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Beiriger J, Puyana J, Deeb AP, Silver D, Lu L, Boland S, Brown JB. Exploring patient and system factors impacting undertriage of injured patients meeting national field triage guideline criteria. J Trauma Acute Care Surg 2024:01586154-990000000-00779. [PMID: 39093636 DOI: 10.1097/ta.0000000000004407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Trauma systems save lives by coordinating timely and effective responses to injury. However, trauma system effectiveness varies geographically, with worse outcomes observed in rural settings. Prior data suggest that undertriage may play a role in this disparity. Our aim was to explore potential driving factors for decision making among clinicians for undertriaged trauma patients. METHODS We performed a retrospective analysis of the National Emergency Medical Services Information System database among patients who met physiologic or anatomic national field triage guideline criteria for transport to the highest level of trauma center. Undertriage was defined as transport to a non-level I/II trauma center. Multivariable logistic regression was used to determine demographic, injury, and system characteristics associated with undertriage. Undertriaged patients were then categorized into "recognized" and "unrecognized" groups using the documented reason for transport destination to identify underlying factors associated with undertriage. RESULTS A total of 36,094 patients were analyzed. Patients in urban areas were more likely to be transported to a destination based on protocol rather than the closest available facility. As expected, patients injured in urban regions were less likely to be undertriaged than their suburban (adjusted odds ratio [aOR], 2.69; 95% confidence interval [95% CI], 2.21-3.31), rural (aOR, 2.71; 95% CI, 2.28-3.21), and wilderness counterparts (aOR, 3.99; 95% CI, 2.93-5.45). The strongest predictor of undertriage was patient/family choice (aOR, 6.29; 5.28-7.50), followed by closest facility (aOR, 5.49; 95% CI, 4.91-6.13) as the reason for hospital selection. Nonurban settings had over twice the odds of recognizing the presence of triage criteria among undertriaged patients (p < 0.05). CONCLUSION Patients with injuries in nonurban settings and those with less apparent causes of severe injury are more likely to experience undertriage. By analyzing how prehospital clinicians choose transport destinations, we identified patient and system factors associated with undertriage. Targeting these at-risk demographics and contributing factors may help alleviate regional disparities in undertriage. LEVEL OF EVIDENCE Diagnostic; Level IV.
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Affiliation(s)
- Jamison Beiriger
- From the Division of Trauma and General Surgery, Department of Surgery (J.B., J.P., D.S., L.L., S.B., J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Department of Surgery (A.-P.D.), Advent Health, Orlando, Florida
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Zanic A, Kovacic V, Jukic I. Emergency Air Transport of Patients with Acute Chest Pain in the Adriatic Islands of Croatia: A Four-Year Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5422. [PMID: 37048036 PMCID: PMC10094717 DOI: 10.3390/ijerph20075422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/26/2023] [Accepted: 03/28/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND An efficient first-aid system usually supports ground services with a helicopter emergency medical service (HEMS). An HEMS is important for patients with acute chest pain on remote islands. The current study sought to identify the characteristics of HEMS in acute chest pain cases on the Croatian Adriatic islands over a four-year period. METHODS We conducted a four-year observational study to investigate HEMS from Adriatic islands. The study population consisted of all patients with acute coronary syndrome or pulmonary embolisms who were urgently transferred by HEMS to the University Hospital in Split 1 June 2018-1 June 2022. RESULTS During the observation period, 222 adult patients (67 females, or 30.2%) were urgently transferred. The mean age was 71.81 ± 13.42 years. The most common diagnosis was ST-elevated myocardial infarction (113, 50.9%). Most of the HEMS cases were from Hvar (91, 41.0%). The mean call-to-flight time was 19.10 ± 10.94 min, and the total time from call to hospital was 68.50 ± 22.29 min. The total time from call to hospital was significantly correlated with call-to-flight time (r = 0.761, P < 0.001). Of the 222 participants, 5 (2.25%) were transported for more than 120 min, and 35 (15.8%) were transported for more than 90 min. CONCLUSION This study provided a detailed insight into HEMS in the area of the Croatian Adriatic islands. The average time from the call to the helicopter taking off was 19.10 min. An increase in dispatching time has a significant impact on the prolongation of the total time for the hospital admission. Shortening the response time is critical to reducing hospital arrival time.
