A Meta-Analysis of Prehospital Care Times for Trauma

[Prehospital Care Times and Interventions for Victims of Major Trauma in the Central Region of Portugal: A Retrospective Study]

INTRODUCTION

The quality and promptness of prehospital care for major trauma patients are vital in order to lower their high mortality rate. However, the effectiveness of this response in Portugal is unknown. The objective of this study was to analyze response times and interventions for major trauma patients in the central region of Portugal.

METHODS

This was a retrospective, descriptive study, using the 2022 clinical records of the National Institute of Medical Emergency's differentiated resources. Cases of death prior to arrival at the hospital and other non-transport situations were excluded. Five-time intervals were determined, among which are the response time (T1, between activation and arrival at the scene), on-scene time (T2), and transportation time (T5; between the decision to transport and arrival at the emergency service). For each ambulance type, averages and dispersion times were calculated, as well as the proportion of cases in which the nationally and internationally recommended times were met. The frequency of recording six key interventions was also assessed.

RESULTS

Of the 3366 records, 602 were eliminated (384 due to death), resulting in 2764 cases: nurse-technician ambulance (SIV) = 36.0%, physician- nurse ambulance (VMER) = 62.2% and physician-nurse helicopter = 1.8%. In a very large number of records, it was not possible to determine prehospital care times: for example, transport time (T5) could be determined in only 29%, 13% and 8% of cases, respectively for SIV, VMER and helicopter. The recommended time for stabilization (T2 ≤ 20 min) was met in 19.8% (SIV), 36.5% (VMER) and 18.2% (helicopter). Time to hospital (T5 ≤ 45 min) was achieved in 80.0% (SIV), 93.1% (VMER) and 75.0% (helicopter) of the records. The administration of analgesia (42% in SIV) and measures to prevent hypothermia (23.5% in SIV) were the most recorded interventions.

CONCLUSION

There was substantial missing data on statuses and a lack of information in the records, especially in the VMER and helicopter. According to the records, the time taken to stabilize the victim on-scene often exceeded the recommendations, while the time taken to transport them to the hospital tended to be within the recommendations.

Pediatric Trauma Center Access, Regional Injury Burden, and Socioeconomic Disadvantage

This cross-sectional study assesses whether populations in socioeconomically disadvantaged regions in the US lack timely access to pediatric trauma centers.

Lack of Public Awareness and Prehospital Care in Severe Trauma Patients: The Weakest Link in the Indian Healthcare System

INTRODUCTION

Management of trauma involves both in-hospital and prehospital care. The level of prehospital care plays a vital role in trauma management. Low- and middle-income countries are still in the nascent stages of development of their emergency medical services (EMS) systems. Also, there have been insufficient studies assessing the availability and level of prehospital care in developing nations such as India. Therefore, we decided to study the level of awareness and prehospital care given to severe trauma patients.

MATERIALS AND METHODS

We conducted this prospective observational study at the emergency department of Fortis Hospital, Noida, Uttar Pradesh, in Northern India. All adults between ages 18 and 85 years presenting with severe trauma (immediate life- or limb-threatening conditions requiring emergent intervention) were included. We measured the primary outcome in terms of why people did not avail EMS. We measured secondary outcomes in terms of intervention done in patients coming to us via EMS.

RESULTS

Out of 101 patients, 89 (88.12%) were transported to Fortis Hospital through non-EMS, whereas only 12 (11.88%) patients were transported by EMS. We found the difference to be statistically significant. The major reason given for not summoning advanced trauma care services in patients was a lack of awareness about the potential benefits of EMS (n = 64 [72%]), followed by a lack of availability (n = 24 [27%]), and financial reasons (n = 1 [1.1%]).

CONCLUSION

We conclude that the level of awareness about EMS for severe trauma patients was found to be low in our study. There is a need for an awareness-creation program across the nation to fill this gap.

Access to Burn Care in the US

This cross-sectional study examines burn incidence rates and accessibility of American Burn Association–verified or self-designated burn centers from 2013 to 2019.

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

BACKGROUND

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

RESEARCH QUESTIONS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Community Socioeconomic Characteristics on Emergency Medical Service Delays in Responding to Fatal Vehicle Crashes

Introduction

This study aimed to determine the impact of community socioeconomic status on emergency medical services' response time for fatal vehicle crashes.

Methods

Authors used the 2019 National Highway Traffic Safety Administration Fatality Analysis Reporting System and 2019-2020 Area Health Resource Files to obtain emergency medical services' time intervals and county socioeconomic characteristics (e.g., median household income, availability of trauma centers, and rurality), generating a study sample of 18,540 individuals involved in fatal vehicle crashes between January and December 2019. Generalized linear models with log-link and Gamma-family were used to obtain estimates, and other variables were adjusted in the model.

Results

Both the mean time of the emergency medical service arrival to the site of the crash and the mean transport time from the crash site to hospital varied by county SES. Counties with a higher mean household income had 12% shorter emergency medical services' arrival times and up to 7% shorter emergency medical services' hospital transport times than counties with lower SES. The emergency medical services' hospital transport times by emergency medical services also varied by proximity to trauma centers and were 15% shorter in counties that had ≥2 trauma centers than in counties without trauma centers.

Conclusions

This study shows socioeconomic disparities in emergency medical service rescue time for fatal vehicle crashes. Community characteristics play a major role in emergency medical services' arrival time intervals. Prior research demonstrated a strong link between the timeliness of emergency medical service response and the likelihood of survival in fatal motor vehicle accidents. These findings showing that socioeconomically disadvantaged areas and those lacking trauma facilities had slower emergency medical service rescue times, suggest that socioeconomic status may be a predictor of mortality in fatal motor vehicle accidents. Effective emergency medical services are essential to reduce the morbidity and mortality among motor vehicle crash victims; however, disparities exist in the timeliness of these services by geographic and socioeconomic county characteristics. Further research is urgently needed to inform policy interventions.

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.

Epidemiology of open limb fractures attended by ambulance clinicians in the out-of-hospital setting: A retrospective analysis

BACKGROUND

Open limb fractures are a time-critical orthopaedic emergency that present to jurisdictional ambulance services. This study describes the demographic characteristics and epidemiological profile of these patients METHODS: We undertook a retrospective analysis of all patients that presented to Queensland Ambulance Service with an open limb fracture (fracture to the humerus, radius/ulna, tibia/fibula or femur) over a two-year period (January 2018 - December 2019).

RESULTS

Overall, 1020 patients were included. Patients were mainly male (65.9%) and middle-aged (age 41 years, IQR 22-59). Fractures predominately occurred in the lower extremities (64.9%) with transport crashes the primary mechanism of injury (47.8%). The location of the fracture varied depending on the cause of injury, with femur fractures associated with motorcycle crashes, and fractures to the radius/ulna attributed to falls of greater than one metre (p = 0.001). The median prehospital episode of care was 83 min (IQR 62-144) with aeromedical air ambulance involvement and the attendance of a critical care paramedic or emergency physician, both independent factors that increased this time interval.

