1
|
Baumkirchner JM, Havlicek M, Voelckel W, Trimmel H. Resuscitation of out-of-hospital cardiac arrest victims in Austria's largest helicopter emergency medical service: A retrospective cohort study. Resusc Plus 2024; 19:100678. [PMID: 38912530 PMCID: PMC11190555 DOI: 10.1016/j.resplu.2024.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/12/2024] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Background Helicopter emergency medical services (HEMS) play a fundamental role in prehospital care. However, the impact of HEMS on survival of patients with out-of-hospital cardiac arrest (OHCA) is widely unknown. Therefore, the purpose of this study was to assess demographics, treatment, and outcome of patients with OHCA attended by physician-staffed helicopters. Methods Retrospective cohort study enrolling OHCA patients treated by HEMS during a ten-year period (2010-2019) in Austria. Patients were identified using electronic mission records of 13 HEMS bases run by the Austrian Automobile, Motorcycle and Touring Club (OEAMTC), and subsequently matched with the national register of deaths to determine 30-day and one-year survival rates. Results are reported according to the 2015 Utstein Style. Multivariable logistic regression analysis was used to identify factors associated with patient outcome. Results In total, 9344 presumed OHCA missions were identified. Cardiopulmonary resuscitation was attempted or continued by HEMS in 3889 cases. Approximately 32.2% of patients achieved return of spontaneous circulation (ROSC) and 22.5% sustained ROSC until arrival at the emergency department. Thirty-day and one-year survival rates were 14.0% and 12.4% respectively. HEMS response time, on-scene time, age, pathogenesis, arrest location, witness-status, first monitored rhythm, bystander automated external defibrillator (AED) use, airway type and administration of adrenaline were independent predictors of 30-day survival. Conclusions This study provides an extensive insight into the management of OHCA in an almost nationwide HEMS sample. Thirty-day and one-year survival rates are high, indicating high-quality care and systematic selection of patients with favorable prognosis.
Collapse
Affiliation(s)
- Julian M. Baumkirchner
- Medical University of Vienna, Vienna, Austria
- Department of Surgery, Zuger Kantonsspital, Baar, Switzerland
| | | | - Wolfgang Voelckel
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
- University of Stavanger, Network for Medical Science, Stavanger, Norway
- Christophorus Air Rescue, OEAMTC, Vienna, Austria
| | - Helmut Trimmel
- Christophorus Air Rescue, OEAMTC, Vienna, Austria
- Department of Anaesthesiology, Emergency Medicine and Intensive Care, County Hospital Wiener Neustadt, Wiener Neustadt, Austria
- Karl Landsteiner Institute for Emergency Medicine, Wiener Neustadt, Austria
- Danube Private University, Krems, Austria
| |
Collapse
|
2
|
Ciaraglia A, Lumbard D, Murala A, Moreira A, Rajasekaran K, Nicholson S, Moreira A. Comparison of helicopter and ground transportation in pediatric trauma patients. Pediatr Res 2024; 95:188-192. [PMID: 37537235 DOI: 10.1038/s41390-023-02761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/23/2023] [Accepted: 07/17/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Decision making regarding transportation mode after a traumatic injury may have a significant impact on outcomes, due to differences in time to definitive care. The objective of this study was to determine if transport mode had an impact on in-hospital mortality and discharge disposition in pediatric trauma patients. METHODS Data were abstracted from the National Trauma Data Bank from 2007 to 2016 comparing helicopter and ground transportation modes effects on mortality and discharge outcomes. The primary outcome was in-hospital death, while the secondary outcome was discharge home without services (DCHWOS). Analyses included logistic regression modeling and propensity score matching. RESULTS Significant variables from univariate analysis were included in the multivariate, propensity-matched regression model. Pediatric trauma patients transported by helicopter had lower odds of mortality (OR 0.69 [0.64,0.75]) and higher odds of DCHWOS (1.29 [1.20,1.39]). There were no differences in overall mechanism, but individual injury patterns showed higher odds of mortality. CONCLUSION Critical decisions regarding triage of patients by different modes of transport occur every day. This study supports the current literature on the topic and shows a potential additional benefit of a meaningful discharge outcome for those transported by helicopter. IMPACT This study may impact prehospital triage decision making process for pediatric trauma patients on mortality. Prehospital transport mode may contribute to pediatric trauma discharge outcomes. Highlights the need for future research regarding non-clinical data that is unable to be abstracted from national databases (e.g., family dynamics, insurance status, weather, access to post-discharge resources).