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Affiliation(s)
- Antonija Zanic
- Institute of Emergency Medicine of Split–Dalmatia County, 21000 Split, Croatia
| | - Vedran Kovacic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, University Hospital of Split, 21000 Split, Croatia
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Ivana Jukic
- Internal Medicine Department, Gastroenterology Division, University Hospital of Split, 21000 Split, Croatia
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Udekwu P, Simonson B, Stiles A, Mclntyre S, Tann K, Schiro S. Prolonged Emergency Department Stay at Referring Facilities: A Poor Trauma Performance Improvement Tool. Am Surg 2021; 88:728-733. [PMID: 34732064 DOI: 10.1177/00031348211050819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Delays in the transfers of injured patients are perceived to increase morbidity and mortality and drive initiatives to limit the emergency department length of stay (LOS) at referring facilities (RF). RF LOS >4 hours is used for performance improvement (PI) with a large review burden with few improvement opportunities. METHODS A statewide trauma registry 2013-2018 was used. Descriptive and inferential statistics including logistic regression were used to evaluate nongeriatric adult patients with ED LOS <12 hours. Paired data analyses utilizing prehospital (PH) and RF variables, vital signs (VS), Glasgow Coma Score-Motor component (GCS-M), RF LOS, mortality, trauma center hospital LOS (HLOS), and intensive care unit (ICU) LOS were performed. RESULTS 13,721 of 56,702 transfer patients were selected. Mortality fell over time in all abbreviated injury score groups. GCS-M and systolic blood pressure (SBP) were correlated with mortality in both prehospital and RF data and highest in patients with abnormal GCS-M or SBP in both settings (38.0%, 30.1%). Examination of mortality over time in the group with abnormal VS showed SBP as the only variable with increasing mortality related to RF LOS. Average HLOS and ICU LOS were longest in patients with abnormal PH and RF SBP and GCS-M. DISCUSSION Support for PI evaluation of RF LOS >4 hours was not identified. Increased survival over time is explained by early transfers of high mortality patients. Our data support existing efficient statewide transfers and recommend PI review of transfer patients with abnormal GCS-M and SBP in a narrower timeframe.
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Affiliation(s)
- Pascal Udekwu
- 10848WakeMed Health and Hospitals, Raleigh, NC, USA.,North Carolina Office of Emergency Medical Services, Raleigh, NC, USA
| | - Brian Simonson
- 24520New Hanover Regional Medical Center, Wilmington, NC, USA.,North Carolina Office of Emergency Medical Services, Raleigh, NC, USA
| | - Anquonette Stiles
- 10848WakeMed Health and Hospitals, Raleigh, NC, USA.,North Carolina Office of Emergency Medical Services, Raleigh, NC, USA
| | - Sarah Mclntyre
- 10848WakeMed Health and Hospitals, Raleigh, NC, USA.,North Carolina Office of Emergency Medical Services, Raleigh, NC, USA
| | - Kimberly Tann
- 10848WakeMed Health and Hospitals, Raleigh, NC, USA.,North Carolina Office of Emergency Medical Services, Raleigh, NC, USA
| | - Sharon Schiro
- 6797University of North Carolina, Chapel Hill, NC, USA.,North Carolina Office of Emergency Medical Services, Raleigh, NC, USA
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Jang JY, Kwon WK, Roh H, Moon JH, Hwang JS, Kim YJ, Kim JH. Time-saving effects using helicopter transportation: comparison to a ground transportation time predicted using a social navigation software. Medicine (Baltimore) 2021; 100:e26569. [PMID: 34232201 PMCID: PMC8270619 DOI: 10.1097/md.0000000000026569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
Previous comparison studies regarding 2 types of transportation, helicopter (HEMS) versus ground emergency medical services (GEMS), have shown underlying heterogeneity as these options have completely different routes and consequent times with reference to one patient. To compare the 2 types of transportation on a case-by-case basis, we analyzed the retrospectively reviewed HEMS and predicted GEMS data using an open-source navigation software.Patients transferred by military HEMS from 2016 to 2019 were retrospectively enrolled. The HEMS records on the time of notification, injury point and destination address, and time required were reviewed. The GEMS data on distance and the predicted time required were acquired using open-source social navigation systems. Comparison analyses between the two types of transportation were conducted. Furthermore, linear logistic regression analyses were performed on the distance and time of the two options.A total of 183 patients were enrolled. There was no statistical difference (P = .3021) in the distance between the 2 types of transportation, and the HEMS time was significantly shorter than that of GEMS (61.31 vs 116.92 minutes, P < .001). The simple linear curves for HEMS and GEMS were separately secured, and two graphs presented the statistical significance (P) as well as reasonable goodness-of-fit (R2). In general, the HEMS graph demonstrates a more gradual slope and narrow distribution compared to that of GEMS.Ideally, HEMS is identified as a better transportation modality because it has a shorter transportation time (56 minutes saved) and a low possibility of potential time delays (larger R2). With a strict patient selection, HEMS can rescue injured or emergent patients who are "out of the golden hour."