CONCLUSION

Open limb fractures are a relatively infrequent injury presentation encountered by ambulance clinicians. The characteristics of these patients is consistent with previously described national and international out-of-hospital trauma cohorts.

Effect of on-site first aid for industrial injuries on healthcare utilization after medical treatment: a 4-year retrospective longitudinal study

BACKGROUND

The number of industrially injured workers (IIW) is increasing in Korea. However, little research has been conducted on whether first aid is performed at industrial sites or on the association between first aid for industrial injuries and the prognosis of IIW, including healthcare utilization.

METHODS

A total of 3,092 participants (2,562 males and 530 females) were analyzed during the 4-year study period, which contributed to 11,167 observations. Healthcare utilization was evaluated based on the number of outpatient visits, hospitalizations, and duration of hospitalization using a generalized estimating equation Poisson regression. Several time-varying socioeconomic characteristics and information about the injury were adjusted, and transfer time to the medical institutions was also considered.

RESULTS

During 4-year after the termination of medical treatment, participants who had not receive first aid visited outpatient clinics 15.243 times per year, and those who had visited 13.928 times per year, which is 16.16% less (adjusted relative risk [aRR]: 0.838, 95% CI = 0.740-0.950). Participants who had received on-site first aid with less than a 0.5-hour transfer time to the medical institutions visited outpatient clinics 14.87% less per year than those who had not received first aid (aRR: 0.851, 95% CI = 0.750-0.966).

CONCLUSION

To reduce the long-term outpatient utilization rate for IIW after medical treatment, on-site first aid must be provided in a timely manner. Employee education and first aid training are also necessary.

Racial and Ethnic Disparities in Access to Pediatric Trauma Centers in the United States: A Geographic Information Systems Analysis

STUDY OBJECTIVE

Injury is the leading cause of death and disability for children, making access to pediatric trauma centers crucial to pediatric trauma care. Our objective was to describe the pediatric population with timely access to a pediatric trauma center by demographics and geography in the United States.

METHODS

Level 1, 2, and 3 pediatric trauma center locations were provided by the American Trauma Society. Geographic information systems road network and rotor wing analysis determined US Census Block Groups with the ground and/or air access to a pediatric trauma center within a 60-minute transport time. We then described, at the national and state levels, the 2020 pediatric population (< 15 years old) with and without pediatric trauma center access by ground and air, stratified by race, ethnicity, and urbanicity.

RESULTS

There were 157 pediatric trauma centers (82 Level 1, 64 Level 2, 11 Level 3). Of the 2020 US pediatric population, 33,352,872 (54.5%) had timely access to Level 1-3 pediatric trauma centers by ground and 45,431,026 (74.1%) by air. The percentage of children with access by race and ethnicity were (by ground, by air): American Indian/Alaskan Native (31.0%, 43.5%), White (48.7%, 71.3%), Native Hawaiian/Pacific Islander (59.3%, 61.0%), Hispanic (60.2%, 76.9%), Black (64.2%, 78.0%), and Asian (76.5%, 89.5%). Only 48.2% of children living in rural block groups had access, compared with 83.6% in urban block groups.

CONCLUSION

Significant disparities in current access to pediatric trauma centers exist by race and ethnicity, and geography, leaving some children at risk for poor trauma outcomes.

Activation and On-Scene Intervals for Severe Trauma EMS Interventions: An Analysis of the NEMSIS Database

Objective: Time to care is a determinant of trauma patient outcomes, and timely delivery of trauma care to severely injured patients is critical in reducing mortality. Numerous studies have analyzed access to care using prehospital intervals from a Carr et al. meta-analysis of studies from 1975 to 2005. Carr et al.'s research sought to determine national mean activation and on-scene intervals for trauma patients using contemporary emergency medical services (EMS) records. Since the Carr et al. meta-analysis was published, the National Highway Traffic Safety Administration (NHTSA) created and refined the National Emergency Medical Services Information System (NEMSIS) database. We sought to perform a modern analysis of prehospital intervals to establish current standards and temporal patterns.Methods: We utilized NEMSIS to analyze EMS data of trauma patients from 2016 to 2019. The dataset comprises more than 94 million EMS records, which we filtered to select for severe trauma and stratified by type of transport and rurality to calculate mean activation and on-scene intervals. Furthermore, we explored the impact of basic life support (BLS) and advanced life support (ALS) of ground units on activation and on-scene time intervals.Results: Mean activation and on-scene intervals for ground transport were statistically different when stratified by rurality. Urban, suburban, and rural ground activation intervals were 2.60 ± 3.94, 2.88 ± 3.89, and 3.33 ± 4.58 minutes, respectively. On-scene intervals were 15.50 ± 10.46, 17.56 ± 11.27, and 18.07 ± 16.13 minutes, respectively. Mean helicopter transport activation time was 13.75 ± 7.44 minutes and on-scene time was 19.42 ± 16.09 minutes. This analysis provides an empirically defined mean for activation and on-scene times for trauma patients based on transport type and rurality. Results from this analysis proved to be significantly longer than the previous analysis, except for helicopter transport on-scene time. Shorter mean intervals were seen in ALS compared to BLS for activation intervals, however ALS on-scene intervals were marginally longer than BLS.Conclusions: With the increasing sophistication of geospatial technologies employed to analyze access to care, these intervals are the most accurate and up-to-date and should be included in access to care models.

Outcomes after rib fractures: more complex than a single number

Purpose

Rib fractures are common injuries that can lead to morbidity and mortality.

Methods

Data on all patients with rib fractures admitted to a single trauma center between January 1, 2008 and December 31, 2018 were reviewed.

Results

A total of 1,671 admissions for rib fracture were examined. Patients' median age was 57 years, the median Injury Severity Score (ISS) was 14, and the median number of fractured ribs was three. The in-hospital mortality rate was 4%. Age, the number of rib fractures, and Charlson Comorbidity Index scores were poor predictors of mortality, while the ISS was a slightly better predictor, with area under the receiver operating characteristic curve values of 0.60, 0.55, 0.58, and 0.74, respectively. Multivariate regression showed that age, ISS, and Charlson Comorbidity Index score, but not the number of rib fractures, were associated with significantly elevated adjusted odds ratios for mortality (1.03, 1.14, and 1.28, respectively).

