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

[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.

Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury

Importance

Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system.

Objective

To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded.

Design, Settings, and Participants

This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023.

Exposures

Acute painful traumatic injuries including burns.

Main Outcomes and Measures

Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine.

Results

The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients.

Conclusions and Relevance

In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.

Access to trauma center care: A statewide system-based approach

BACKGROUND

Timely access to specialized trauma care is a vital element in patient outcome after severe and critical injury requiring the skills of trauma teams in levels I and II trauma centers to avoid preventable mortality. We used system-based models to estimate timely access to care.

METHODS

Trauma system models consisted of ground emergency medical services, helicopter emergency medical services, and designated levels I to V trauma centers were constructed for five states. These models incorporated geographic information systems along with traffic data and census block group data to estimate population access to trauma care within the "golden hour." Trauma systems were further analyzed to identify the optimal location for an additional level I or II trauma center that would provide the greatest increase in access.

RESULTS

The population of the states studied totaled 23 million people, of which 20 million (87%) had access to a level I or II trauma center within 60 minutes. Statewide-specific access ranged from 60% to 100%. Including levels III to V trauma centers, access within 60 minutes increased to 22 million (96%), ranging from 95% to 100%. The addition of a levels I and II trauma center in an optimized location in each state would provide timely access to a higher trauma capability for an additional 1.1 million, increasing total access to approximately 21.1 million people (92%).

CONCLUSION

This analysis demonstrates that nearly universal access to trauma care is present in these states when including levels I to V trauma centers. However, concerning gaps remain in timely access to levels I and II trauma centers. This study provides an approach to determine more robust statewide estimates of access to care. It highlights the need for a national trauma system, one in which all components of state-managed trauma systems are assembled in a national data set to accurately identify gaps in care.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Hispanic Farmers Experience Shorter EMS Response Times but Longer Emergency Department Length of Stay Following Occupational Injuries

BACKGROUND

Agriculture has the highest rate of fatal injuries by sector. Hispanic workers also experience more fatal work injuries than every other minority group combined. Pre-hospital and initial trauma evaluation represent an important marker to understand the impact of a trauma system. We sought to investigate whether Hispanic agricultural workers in the United States (US) experience disparities following traumatic occupational injuries in terms of pre-hospital and emergency department care.

METHODS

We retrospectively analyzed the National Trauma Data Bank from 2012-2016 to understand differences between Hispanic and non-Hispanic farmers in Emergency Medical Services (EMS) response and transport times (minutes), transport mode, transfer rates, presentation to University or Level I trauma hospitals, Injury Severity Scores (ISS), length of stay (LOS) in the emergency department (ED, minutes) or hospital (days), need for the operating room (OR), admittance to the Intensive Care Unit (ICU), and mortality.

RESULTS

A total of 6,161 farmers were included in our analyses (median age 47 years, females 7.0%). Multivariable analyses indicate differences regarding EMS response, EMS transport, and LOS in the ED. Rates of admission to the ICU, surgical operations, days on a ventilator, discharge from the hospital with supportive care, and mortality did not differ between groups.

CONCLUSIONS

Non-Hispanic patients have longer median EMS response and total transport times. Hispanic patients have longer median LOS in the ED. However, the lack of significant differences in management variables other than EMS times and ED LOS indicate an equitable delivery of trauma care once patients were transferred from the ED.