Collapse
Affiliation(s)
- Angelo Ciaraglia
- UT Health Science Center San Antonio, Department of Surgery, San Antonio, TX, USA.
| | - Derek Lumbard
- UT Health Science Center San Antonio, Department of Surgery, San Antonio, TX, USA
| | - Anish Murala
- UT Health Science Center San Antonio, Department of Pediatrics, San Antonio, TX, USA
| | - Axel Moreira
- Texas Children's Hospital, Department of Pediatrics, Houston, TX, USA
| | - Karthik Rajasekaran
- University of Pennsylvania, Department of Otorhinolaryngology, Philadelphia, PA, USA
| | - Susannah Nicholson
- UT Health Science Center San Antonio, Department of Surgery, San Antonio, TX, USA
| | - Alvaro Moreira
- UT Health Science Center San Antonio, Department of Pediatrics, San Antonio, TX, USA
| |
Collapse
|
3
|
Wycoff M, Hoag TP, Okeke RI, Culhane JT. Association of Time to Definitive Hemostasis With Mortality in Patients With Solid Organ Injuries. Cureus 2023; 15:e45401. [PMID: 37854760 PMCID: PMC10581328 DOI: 10.7759/cureus.45401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction The Golden Hour is a term used in the trauma setting to refer to the first 60 minutes after injury. Traditionally, definitive care within this period was believed to dramatically increase a patient's survival. Though the period of 60 minutes is unlikely to represent a point of distinct inflection in survival, the effect of time to definitive care on survival remains incompletely understood. This study aims to measure the association of time to definitive hemostasis with mortality in patients with solid organ injuries as well as the effect of survival bias and a form of selection bias known as indication by severity on the relationship between time to treatment and survival. Methodology This is a retrospective cohort study using data obtained from the American College of Surgeons National Trauma Data Bank (NTDB) from the years 2017 through 2019 selecting patients treated for blunt liver, spleen, or kidney injury who required angioembolization or surgical hemostasis within six hours. A Cox proportional hazards regression was used to analyze time to death. The association of probability of death with time was examined with a multivariate logistic regression initially treating the relationship as linear and subsequently transforming time to hemostasis with restricted cubic splines to model a non-linear association with the outcome. To model survival and indication by severity bias, we created a computer-generated data set and used LOESS regressions to display curves of the simulated data. Results The multivariate Cox proportional hazards analysis shows a coefficient of negative 0.004 for minutes to hemostasis with an adjusted hazard ratio of 0.9959 showing the adjusted hazard of death slightly diminishes with each increasing minute to hemostasis. The likelihood ratio chi-square difference between the model with time to hemostasis included as a linear term versus the model with the restricted cubic spline transformation is 97.46 (p<0.0001) showing the model with restricted cubic splines is a better fit for the data. The computer-generated data simulating treatment of solid organ injury with no programmed bias displays an almost linear association of mortality with increased treatment delay. When indications by severity bias and survival bias are introduced, the risk of death decreases with time to hemostasis as in the real-world data. Conclusion Decreasing mortality with increasing delay to hemostasis in trauma patients with solid organ injury is likely due to confounding due to indication by severity and survival bias. After taking these biases into account, the association of delayed hemostasis with better survival is not likely due to the benefit of delay but rather the delay sorts patients by severity of injury with those more likely to die being treated first. These biases are extremely difficult to eliminate which limits the ability to measure the true effect of delay with retrospective data. The findings may however be of value as a predictive model to anticipate the acuity of a patient after an interval of unavoidable delay such as with a long transfer time.