Conclusions

Age, ISS, and comorbidities were independently associated with the risk of mortality; however, they were not accurate predictors of death. The factors associated with rib fracture mortality are complex and cannot be explained by a single variable. Interventions to improve outcomes must be multifaceted.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

A Geographical Analysis of Access to Trauma Centers from US National Parks in 2018

INTRODUCTION

Millions of people visit US national parks annually to engage in recreational wilderness activities, which can occasionally result in traumatic injuries that require timely, high-level care. However, no study to date has specifically examined timely access to trauma centers from national parks. This study aimed to examine the accessibility of trauma care from national parks by calculating the travel time by ground and air from each park to its nearest trauma center. Using these calculations, the percentage of parks by census region with timely access to a trauma center was determined.

METHODS

This was a cross-sectional study analyzing travel times by ground and air transport between national parks and their closest adult advanced trauma center (ATC) in 2018. A list of parks was compiled from the National Parks Service (NPS) website, and the location of trauma centers from the 2018 National Emergency Department Inventory (NEDI)-USA database. Ground and air transport times were calculated using Google Maps and ArcGIS, with medians and interquartile ranges reported by US census region. Percentage of parks by region with timely trauma center access-defined as access within 60 minutes of travel time-were determined based on these calculated travel times.

RESULTS

In 2018, 83% of national parks had access to an adult ATC within 60 minutes of air travel, while only 26% had timely access by ground. Trauma center access varied by region, with median travel times highest in the West for both air and ground transport. At a national level, national parks were unequally distributed, with the West housing the most parks of all regions.

CONCLUSION

While most national parks had timely access to a trauma center by air travel, significant gaps in access remain for ground, the extent of which varies greatly by region. To improve the accessibility of trauma center expertise from national parks, the study highlights the potential that increased implementation of trauma telehealth in emergency departments (EDs) may have in bridging these gaps.

Assessment of Knowledge, Skills, and Preparedness of General-Duty Police on Prehospital Care of Road Traffic Accident Victims in Abuja, Nigeria

OBJECTIVES

Prompt prehospital care (PHC) is essential for improving outcomes of road traffic accident victims. Previous studies in Nigeria show that little or no PHC is delivered to trauma victims by first responders. This study was conducted to assess police officers' experience with FA/BLS, to identify gaps in their FA/BLS knowledge and skills, and assess police stations' FA/BLS equipment capacity for PHC of road traffic accident victims.

METHODS

This cross-sectional study was conducted among 428 GD police in Abuja between November and December 2018. Respondents were selected using stratified random sampling with proportional allocation method. Data were collected using self-administered electronic semi-structured questionnaires. Data analysis was done using STATA v 14.0 (StataCorp, College Station, TX). Chi-square and multivariate logistic regression were used to assess associations.

RESULTS

We analyzed data from 419 respondents. Almost all (90.2%) of the police were aware of FA/BLS. The proportion of police with poor, fair, and good knowledge and skills on FA/BLS were 15.3%, 79.0%, and 5.7%, respectively. Tertiary (OR = 3.35, 95% CI: 1.01-11.11, P = 0.048) and postgraduate (OR = 6.89, 95% CI: 1.63-29.19, P = 0.009) levels of education had statistically significant association with good knowledge and skills.

CONCLUSION

This highlights the need to implement an educational intervention to increase FA/BLS competencies within the first responder population.

IMPACT OF TIME TO EMERGENCY DEPARTMENT RESUSCITATIVE AORTIC OCCLUSION AFTER NONCOMPRESSIBLE TORSO HEMORRHAGE

Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P &lt; 0.001) and admission to successful AO (10 vs. 22 minutes, P &lt; 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P &lt; 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.

Access to American College of Surgeons Committee on Trauma-Verified Trauma Centers in the US, 2013-2019

This study uses data from the American Trauma Society’s Trauma Information Exchange Program to evaluate trends in nationwide 60-minute access to American College of Surgeons Committee on Trauma–verified level I-IV trauma centers between 2013 and 2019.

A novel scoring system using easily assessible predictors of return of spontaneous circulation and mortality in traumatic out-of-hospital cardiac arrest patients: A retrospective cohort study

BACKGROUND

An accident event may necessitate triage of multiple cases of traumatic out-of-hospital cardiac arrest (TOHCA). However, factors for prioritizing treatment among multiple TOHCA patients have not been established. This study aims to use easily assessible predictors of TOHCA outcomes to develop a triage scoring system.

METHODS

Patients with TOHCA brought to our hospital by emergency medical services (EMS) were included for analysis to identify independent risk factors for poor outcomes. A scoring system was developed and validated internally and externally.

RESULTS

Of the 401 included patients, 86 (21.4%) had return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) for 30 min (81 patients, 94.2%) or 45 min (86 patients, 100%). The emergency department (ED) mortality rate was 89.3% and overall in-hospital mortality rate was 99%. Univariate and multivariate analyses identified body temperature <33 °C (OR, 4.65; 95% CI, 1.37-15.86), obvious chest injury (OR, 2.11; 95% CI, 1.03-4.34), and presumable etiology of out-of-hospital cardiac arrest (OR, 1.73; 95% CI, 1.01-2.98) as significant independent risk factors for non-ROSC. The TOHCA score, calculated as 1 point per risk factor, correlated significantly with the rate of non-ROSC and ED mortality (TOHCA score 0, 1, 2, 3: non-ROSC rate, 63.0%, 80.4%, 90.8%, 100%, respectively; ED mortality rate, 79.5%, 91.5%, 96.1%, and 100% respectively). The results of internal and external validations show a similar trend in both non-ROSC and mortality in the ED with increasing score.

CONCLUSIONS

Termination of CPR for TOHCA after 45 min is reasonable; a 30-minute resuscitation is acceptable in case of insufficient medical staff or resources. The TOHCA score may be able to be used with caution for triage.

A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision

BACKGROUND

Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed.

METHODS

This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based.

RESULTS

Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus.

CONCLUSION

This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.

Maximising access to timely trauma care across population of Karachi and its districts: a geospatial approach to develop a trauma care network

OBJECTIVES

To develop and propose a cost-effective trauma care network for Karachi, Pakistan, by calculating maximum timely trauma care (TTC) coverage achieved with the addition of potential designated private and public level 1 and level 2 trauma centres (TCs).

SETTING

A lower middle-income country metropolis, Karachi is Pakistan's largest city with a population of 16 million and a total of 56 hospitals as per government registry data.

PARTICIPANTS

41 potential TCs selected using a two-level, contextually-relevant TC designation criteria adapted from various international guidelines.

PRIMARY AND SECONDARY OUTCOME MEASURES

Maximum TTC coverage achievable with the addition of potential TCs. Proposed trauma care network composition to achieve maximum TTC coverage.

