needed to identify the optimal number and location of trauma centers to improve IRM.

LEVEL OF EVIDENCE

Epidemiologic, level III; Care management, level III.

Association between Mode of Transportation and Survival in Adult Trauma Patients with Blunt Injuries: Matched Cohort Study between Police and Ground Ambulance Transport

INTRODUCTION

Early police transport (PT) of penetrating trauma patients has the potential to improve survival rates for trauma patients. There are no well-established guidelines for the transport of blunt trauma patients by PT currently.

STUDY OBJECTIVE

This study examines the association between the survival rate of blunt trauma patients and the transport modality (police versus ground ambulance).

METHODS

A retrospective, matched cohort study was conducted using the National Trauma Data Bank (NTDB). All blunt trauma patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by ground Emergency Medical Services (EMS) for analysis. Descriptive analysis was carried out. This was followed by comparing all patients' characteristics and their survival rates in terms of the mode of transportation.

RESULTS

Out of the 2,469 patients with blunt injuries, EMS transported 1,846 patients and police transported 623 patients. Most patients were 16-64 years of age (86.2%) with a male predominance (82.5%). Fall (38.4%) was the most common mechanism of injury with majority of injuries involving the head and neck body part (64.8%). Fractures were the most common nature of injury (62.1%). The overall survival rate of adult blunt trauma patients was similar for both methods of transportation (99.2%; P = 1.000).

CONCLUSION

In this study, adult blunt trauma patients transported by police had similar outcomes to those transported by EMS. As such, PT in trauma should be encouraged and protocolized to improve resource utilization and outcomes further.

Prehospital Response Time of the Emergency Medical Service during Mass Casualty Incidents and the Effect of Triage: A Retrospective Study

OBJECTIVE

Prehospital time affects survival in trauma patients. Mass casualty incidents (MCIs) are overwhelming events where medical care exceeds available resources. This study aimed at evaluating the prehospital time during MCIs and investigating the effect of triage.

METHODS

A retrospective analysis was performed using Florida's Event Medical Services Tracking and Reporting System database. All patients involved in MCIs during 2018 were accessed, and prehospital time intervals were evaluated and compared to that of non-MCIs. The effect of MCI triage and field triage (Field Triage Criteria) on prehospital time was evaluated.

RESULTS

In 2018, it was estimated that 2236 unique MCIs occurred in Florida, with a crude incidence of 10.1-10.9/100000 people. 2180 EMS units arrived at the hospital for patient disposition with a median alarm-to-hospital time of 43.74 minutes, significantly longer than non-MCIs (39.15 min; P < 0.001). MCI triage and field triage were both associated with shorter alarm-to-hospital time (39.37 min and 37.55 min, respectively).

CONCLUSIONS

MCIs resulted in longer prehospital time intervals than non-MCIs. This finding suggests that additional efforts are needed to reduce the prehospital time for MCI patients. MCI triage and field triage were both associated with shorter alarm-to-hospital times. Widespread use may improve prehospital MCI care.

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

BACKGROUND

Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

MAIN BODY

We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

CONCLUSION

The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.

Factors Associated with Survival in Adult Trauma Patients Transported to US Trauma Centers by Police

INTRODUCTION

Police units often reach the trauma scene before Emergency Medical Services (EMS). Initiatives aiming at delivering early basic trauma care by non-medical providers including police personnel are on the rise. This study describes characteristics of trauma patients transported by police to US hospitals and identifies factors associated with survival in this patient population.

METHODS

Using the 2015 National Trauma Data Bank (NTDB), an observational study was conducted of adult trauma patients who were transported by police. After describing the study population, the factors associated with survival to hospital discharge were evaluated using a multivariate analysis.

RESULTS

A total of 2,394 patients were included in the study. Patients had a median age of 34.0 years (interquartile range [IQR]: 25-48) and most were males (84.5%). Blunt trauma mechanism (59.4%) was more common than penetrating trauma (29.4%). Factors associated with improved survival included: comorbidity (odds ratio [OR] = 2.92; 95% CI, 1.33-6.40); use of drugs (OR = 2.91; 95% CI, 1.07-7.92); cut/pierce (OR = 11.07; 95% CI, 2.10-58.43); motor vehicle traffic (MVT) mechanism (OR = 6.56; 95% CI, 1.60-26.98); trauma resulting in fractures (OR = 3.03; 95% CI, 1.38-6.64); and private/commercial insurance (OR = 3.41; 95% CI, 1.10-10.55).

CONCLUSION

In this study population, a relatively high survival rate was noted (93.5%). Police transport of patients with blunt trauma was unexpectedly more common. Factors associated with survival to hospital discharge were identified. These factors can be used to implement more standardized and protocol-driven risk stratification tools of trauma patients on scene to improve police involvement in trauma patient transport.

Drone for medical products transportation in maternal healthcare: A systematic review and framework for future research

INTRODUCTION

Medical products transportation has become an important research topic requiring multidisciplinary collaboration among experts in medicine, engineering, and health economics. Current modes of transportation are unable to overcome the limited settings in maternal healthcare, particularly during the event of obstetric emergencies. The drone is a promising medical product aerial transportation (MedART) that holds an enormous potential for delivery of medical supplies in the healthcare system. We conducted a systematic review to examine scientific evidence of positive impact of drone transportation on maternal health.

METHODS

The following electronic databases were searched from inception to July 2019: ScienceDirect, PubMed, and EMBASE. The report was made in accordance with the principles of PRISMA guidelines. The search terms used were related to drones including unmanned aerial vehicle (UAV) and unmanned aerial system (UAS), and related to obstetric/maternal including obstetric emergencies and postpartum hemorrhage. Studies were selected if the intervention used were drones, and if any direct or indirect maternal health indicators were reported. Meta-analysis was not done throughout the study in view of the anticipated heterogeneity of each study.

RESULTS

Our initial search yielded a total of 244 relevant publications, from which 236 were carried forward for a title and abstract screening. After careful examination, only two were included for systematic synthesis. Among the reasons for exclusion were irrelevance to maternal health purpose, and irrelevance to drone applications in healthcare. An updated search yielded one additional study that was also included. Overall, two studies assessed drones for blood products delivery, and one study used drones to transport blood samples.

CONCLUSION

A significant deficiency was found in the number of reported studies analyzing mode of medical products transportation and adaptation of drones in maternal healthcare. Future drone research framework should focus on maternal healthcare-specific drone applications in order to reap benefits in this area.

Introduction and characteristics of helicopter emergency medical services

Helicopter emergency medical services (HEMS) are a part of air medical services. The transportation of patients using helicopters or airplanes is a core element of the air medical services. HEMS have developed from militarybased transportation, which used helicopters on the battlefield. HEMS have played an important role in properly transporting critical patients before the golden time elapses. The optimal strategies for the operation of HEMS at any emergency medical system are dependent on the characteristics of the regional emergency medical system, diversitiy of HEMS organizations, and the legal background of each country. Therefore, every participant, including the government, medical personnel, and HEMS organizations, should concentrate their efforts toward the establishment of HEMS. Other than the factors related to patients, the key element in facilitating the establishment of HEMS is the safety of the flight and crew members.