Collapse
Affiliation(s)
- Michaela Wycoff
- General Surgery, MercyOne Des Moines Medical Center, Des Moines, USA
| | - Thomas P Hoag
- General Surgery, Saint Louis University School of Medicine, Saint Louis, USA
| | - Raymond I Okeke
- General Surgery, Saint Louis University School of Medicine, Saint Louis, USA
| | - John T Culhane
- General Surgery, Saint Louis University School of Medicine, Saint Louis, USA
| |
Collapse
|
4
|
Árnason B, Hertzberg D, Kornhall D, Günther M, Gellerfors M. Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams. Acta Anaesthesiol Scand 2021; 65:1329-1336. [PMID: 34152597 PMCID: PMC9291089 DOI: 10.1111/aas.13946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/06/2021] [Accepted: 05/08/2021] [Indexed: 12/05/2022]
Abstract
Background Pre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult. Method The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality. Result The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED. Conclusion Pre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.
Collapse
Affiliation(s)
- Bjarni Árnason
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Rapid Response CarCapio Stockholm Sweden
| | - Daniel Hertzberg
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and PharmacologyKarolinska Institutet Stockholm Sweden
| | - Daniel Kornhall
- Swedish Air Ambulance (SLA) Mora Sweden
- East Anglian Air Ambulance Cambridge UK
| | - Mattias Günther
- Department of Clinical Research and Education Karolinska Institutet Stockholm Sweden
| | - Mikael Gellerfors
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Rapid Response CarCapio Stockholm Sweden
- Department of Physiology and PharmacologyKarolinska Institutet Stockholm Sweden
- Swedish Air Ambulance (SLA) Mora Sweden
| |
Collapse
|
5
|
Berkeveld E, Popal Z, Schober P, Zuidema WP, Bloemers FW, Giannakopoulos GF. Prehospital time and mortality in polytrauma patients: a retrospective analysis. BMC Emerg Med 2021; 21:78. [PMID: 34229629 PMCID: PMC8261943 DOI: 10.1186/s12873-021-00476-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background The time from injury to treatment is considered as one of the major determinants for patient outcome after trauma. Previous studies already attempted to investigate the correlation between prehospital time and trauma patient outcome. However, the outcome for severely injured patients is not clear yet, as little data is available from prehospital systems with both Emergency Medical Services (EMS) and physician staffed Helicopter Emergency Medical Services (HEMS). Therefore, the aim was to investigate the association between prehospital time and mortality in polytrauma patients in a Dutch level I trauma center. Methods A retrospective study was performed using data derived from the Dutch trauma registry of the National Network for Acute Care from Amsterdam UMC location VUmc over a 2-year period. Severely injured polytrauma patients (Injury Severity Score (ISS) ≥ 16), who were treated on-scene by EMS or both EMS and HEMS and transported to our level I trauma center, were included. Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS were analyzed using logistic regression analysis. The outcome measure was in-hospital mortality. Results In total, 342 polytrauma patients were included in the analysis. The total mortality rate was 25.7% (n = 88). Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) respectively (p = 0.819). The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156). Conclusion This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality.