RESULTS

Coverage with five public level 1 hospitals alone is 74.4%. Marginal benefit with stepwise addition of five potential private level 1 TCs, four public level 2 TCs and two private level 2 TCs is 12.2%, 7.1% and 3.1%, respectively. Maximum possible TTC coverage is 96.7%. Poorest coverage with the proposed 16 hospital network is noted in Malir district while 100% coverage is achieved in the centrally located South, Central and East districts.

CONCLUSION

Addition of private level 1 and private and public level 2 hospitals to the trauma care network is necessary. Implementation of the proposed trauma care network requires strong stewardship from the government and coordinated effort of multiple stakeholders is needed to ensure standard TC designation. The study exhibits an effective method to scientifically plan and develop a cost-effective trauma system which can be applied in other resource-limited geographical areas.

Tourniquet Application for Bleeding Control in a Rural Trauma System: Outcomes and Implications for Prehospital Providers

Introduction: Uncontrolled bleeding is a preventable cause of death in rural trauma. Herein, we examined the appropriateness, effectiveness, and safety of tourniquet application for bleeding control in a rural trauma system.Methods: Medical records of adult patients admitted to our academic Level I trauma center between July 2015 and December 2018 were retrospectively reviewed. Demographics (age, gender), injury (Injury severity score, Glascow Coma scale, mechanism of injury), tourniquet (type, tourniquet application site, tourniquet duration, place of application and removal, indication), and outcome data (complications such as amputation, acute kidney injury, rhabdomyolysis, or nerve palsy and mortality) were collected. Tourniquet indications, effectiveness, and complications were evaluated. Data were compared to those in urban settings.Results: Ninety-two patients (94 tourniquets) were identified, of which 58.7% incurred penetrating injuries. Eighty-seven tourniquets (92.5%) were applied in the prehospital setting. Twenty tourniquets (21.3%) were applied to patients without an appropriate indication. Two of these tourniquets were applied in a hospital setting, while 18 occurred in the prehospital setting (p = 0.638). Patients with a non-indicated tourniquet presented with a higher hemoglobin level on admission, received less packed red blood cell units within the first 24 hours of hospitalization, and were less likely to require surgery for hemostasis. None of the non-indicated tourniquets led to a complication. Indicated tourniquets were deemed ineffective in seven cases (9.5%); they were all applied in the prehospital setting. The average tourniquet time was 123 min in rural vs. 48 min in urban settings, p < 0.001. There was no significant difference in mortality, amputation rates and incidence of nerve palsy between the rural and urban settings.Conclusion: Even with long transport times, early tourniquet application for hemorrhage control in rural settings is safe with no significant attributable morbidity and mortality compared to published studies on urban civilian tourniquet use. The observed rates of non-indicated and ineffective tourniquets indicate suboptimal tourniquet usage and application. Opportunity exists for standardized hemorrhage control training on the use of direct pressure and pressure dressings, indications for tourniquet use, and effective tourniquet application.

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.

Socio-spatial disparities in access to emergency health care-A Scandinavian case study

Having timely access to emergency health care (EHC) depends largely on where you live. In this Scandinavian case study, we investigate how accessibility to EHC varies spatially in order to reveal potential socio-spatial disparities in access. Distinct measures of EHC accessibility were calculated for southern Sweden in a network analysis using a Geographical Information System (GIS) based on data from 2018. An ANOVA test was carried out to investigate how accessibility vary for different measures between urban and rural areas, and negative binominal regression modelling was then carried out to assess potential disparities in accessibility between socioeconomic and demographic groups. Areas with high shares of older adults show poor access to EHC, especially those in the most remote, rural areas. However, rurality alone does not preclude poor access to EHC. Education, income and proximity to ambulance stations were also associated with EHC accessibility, but not always in expected ways. Despite indications of a well-functioning EHC, with most areas served within one hour, socio-spatial disparities in access to EHC were detected both between places and population groups.

Preventable deaths following road traffic collisions in Botswana: A retrospective review

Road traffic collisions (RTC) are a major cause of mortality and morbidity in Botswana. To our knowledge no research has been conducted in Botswana to investigate preventable deaths that occur as a result of RTCs. The aim of this study is to establish the rate of preventable deaths from RTCs in the greater Gaborone area in Botswana. This was a 5-year retrospective study conducted at the forensic pathology department for the greater Gaborone area, in Botswana. Nine hundred and nine (909) forensic pathology reports were retrieved. Sixty-eight percent (68.2%) of RTC deaths were considered preventable. Head injury in isolation and in combination with other injuries accounted for 87.6% (796/909) of deaths. Haemorrhagic shock was present in 70.2% (638) of all documented injuries. Another documented injury contributing to fatal RTCs was high spinal cord injury. This injury was documented in 13.1% (119/909) of all deaths. We recommend the implementation of a comprehensive trauma system in Botswana to reduce the number of deaths from RTCs.

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

BACKGROUND

Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada.

METHODS

We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers.

RESULTS

Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT).

CONCLUSIONS

Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.

Use of prehospital, hospitalization and presence of sequelae and/or disability in road traffic injury victims in Brazil

Objective

To estimate the prevalence and analyze the association between sociodemographic and behavioral variables with the use of prehospital care, hospitalization and sequelae and/or disability in victims of road traffic accidents victims in Brazil.

Methods

Data from the National Health Survey conducted in 2013 in Brazil were used. Data were collected through a direct household survey. The research sample consisted of 1,840 individuals who reported road traffic accidents in the previous 12 months. Poisson regression analysis was used to evaluate the factors associated with the use of prehospital care services, hospitalization, and the presence of sequelae and/or disability.

Results

The prevalence of road traffic accidents victims who received prehospital care was 13.0% (95% Confidence Interval [95% CI]: 10.3–16.3) and the factors associated with this outcome were: residing in the Northeast or North region of Brazil; residing in rural areas; and being a motorcycle occupant at the moment of the road traffic accident. The frequency of hospitalization was 7.7% (95% CI: 6.0–10.0) and the associated factors were: age between 40 and 59 years; being a motorcycle occupant or pedestrian and having received on-site care at the moment of the road traffic accident. The prevalence of sequelae and/or disability was 15.1% (95% CI: 12.5–18.2) and the associated factors were: age range between 30 and 39 years or 40 and 59 years; being a motorcycle occupant, being a pedestrian or belonging to other category of modes of transport and having received on-site care at the moment of the road traffic accident.

Conclusion

The study allowed to evaluate the factors associated with prehospital care, hospitalization and presence of sequelae and/or disability in the victims of road traffic accident and the results can guide the implementation of interventions that prioritize the population exposed to the highest risk of road traffic accident injuries and with less access to prehospital and hospital care services in Brazil.

Helicopter Transportation of Brazilian Trauma Patients: A Comparison of Times to Care

OBJECTIVE

The purpose of this study was to analyze helicopter emergency medical service (HEMS) transport with secondary land ambulance transfer, comparing landings performed inside and outside the hospital complex to the emergency department.