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Affiliation(s)
- Ji Young Jang
- Department of Neurosurgery, Armed Forces Capital Hospital, Gyeonggi-do
| | - Woo-Keun Kwon
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul
| | - Haewon Roh
- Department of Neurosurgery, Armed Forces Capital Hospital, Gyeonggi-do
| | - Jong Ha Moon
- Medical Emergency Operation Center, Armed Forces Medical Command
| | - Jun Seong Hwang
- Medical Emergency Operation Center, Armed Forces Medical Command
| | - Yoon Jic Kim
- Medical Emergency Operation Center, Armed Forces Medical Command
| | - Jang Hun Kim
- Department of Neurosurgery, Armed Forces Capital Hospital, Gyeonggi-do
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi-do, Republic of Korea
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Le Borgne P, Oberlin M, Bassand A, Abensur Vuillaume L, Gottwalles Y, Noizet M, Gennai S, Baicry F, Jaeger D, Girerd N, Lefebvre F, Bilbault P, Chouihed T. Pre-Hospital Management of Critically Ill Patients with SARS-CoV-2 Infection: A Retrospective Multicenter Study. J Clin Med 2020; 9:E3744. [PMID: 33233324 PMCID: PMC7700636 DOI: 10.3390/jcm9113744] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The COVID-19 outbreak had a major impact on healthcare systems worldwide. Our study aims to describe the characteristics and therapeutic emergency mobile service (EMS) management of patients with vital distress due to COVID-19, their in-hospital care pathway and their in-hospital outcome. METHODS This retrospective and multicentric study was conducted in the six main centers of the French Greater East region, an area heavily impacted by the pandemic. All patients requiring EMS dispatch and who were admitted straight to the intensive care unit (ICU) were included. Clinical data from their pre-hospital and hospital management were retrieved. RESULTS We included a total of 103 patients (78.6% male, median age 68). In the initial stage, patients were in a critical condition (median oxygen saturation was 72% (60-80%)). In the field, 77.7% (CI 95%: 71.8-88.3%) were intubated. Almost half of our population (45.6%, CI 95%: 37.1-56.9%) had clinical Phenotype 1 (silent hypoxemia), while the remaining half presented Phenotype 2 (acute respiratory failure). In the ICU, a great number had ARDS (77.7%, CI 95% 71.8-88.3% with a PaO2/FiO2 < 200). In-hospital mortality was 33% (CI 95%: 24.6-43.3%). The two phenotypes showed clinical and radiological differences (respiratory rate, OR = 0.98, p = 0.02; CT scan lesion extension >50%, OR = 0.76, p < 0.03). However, no difference was found in terms of overall in-hospital mortality (OR = 1.07, p = 0.74). CONCLUSION The clinical phenotypes appear to be very distinguishable in the pre-hospital field, yet no difference was found in terms of mortality. This leads us to recommend an identical management in the initial phase, despite the two distinct presentations.
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Affiliation(s)
- Pierrick Le Borgne
- Emergency Department, University Hospital of Strasbourg, 1 Avenue Molière, 67000 Strasbourg, France; (M.O.); (F.B.); (P.B.)