Collapse
Affiliation(s)
- E Berkeveld
- Department of Trauma Surgery, Amsterdam University Medical Center, location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Z Popal
- Department of Trauma Surgery, Amsterdam University Medical Center, location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - P Schober
- Department of Anesthesiology, Amsterdam University Medical Center, location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - W P Zuidema
- Department of Trauma Surgery, Amsterdam University Medical Center, location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - F W Bloemers
- Department of Trauma Surgery, Amsterdam University Medical Center, location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - G F Giannakopoulos
- Department of Trauma Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Comparative Study on the Outcome of Stroke Patients Transferred by Doctor Helicopters and Ground Ambulances in South Korea: A Retrospective Controlled Study. Emerg Med Int 2020; 2020:8493289. [PMID: 33224530 PMCID: PMC7670300 DOI: 10.1155/2020/8493289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/22/2020] [Accepted: 09/27/2020] [Indexed: 11/24/2022] Open
Abstract
The purpose of this study was to analyze the effectiveness of helicopter emergency medical services (HEMS) for its economic operations in South Korea. This study targeted stroke patients who were transported via HEMS or ground emergency medical services (GEMS) from the scene of an accident to a regional emergency medical center. From this patient population, stroke patients who traveled at least 50 km from the scene of the cerebral infarction to the hospital with analyzable outcome data were extracted and included in this study. This study included 26 HEMS and 102 GEMS stroke patients from a pool of 183 potential patients. The survival-to-discharge rate of patients transported via HEMS (96.2%; 25/26) was significantly higher than that of patients transported via GEMS (83.2%; 104/128) (P=0.001). The HEMS transfer was quicker with respect to the decision-making process because the emergency physician actively evaluates and communicates on-site and during in-transit travel to request an appointment immediately upon arrival at the emergency room. These results indicate that using HEMS increased discharge and survival rates and reduced in-hospital mortality of HEMS of stroke patients with a reduced admission time. This result association leads to reasonable cost-effectiveness and efficient estimates overall. In conclusion, HEMS indicate reduced time taken for stroke patients to be hospitalized and treated and decreased mortality after 24 hours. According to this result, HEMS transport can be more effective than GEMS in long-distance delivery of stroke patients.
Collapse
|
7
|
Kim HW, Yun JH. Treatment Experiences of Traumatic Brain Injury Patients using Doctor-Helicopter Emergency Medical Service: Early Data in a Regional Trauma Center. Korean J Neurotrauma 2020; 16:157-165. [PMID: 33163423 PMCID: PMC7607028 DOI: 10.13004/kjnt.2020.16.e50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/16/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this study is to analyze the results of doctor helicopter emergency medical service (HEMS) in traumatic brain injury (TBI) patients and to understand the effect and improvement of doctor HEMS. Methods We included TBI patients transferred by doctor HEMS of our hospital between February 2016 and December 2017. Basic characteristics, HEMS data, treatment and results data were analyzed retrospectively. We divided the patients into 3 groups as regarding severity of patient, relevance of treatment and transfer. We investigated the preventable trauma death rate (PTDR) of these groups to increase the reliability of the treatment outcome. Results TBI patients using doctor HEMS were indicated in 98 patients (18.7%) among 522 overall HEMS patients. The overall mortality was consisted in 21.4% and 43.2% was resulted in Glasgow outcome scale 4 or 5. The group of proper transport and treatment for severe TBI was consisted in 62.2% including 13 mortality cases and no preventable death. The group of delayed transport or treatment for severe TBI was 18.3% including 8 mortality cases and 1 preventable death. The PTDR of TBI after doctor HEMS was significantly lower than that of overall TBI (4.8% vs. 11.6%, p=0.045). Conclusion In patients with severe TBI, doctor HEMS can improve treatment outcomes by reducing treatment delay and unnecessary examinations and this result was evidenced that the PTDR were decreased significantly after doctor HEMS transport. The appropriate treatment is mandatory for real-time communication with the emergency doctor and treatment preparation of the trauma team during the HEMS transport.
Collapse
Affiliation(s)
- Hyun Woo Kim
- Department of Neurosurgery, Dankook University Hospital, Cheonan, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University Hospital, Cheonan, Korea
| |
Collapse
|
8
|
Nasser AAH, Khouli Y. The Impact of Prehospital Transport Mode on Mortality of Penetrating Trauma Patients. Air Med J 2020; 39:502-505. [PMID: 33228903 DOI: 10.1016/j.amj.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/10/2020] [Accepted: 07/21/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality. METHODS Using the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates. RESULTS A total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P < .0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P < .0001). CONCLUSION Helicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.