METHODS

This was a cross-sectional observational study of HEMS transports of trauma patients between 2016 and 2018 in southern Brazil. Patients were attended by the HEMS team at the trauma site or stabilized in hospitals nearby and subsequently referred to trauma centers. In this region, no trauma centers have their own helipads so helicopters land in remote areas close to the hospital, which may be inside or outside the hospital complex. Both landings require ground emergency medical service transport, with off-site landings necessitating ground emergency medical service transport via public access roads to reach the hospital. Data were analyzed using descriptive statistics, and on-site and off-site transport times were compared using a t-test for independent samples.

RESULTS

Of 176 transports, 28.5% resulted in on-site landings, whereas 71.5% occurred off-site. The ground transport time when the landing zone was off-site was 5 minutes longer than on-site (P < .001).

CONCLUSION

Off-site landings result in longer transports to the emergency room. The construction of helipads in trauma centers can reduce transport time, in addition to reducing the costs and sequelae of trauma.

Effect of Distance to Trauma Centre, Trauma Centre Level, and Trauma Centre Region on Fatal Injuries among Motorcyclists in Taiwan

Background: Studies have suggested that trauma centre-related risk factors, such as distance to the nearest trauma hospital, are strong predictors of fatal injuries among motorists. Few studies have used a national dataset to study the effect of trauma centre-related risk factors on fatal injuries among motorists and motorcyclists in a country where traffic is dominated by motorcycles. This study investigated the effect of distance from the nearest trauma hospital on fatal injuries from two-vehicle crashes in Taiwan from 2017 to 2019. Methods: A crash dataset and hospital location dataset were combined. The crash dataset was extracted from the National Taiwan Traffic Crash Dataset from 1 January 2017 through 31 December 2019. The primary exposure in this study was distance to the nearest trauma hospital. This study performed a multiple logistic regression to calculate the adjusted odds ratios (AORs) for fatal injuries. Results: The multivariate logistic regression models indicated that motorcyclists involved in crashes located ≥5 km from the nearest trauma hospital and in Eastern Taiwan were approximately five times more likely to sustain fatal injuries (AOR = 5.26; 95% CI: 3.69–7.49). Conclusions: Distance to, level of, and region of the nearest trauma centre are critical risk factors for fatal injuries among motorcyclists but not motorists. To reduce the mortality rate of trauma cases among motorcyclists, interventions should focus on improving access to trauma hospitals.

Developing a Low-resource Approach to Trauma Patient Care - Findings from a Nigerian Trauma Registry

Background:

Trauma is a worldwide problem that results in significant morbidity and mortality in developing countries.

Objective:

This study looks at the demography of trauma from data abstracted from a Nigerian trauma registry and considers the peculiarities of a low-resource setting from this perspective.

Methods:

Trauma registry data from January 2013 to June 2014 were analyzed.

Results:

A total of 542 patients were included in the study. The mean age of the patients was 33.43 ± 12.79 years; the median time from injury to arrival at the hospital was 3 h (interquartile range IQR 1 – 5.1 h); three-quarters of the patients sustained their injuries on the road-tricycles were rarely involved in road traffic injuries (RTIs) (6.9% of RTIs) but were used in transporting a third of the patients whose data on means of transportation were captured. There were 15 (2.7%) deaths in the first 24 h period postinjury covered by the study – 13 (86.7%) of these patients had head-and-neck injury. About half of the assault injury (50.5%) was from persons known to the victim. The shock indices suggested that a majority of the patients were not at a high risk of mortality.

Conclusion:

Most of the trauma patients at our hospital were in low- to middle-income categories. The median time to arrival of injured patients was 3 h (IQR 1 – 6 h). Most injuries occurred on the road because of RTIs. The involvement of tricycles in accidents was uncommon, but they were used fairly commonly by lay responders in transporting the injured victim to hospital. A high proportion of assailants were known to the victim. The use of trauma registries provides essential data for prioritizing limited resources and can guide a contextualized approach to reducing trauma and improving trauma patient care.

Evidence-Based and Clinically Relevant Outcomes for Hemorrhage Control Trauma Trials

OBJECTIVE

To address the clinical and regulatory challenges of optimal primary endpoints for bleeding patients by developing consensus-based recommendations for primary clinical outcomes for pivotal trials in patients within 6 categories of significant bleeding, (1) traumatic injury, (2) intracranial hemorrhage, (3) cardiac surgery, (4) gastrointestinal hemorrhage, (5) inherited bleeding disorders, and (6) hypoproliferative thrombocytopenia.

BACKGROUND

A standardized primary outcome in clinical trials evaluating hemostatic products and strategies for the treatment of clinically significant bleeding will facilitate the conduct, interpretation, and translation into clinical practice of hemostasis research and support alignment among funders, investigators, clinicians, and regulators.

METHODS

An international panel of experts was convened by the National Heart Lung and Blood Institute and the United States Department of Defense on September 23 and 24, 2019. For patients suffering hemorrhagic shock, the 26 trauma working-group members met for almost a year, utilizing biweekly phone conferences and then an in-person meeting, evaluating the strengths and weaknesses of previous high quality studies. The selection of the recommended primary outcome was guided by goals of patient-centeredness, expected or demonstrated sensitivity to beneficial treatment effects, biologic plausibility, clinical and logistical feasibility, and broad applicability.

CONCLUSIONS

For patients suffering hemorrhagic shock, and especially from truncal hemorrhage, the recommended primary outcome was 3 to 6-hour all-cause mortality, chosen to coincide with the physiology of hemorrhagic death and to avoid bias from competing risks. Particular attention was recommended to injury and treatment time, as well as robust assessments of multiple safety related outcomes.

Mapping access to endovascular stroke care in the USA and implications for transport models

BACKGROUND

The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive.

METHODS

Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated.

RESULTS

Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive.

CONCLUSION

Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19

Introduction

Longer prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients.

Methods

This retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes.

Results

There were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01].

Conclusion

The median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.

Evaluating the impact of prehospital care on mortality following major trauma in New Zealand: a retrospective cohort study

BACKGROUND

Injury is a leading cause of death and health loss in New Zealand and internationally. The potentially fatal or severe consequences of many injuries can be reduced through an optimally structured prehospital trauma care system that can provide timely and appropriate care.

OBJECTIVE

To investigate the relationship between emergency medical services (EMS) care and survival to hospital for major trauma cases in New Zealand.

METHODS

This project is a retrospective cohort study of New Zealand major trauma cases attended by EMS providers over a 2-year period. Outcomes include survival to hospital and survival in hospital for at least 24 hours. The project has three phases: (1) identification of the cohort and assembling a bespoke longitudinal dataset linking EMS, New Zealand Major Trauma Registry and Coronial data; (2) describing the pathways and processes of care to inform an investigation of the relationships between types of EMS care and survival using propensity score modelling to adjust for case-mix differences; (3) assessment of the implications for future practice, policy and research.