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), University of Strasbourg, 67000 Strasbourg, France
| | - Mathieu Oberlin
- Emergency Department, University Hospital of Strasbourg, 1 Avenue Molière, 67000 Strasbourg, France; (M.O.); (F.B.); (P.B.)
| | - Adrien Bassand
- Emergency Department, University Hospital of Nancy, 29 Avenue du Maréchal de Lattre de Tassigny, 54035 Nancy, France; (A.B.); (D.J.); (T.C.)
| | - Laure Abensur Vuillaume
- Emergency Department, Regional Hospital of Metz-Thionville, 1, Allée du Château, 57530 Ars-Laquenexy, France;
| | - Yannick Gottwalles
- Emergency Department, General Hospital of Colmar, 39 Avenue de la Liberté, 68024 Colmar, France;
| | - Marc Noizet
- Emergency Department, Mulhouse hospital, 20 Avenue du Dr René Laennec, 68100 Mulhouse, France;
| | - Stéphane Gennai
- Emergency Department, Reims University Hospital, 45 Rue Cognac-Jay, 51100 Reims, France;
| | - Florent Baicry
- Emergency Department, University Hospital of Strasbourg, 1 Avenue Molière, 67000 Strasbourg, France; (M.O.); (F.B.); (P.B.)
| | - Deborah Jaeger
- Emergency Department, University Hospital of Nancy, 29 Avenue du Maréchal de Lattre de Tassigny, 54035 Nancy, France; (A.B.); (D.J.); (T.C.)
| | - Nicolas Girerd
- Centre d’Investigations Cliniques-1433, and INSERM U1116, F-CRIN INI-CRCT, Université de Lorraine, 54000 Nancy, France;
| | - François Lefebvre
- Department of Public Health, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67000 Strasbourg, France;
| | - Pascal Bilbault
- Emergency Department, University Hospital of Strasbourg, 1 Avenue Molière, 67000 Strasbourg, France; (M.O.); (F.B.); (P.B.)
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), University of Strasbourg, 67000 Strasbourg, France
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, 29 Avenue du Maréchal de Lattre de Tassigny, 54035 Nancy, France; (A.B.); (D.J.); (T.C.)
- Centre d’Investigations Cliniques-1433, and INSERM U1116, F-CRIN INI-CRCT, Université de Lorraine, 54000 Nancy, France;
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Stassen W, Alkzair S, Kurland L. Helicopter Emergency Medical Services in Trauma Does Not Influence Mortality in South Africa. Air Med J 2020; 39:479-483. [PMID: 33228898 DOI: 10.1016/j.amj.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/19/2020] [Accepted: 08/02/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Sub-Saharan Africa carries a large trauma burden. Helicopter emergency medical services (HEMS) have been suggested to reduce prehospital time and mortality. It is not clear whether HEMS infers a mortality benefit over ground transport in South Africa. This study aimed to determine whether HEMS improved 30-day mortality over ground emergency medical services (GEMS). METHODS A retrospective, case-control study was undertaken for major trauma patients transported to a private trauma center in Johannesburg. A 1-year cohort of HEMS patients was extracted and matched to GEMS patients based on mechanism, injury severity or percentage of the total body surface area burned, age, sex, and comorbidities. The odds ratio (OR) for 30-day mortality was calculated to determine the risk of death. RESULTS A total of 822 cases (HEMS: 272 [33%], GEMS: 550 [67%]) were reviewed. We included 410 patients in the matched cohort with equal distribution between transportation modes. The OR for mortality in the total cohort was 2.69 (95% confidence interval, 1.6-4.6; P = .003) for HEMS patients, whereas in the matched cohort the OR was 1.35 (95% confidence interval, 0.5-3.4; P = .503) for patients transported by HEMS. CONCLUSION In a matched cohort of major trauma patients, HEMS does not seem to improve mortality over GEMS. These results might reflect the South African HEMS dispatch model.
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Affiliation(s)
- Willem Stassen
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | | | - Lisa Kurland
- School of Medical Sciences, Ӧrebro University, Ӧrebro, Sweden
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The effect of emergency medical system transport time on in route clinical decline in a rural system. J Trauma Acute Care Surg 2020; 88:734-741. [DOI: 10.1097/ta.0000000000002675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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