Collapse
Affiliation(s)
- Ahmed A H Nasser
- Trauma and Orthopaedics Department, West Middlesex University Hospital, Chelsea and Westminster NHS Foundation Trust, Isleworth, United Kingdom.
| | - Yousef Khouli
- General Surgery Department, Broomfield Hospital, Mid Essex Hospitals NHS Trust, Broomfield, United Kingdom
| |
Collapse
|
9
|
Schneider AM, Ewing JA, Cull JD. Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time. Am Surg 2020; 87:538-542. [PMID: 33111567 DOI: 10.1177/0003134820943564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Helicopter transport of trauma patients remains controversial. We examined the survival rates of patients undergoing helicopter versus ground transport to a Level 1 trauma center. METHODS Retrospective analysis was performed on trauma patients treated between 2014 and 2017. Student's t-test was used to compare air versus ground transport times. A logistic regression was then used to examine the association of transportation type on survival controlling for demographics, mechanism of injury, transport time, field intubation, and injury severity. RESULTS Of 3967 patients identified, 69.6% (2762) were male, and the average age was 40 years. Most patients suffered blunt injuries (86.8%, 3445), while the remaining had penetrating injuries (11.6%, 459) or burns (1.6%, 63). The majority of patients were transferred by ground (3449) with only 13% (518) transferred by air. Patients transported by air had increased Injury Severity Score (ISS) with a median of 17 (IQR 9-24) versus 9 (IQR 5-14), increased length of stay (LOS) at 6 days versus 3 (P < .001), and increased mortality at 12.6% vs 6.5% (P < .001). Patients transported by air arrived 16.6 ± 6.7 minutes faster compared with ground for the zip codes examined. When adjusting for the mechanism of injury, ISS, age, gender, intubation status, and transport time, air transport was associated with an increased likelihood of survival (odds ratio [OR] = 1.57, 95% CI = 1.06-2.40). CONCLUSION In our analysis of 3967 patients, those transported by air had a significant improvement in the likelihood of survival compared with those transported by ground even when adjusting for both ISS and time.
Collapse
Affiliation(s)
- Andrew M Schneider
- Department of Surgery, Prisma Health Greenville Memorial Hospital, Greenville, SC, USA
| | - Joseph A Ewing
- Department of Surgery, Prisma Health Greenville Memorial Hospital, Greenville, SC, USA
| | - John D Cull
- Department of Surgery, Prisma Health Greenville Memorial Hospital, Greenville, SC, USA
| |
Collapse
|
10
|
Nasser AAH. Most of the Variation in Prehospital Scene Time Is Not Related to Patient Factors, Injury Characteristics, or Geography. Air Med J 2020; 39:374-379. [PMID: 33012475 DOI: 10.1016/j.amj.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/09/2020] [Accepted: 05/25/2020] [Indexed: 05/16/2023]
Abstract
OBJECTIVE The time spent on scene by emergency medical services remains highly variable. We sought to investigate how much of the prehospital scene time variation in penetrating trauma patients could be explained by prehospital factors. METHODS Using the 2010 to 2016 Trauma Quality and Improvement database, all adult penetrating trauma patients were included. The prehospital scene time was defined as the time from emergency medical service scene arrival to departure. Using all Trauma Quality and Improvement database variables including patient, injury (eg, Injury Severity Score), geography, and logistical (eg, transport mode) factors, multivariable linear regression models were created to predict the prehospital scene time. The prehospital scene time was treated as a continuous variable, and the degree to which the models could explain the variation in scene time was measured using the coefficient of determination (R). RESULTS A total of 45,560 patients were included. The median prehospital scene time was 6 minutes (interquartile range, 3-10 minutes). The R for factors in the multivariable regression model was 0.06, suggesting that 94% of the prehospital scene time variation cannot be explained by the wide range of prehospital factors. CONCLUSION Most of the variation in prehospital scene time cannot be explained by injury characteristics. The variation may be caused by logistical delays or system-related factors.