DISCUSSION

The study findings will help identify opportunities to optimise the delivery of EMS care in New Zealand by informing the development or revision of existing major trauma EMS policies and guidelines, and to provide a baseline for monitoring the impact of future initiatives. Establishing an evidence-base will support a whole-of-system appraisal that could include broader complex variables relating to healthcare services throughout the continuum of trauma care.

Can a new emergency response system reduce traffic fatalities? The case of the 911-emergency response system in the Dominican Republic

BACKGROUND

In May 2014, the Dominican Republic introduced the 911-emergency response system (ERS) in Santo Domingo. Before its introduction, more than 40 phone numbers were available to report emergencies. The objective of this work is to assess whether this new emergency response system was effective in reducing traffic fatalities.

METHODS

Weekly numbers of traffic fatalities per population and per vehicle fleet from January 2013 to December 2015 were obtained from the Ministry of Health and the National Institute of Statistics. A hybrid time-series difference-in-difference analysis using multivariable negative binomial regression models were used to compare trends in rates of traffic fatalities in Santo Domingo to La Romana and Santiago, before and after the introduction of the 911-ERS.

RESULTS

Estimates from negative binomial models suggest that the introduction of the 911-ERS in Santo Domingo relative to Santiago-La Romana was associated with a 17% reduction in the Incidence Rate Ratio (IRR) of traffic fatalities per 1 000 000 population (IRR = 0.83, 95% confidence interval [CI]: 0.67; 1.03) and with a 20% reduction in the IRR of weekly traffic fatalities per 1 000 000 vehicle fleet (IRR = 0.80, 95% CI:0.67; 0.99).

DISCUSSION

Our findings suggest that transitioning from multiple to one unique emergency phone number should be considered more attentively. Furthermore, the case of the Dominican Republic calls for more theoretical and methodological research to understand how to assess these road safety policies more accurately. Since various studies suggest that 911-ERS mature in the long run, how these systems evolve over time and other related variables should be carefully considered.

The Effect of Lights and Sirens on Critical Care Transport Time

BACKGROUND

In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation.

OBJECTIVE

The objective of this study was to evaluate the indications for L&S and the impact of L&S on transport times in interfacility critical care transport.

METHODS

We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization. The indications for L&S were assessed and the transport times with and without L&S were compared using distance matching for common transport routes. Median times were compared for temporal subgroups.

RESULTS

L&S were used in 7.3% of transports and were most strongly associated with transport directly to the operating room (odds ratio 15.8; 95% confidence interval 6.32-39.50; p < 0.001). The timing of the transport was not associated with L&S use. For all transports, there was a significant decrease in the transport time using L&S, with a median of 8 min saved, corresponding to 19.5% of the overall transportation time without L&S (33 vs. 41 min; p < 0.001). The reduction in transport times was consistent across all temporal subgroups, with a greater time reduction during rush hour transports.

CONCLUSIONS

The use of L&S during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of L&S was not associated with rush-hour transports, the greatest time reduction was associated with L&S transport during these hours.

Use of 911 for Rapid Re-Triage of Critical Trauma Patients

OBJECTIVES

The objective of this study was to evaluate the effectiveness of a 911 trauma re-triage protocol implemented at a new community hospital in a region with a high volume of trauma and frequent transports by private vehicle.

METHODS

This retrospective cohort study included all trauma patients ≥15 years old transferred via 911 trauma re-triage from a new community hospital over a 10-month period from August 2015 through April 2016. Criteria for 911 trauma re-triage were developed with input from local Emergency Medical Services (EMS) and trauma experts. An educational module, along with the criteria and implementation steps, was distributed to the emergency department (ED) personnel at the community hospital. Data were abstracted from the regional trauma registry, and the EMS patient care records were reviewed. Primary outcomes were: (1) median total transport time; and (2) proportion of patients who met the 911 re-triage criteria.

RESULTS

During the study period, 32 patients with traumatic injuries were transferred via 911 re-triage to the closest trauma center (TC). The median age of patients was 31 years (IQR 24-45 years) with 78% male and 66% suffering from a penetrating mechanism. The median prehospital provider scene time was 10 minutes (IQR 8-12 minutes) and transport time was seven minutes (IQR 6-9 minutes). Median total transport time was 17 minutes (IQR 15-20 minutes). Seventeen patients (53%) met 911 re-triage criteria as determined by study investigators. The most common criteria met was "penetrating injury to the head, neck, or torso" in 14 cases.

CONCLUSION

This study demonstrated that 911 re-triage was a feasible strategy to expeditiously transfer critical trauma patients to a TC within a mature trauma system in an urban-suburban setting with a median total transport time of 17 minutes.

Time to definitive care among severely injured farmers compared to other work-related injuries in a Midwestern state

BACKGROUND

Farming is a high risk occupation that predisposes workers to injury, but may also lead to barriers in reaching trauma care. Little is known about emergency and trauma care for patients with farm-related injuries. The purpose of this study was to determine whether severely injured farmers presenting to a statewide trauma system faced delays in reaching definitive care compared to other severely injured workers.

METHODS

A population-based observational study was performed using the Iowa State Trauma Registry from 2005 to 2011. The registry was used to identify a multiply imputed sample of severe occupational injuries. Time to definitive care for farm- and non-farm-related injuries was compared using Kaplan-Meier curves and an extended, stratified Cox model censoring at 4 h. An interaction with time was included in the Cox model to generate hazard ratios for each hour after injury.

RESULTS

Seven-hundred forty-eight severe occupational injuries were identified; 21% of these were farm-related. The overall median time to definitive care was nearly an hour longer for farmers compared to other workers (2h46m vs. 1h48m, p < 0.05). When adjusted for confounders, farm status remained a significant predictor of delay in reaching definitive care, but only in the first hour after injury (HR = 0.44, 95%CI = 0.24-0.83).

CONCLUSIONS

Farm-related injuries accounted for more than 1 of every 5 severe occupational injuries entered into the Iowa trauma system. We found that severely injured farmers had delays in reaching definitive trauma care, even when adjusted for confounding variables such as rurality. This effect was most pronounced in the first hour.

Impact of a New Helicopter Base on Transport Time and Survival in a Rural Adult Trauma Population

BACKGROUND

Significant disparities in access to prompt helicopter transport exist among rural trauma populations. We evaluated the impact of an additional helicopter base on transport time and mortality in a rural adult trauma population.

MATERIALS AND METHODS

We performed a retrospective cohort study of adult patients with trauma transported by helicopter from scene to a level one trauma center between 2014 and 2018. A new rural helicopter base added to the trauma center's catchment area in 2016 served as the transition time for an interrupted time series analysis. Patients injured in this base's county and adjoining counties were analyzed. Baseline characteristics were compared with a Student's t-test and Pearson's chi-squared test. Cox and linear regression models evaluated the new base's effect on mortality and transport time, respectively.

RESULTS

A total of 332 patients were analyzed: 120 (36.1%) transported before the addition of the new helicopter base and 212 (63.9%) transported after. Patients transported after the addition of the base had higher injury severity score (13.7 versus 10.1, P < 0.001) and were more likely to receive blood en route (19.3% versus 6.7%, P = 0.005). After the addition of the base, there was a decreased hazard ratio for mortality (hazard ratio 0.26, 95% confidence interval: 0.11-0.65, P = 0.004) with no significant change in transport time (-36.7 min, P = 0.071) for the area.

CONCLUSIONS

Local helicopter transport units may confer improved survival for the injured patient. This study demonstrates the important role of helicopter transport within a regional trauma system and the impact that expanded access to rapid air transport can have on mortality.

Aeromedical helicopter transport of prisoners: The Mexico City experience

INTRODUCTION

Helicopter medical transport of prisoner patients has unique logistical and medical challenges, as well as potential risks to healthcare providers. Prisoners have specific requirements for safe transport, and it is of paramount importance to know the variables related to transport related mortality since most prisoners that need air evacuation are critically ill. Because we understand that there is a potentially dangerous nature of transport of this population, and because of the unique nature of them, we aimed to provide a detailed insight on predictors of outcome in prisoners who were injured as a result of trauma and that needed to be transported via air medical transport in Mexico City.

METHODS

A retrospective chart analysis was conducted using data from the Mexico City Police Helicopter Emergency Medical Service (HEMS) for air medical transport of felons that occurred between January 1, 2000 and December 31, 2013. Subject demographics, injury, procedures performed, transport time, Glasgow Coma Scale (GCS), and mortality were collected. Exploratory data analysis, Chi-square, and T-test were performed. Statistical significance was assumed to be p ≤ 0.05 for two-sided hypothesis.

RESULTS

Fifty-three patients were included in this study. Forty-two were men and 11 were women. Median age of the patients was 30 ± 8 years. Total transport time was 23 ± 5 min. Gunshot wounds accounted for 39.6% of patients, stabbing wounds 28.3%, head trauma 7.5%, motor vehicle accidents 5.7%, blunt trauma (i.e., fist assaults) 5.6%, falls 5.7%, motorcycle accidents 3.8%, and prisoner-motor vehicle collisions 3.8%. Median heart rate was 114 ± 41 beats per minute (BPM), median systolic blood pressure (SBP) was 103 ± 14 mmHg, median diastolic blood pressure (DBP) was 70 ± 12 mmHg, and median GCS was 10 ± 5. Mortality rate was 16.9% (n = 9). The variables that were statistically significant, and therefore related to mortality were: heart rate > 130 bpm (p < 0.001), SBP <95 mmHg (p = 0.039), GCS <7 (p = 0.040), age > 42 years (range, 17-47 years) p < 0.001, and need for cardiopulmonary resuscitation (CPR) (p < 0.001).

CONCLUSIONS

As dangerous and challenging as it may seem, air medical transport of prisoners by a police crew physician, may be safe and reliable, since no complications or safety events were observed.

Impact of traffic, poverty and facility ownership on travel time to emergency care in Nairobi, Kenya

BACKGROUND

In many low and middle-income countries (LMICs), timely access to emergency healthcare services is limited. In urban settings, traffic can have a significant impact on travel time, leading to life-threatening delays for time-sensitive injuries and medical emergencies. In this study, we examined travel times to hospitals in Nairobi, Kenya, one of the largest and most congested cities in the developing world.

METHODS

We used a network approach to estimate average minimum travel times to different types of hospitals (e.g. ownership and level of care) in Nairobi under both congested and uncongested traffic conditions. We also examined the correlation between travel time and socioeconomic status.

RESULTS

We estimate the average minimum travel time during uncongested traffic conditions to any level 4 health facility (primary hospitals) or above in Nairobi to be 4.5 min (IQR 2.5-6.1). Traffic added an average of 9.0 min (a 200% increase). In uncongested conditions, we estimate an average travel time of 7.9 min (IQR 5.1-10.4) to level 5 facilities (secondary hospitals) and 11.6 min (IQR 8.5-14.2) to Kenyatta National Hospital, the only level 6 facility (tertiary hospital) in the country. Traffic congestion added an average of 13.1 and 16.0 min (166% and 138% increase) to travel times to level 5 and level 6 facilities, respectively. For individuals living below the poverty line, we estimate that preferential use of public or faith-based facilities could increase travel time by as much as 65%.

CONCLUSION

Average travel times to health facilities capable of providing emergency care in Nairobi are quite low, but traffic congestion double or triple estimated travel times. Furthermore, we estimate significant disparities in timely access to care for those individuals living under the poverty line who preferentially seek care in public or faith-based facilities.

Post-crash emergency care: Availability and utilization pattern of existing facilities in Aligarh, Uttar Pradesh

Context:

Road traffic injuries is estimated to be the ninth leading cause of death across all age groups globally. People in need of trauma care, after a road crash, are most likely to survive if they receive definitive care within the first hour (Golden hour) after the crash. Essential prehospital care includes prompt communication, treatment, and transport of injured people to formal healthcare facilities.

Aims:

To assess the availability and utilization pattern of existing facilities for post-crash emergency care in Aligarh.

Settings and Design:

The present study was undertaken on two National highways- NH-91 and NH-93 and the connecting bypass roads of Aligarh district of Uttar Pradesh.

Subjects and Methods:

All the individuals who met road traffic accident (RTA) between the earmarked areas from 1^st October, 2018 to 30^th September, 2019 and reported for treatment (either on their own or brought by relatives, passersby, ambulance or police) to the selected hospitals were included in the study.

Statistical Analysis Used:

Data presented in the form of frequency tables and percentages.

Results:

Out of 665 patients interviewed during the study period, 556 (83.61%) patients were males and 109 (16.39%) were females with M: F ratio been 5.10:1. Among the first responders, 448 (67.36%) were lay persons and 42 (6.31%) were police personnel. 261 (39.25%) of patients received help within 10–30 min of RTA. Use of toll-free no. was limited to 265 (39.84%) patients. Ambulance was the mode of transport in 155 (23.30%) of RTA cases. 589 (88.58%) of patients reported to Government hospitals.

Conclusions:

Post-crash emergency care is in nascent stage in Aligarh district of Uttar Pradesh. Toll free numbers and ambulances are available but proper utilization and quality of care is lacking. Lay person is the most important personnel in improving the post-crash care.

Effect of predicted travel time to trauma care on mortality in major trauma patients in Nova Scotia

Background

Trauma is a leading contributor to the burden of disease in Canada, accounting for more than 15 000 deaths annually. Although caring for injured patients at designated trauma centres (TCs) is consistently associated with survival benefits, it is unclear how travel time to definitive care influences outcomes. Using a population-based sample of trauma patients, we studied the association between predicted travel time (PTT) to TCs and mortality for patients assigned to ground transport.

Methods

Victims of penetrating trauma or motor vehicle collisions (MVCs) in Nova Scotia between 2005 and 2014 were identified from a provincial trauma registry. We conducted cost distance analyses to quantify PTT for each injury location to the nearest TC. Adjusted associations between TC access and injury-related mortality were then estimated using logistic regression.

Results

Greater than 30 minutes of PTT to a TC was associated with a 66% increased risk of death for MVC victims (p = 0.045). This association was lost when scene deaths were excluded from the analysis. Sustaining a penetrating trauma greater than 30 minutes from a TC was associated with a 3.4-fold increase in risk of death. Following the exclusion of scene deaths, this association remained and approached significance (odds ratio 3.48, 95% confidence interval 0.98–14.5, p = 0.053).

Conclusion

Predicted travel times greater than 30 minutes were associated with worse outcomes for victims of MVCs and penetrating injuries. Improving communication across the trauma system and reducing prehospital times may help optimize outcomes for rural trauma patients.

Efficacy of an ambulance ventilation system in reducing EMS worker exposure to airborne particles from a patient cough aerosol simulator

The protection of emergency medical service (EMS) workers from airborne disease transmission is important during routine transport of patients with infectious respiratory illnesses and would be critical during a pandemic of a disease such as influenza. However, few studies have examined the effectiveness of ambulance ventilation systems at reducing EMS worker exposure to airborne particles (aerosols). In our study, a cough aerosol simulator mimicking a coughing patient with an infectious respiratory illness was placed on a patient cot in an ambulance. The concentration and dispersion of cough aerosol particles were measured for 15 min at locations corresponding to likely positions of an EMS worker treating the patient. Experiments were performed with the patient cot at an angle of 0° (horizontal), 30°, and 60°, and with the ambulance ventilation system set to 0, 5, and 12 air changes/hour (ACH). Our results showed that increasing the air change rate significantly reduced the airborne particle concentration (p < 0.001). Increasing the air change rate from 0 to 5 ACH reduced the mean aerosol concentration by 34% (SD = 19%) overall, while increasing it from 0 to 12 ACH reduced the concentration by 68% (SD = 9%). Changing the cot angle also affected the concentration (p < 0.001), but the effect was more modest, especially at 5 and 12 ACH. Contrary to our expectations, the aerosol concentrations at the different worker positions were not significantly different (p < 0.556). Flow visualization experiments showed that the ventilation system created a recirculation pattern which helped disperse the aerosol particles throughout the compartment, reducing the effectiveness of the system. Our findings indicate that the ambulance ventilation system reduced but did not eliminate worker exposure to infectious aerosol particles. Aerosol exposures were not significantly different at different locations within the compartment, including locations behind and beside the patient. Improved ventilation system designs with smoother and more unidirectional airflows could provide better worker protection.

The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq

BACKGROUND

Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival.

METHODS

A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival.

RESULTS

For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01).

CONCLUSION

Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan.

LEVEL OF EVIDENCE

Performance improvement and epidemiological, level IV.

Profile of trauma mortality and trauma care resources at rural emergency departments and urban trauma centres in Quebec: a population-based, retrospective cohort study

OBJECTIVES

As Canada's second largest province, the geography of Quebec poses unique challenges for trauma management. Our primary objective was to compare mortality rates between trauma patients treated at rural emergency departments (EDs) and urban trauma centres in Quebec. As a secondary objective, we compared the availability of trauma care resources and services between these two settings.

DESIGN

Retrospective cohort study.

SETTING

26 rural EDs and 33 level 1 and 2 urban trauma centres in Quebec, Canada.

PARTICIPANTS

79 957 trauma cases collected from Quebec's trauma registry.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measure was mortality (prehospital, ED, in-hospital). Secondary outcome measures were the availability of trauma-related services and staff specialties at rural and urban facilities. Multivariable generalised linear mixed models were used to determine the relationship between the primary facility and mortality.

RESULTS

Overall, 7215 (9.0%) trauma patients were treated in a rural ED and 72 742 (91.0%) received treatment at an urban centre. Mortality rates were higher in rural EDs compared with urban trauma centres (13.3% vs 7.9%, p<0.001). After controlling for available potential confounders, the odds of prehospital or ED mortality were over three times greater for patients treated in a rural ED (OR 3.44, 95% CI 1.88 to 6.28). Trauma care setting (rural vs urban) was not associated with in-hospital mortality. Nearly all of the specialised services evaluated were more present at urban trauma centres.

CONCLUSIONS

Trauma patients treated in rural EDs had a higher mortality rate and were more likely to die prehospital or in the ED compared with patients treated at an urban trauma centre. Our results were limited by a lack of accurate prehospital times in the trauma registry.

Factors mediating demographic determinants of injury mortality

PURPOSE

Elevated injury mortality rates persist for men and people of color despite attempts to standardize trauma care in the United States. This study investigates the role of injury characteristics and access to trauma care as mediators of the relationships between race, ethnicity, sex, and injury mortality.

METHODS

Data on prehospital and trauma center care were examined for adult injured patients in Maryland who were transported by emergency medical services to designated trauma centers (n = 15,355) or who died while under emergency medical services care (n = 727). Potential mediators of the relationship between demographic characteristics and injury mortality were identified through exploratory analyses. Total, direct, and indirect effects of race, ethnicity, and sex were estimated using multivariable mediation models.

RESULTS

Prehospital time, hospital distance, injury mechanism, and insurance status mediated the effect of African American race, resulting in a 5.7% total increase (95% CI: 1.6%, 9.9%) and 5.6% direct decrease (95% CI: 1.1%, 9.9%) in odds of death. Mechanism, insurance, and distance mediated the effect of Hispanic ethnicity, resulting in an 11.4% total decrease (95% CI: 6.4%, 16.2%) and 13.4% direct decrease (95% CI: 8.1%, 18.3%) in odds of death. Injury severity, mechanism, insurance, and time mediated the effect of male sex, resulting in a 27.3% total increase (95% CI: 21.6%, 10.9%) and a 6.2% direct increase (95% CI: 1.8%, 10.9%) in odds of death.

CONCLUSIONS

Distance, injury characteristics, and insurance mediate the effects of demographic characteristics on injury mortality and appear to contribute to disparities in injury mortality.