Collapse
Affiliation(s)
- Ahmed A H Nasser
- Trauma and Orthopaedics Department, West Middlesex University Hospital, Isleworth, UK.
| |
Collapse
|
11
|
Prehospital Intervals and In-Hospital Trauma Mortality: A Retrospective Study from a Level I Trauma Center. Prehosp Disaster Med 2020; 35:508-515. [PMID: 32674744 DOI: 10.1017/s1049023x20000904] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The increase in mortality and total prehospital time (TPT) seen in Qatar appear to be realistic. However, existing reports on the influence of TPT on mortality in trauma patients are conflicting. This study aimed to explore the impact of prehospital time on the in-hospital outcomes. METHODS A retrospective analysis of data on patients transferred alive by Emergency Medical Services (EMS) and admitted to Hamad Trauma Center (HTC) of Hamad General Hospital (HGH; Doha, Qatar) from June 2017 through May 2018 was conducted. This study was centered on the National Trauma Registry database. Patients were categorized based on the trauma triage activation and prehospital intervals, and comparative analysis was performed. RESULTS A total of 1,455 patients were included, of which nearly one-quarter of patients required urgent and life-saving care at a trauma center (T1 activations). The overall TPT was 70 minutes and the on-scene time (OST) was 24 minutes. When compared to T2 activations, T1 patients were more likely to have been involved in road traffic injuries (RTIs); experienced head and chest injuries; presented with higher Injury Severity Score (ISS: median = 22); and had prolonged OST (27 minutes) and reduced TPT (65 minutes; P = .001). Prolonged OST was found to be associated with higher mortality in T1 patients, whereas TPT was not associated. CONCLUSIONS In-hospital mortality was independent of TPT but associated with longer OST in severely injured patients. The survival benefit may extend beyond the golden hour and may depend on the injury characteristics, prehospital, and in-hospital settings.
Collapse
|
12
|
Risgaard B, Draegert C, Baekgaard JS, Steinmetz J, Rasmussen LS. Impact of Physician-staffed Helicopters on Pre-hospital Patient Outcomes: A systematic review. Acta Anaesthesiol Scand 2020; 64:691-704. [PMID: 31950487 DOI: 10.1111/aas.13547] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/28/2019] [Accepted: 01/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of pre-hospital patients remains a challenge. In developed countries a physician-staffed helicopter emergency medical service (PS-HEMS) is used in addition to ground emergency medical service (GEMS), but the effect is debated. This systematic review aimed to evaluate the effect of PS-HEMS compared with GEMS on patient outcomes based on the published scientific literature. METHODS Medline, EMBASE and the Cochrane Library were systematically searched on November 15, 2019 for prospective, interventional studies comparing outcomes of patients transported by either PS-HEMS or GEMS. Outcomes of interest were mortality, time to hospital and quality of life. RESULTS The majority of 18 studies included were observational and difficult to summarize because of heterogeneity. Meta-analysis could not be carried out. Three studies found reduced mortality in patients transported by PS-HEMS compared with GEMS with Odds ratios (OR) of 0.68 (0.47-0.98); 0.29 (0.10-0.82) and 0.21 (0.06-0.73) respectively. Another two studies found improved survival with OR 1.2 (1.0-1.5) and 6.9 (1.48-32.5) in patients transported by PS-HEMS compared with GEMS. In three studies, PS-HEMS was associated with shorter time to hospital. Three studies reported quality of life and found no benefit of PS-HEMS. CONCLUSION In this systematic review the studies comparing PS-HEMS with GEMS were difficult to summarize because of heterogeneity. We found a possible survival benefit of PS-HEMS but were unable to conduct a meta-analysis. The overall quality of evidence was low.
Collapse
Affiliation(s)
- Bjarke Risgaard
- Department of Anaesthesia Section 4231 Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Christina Draegert
- Department of Anaesthesia Section 4231 Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Josefine S. Baekgaard
- Department of Anaesthesia Section 4231 Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia Section 4231 Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia Section 4231 Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| |
Collapse
|
13
|
Predictors of Prehospital On-Scene Time in an Australian Emergency Retrieval Service. Prehosp Disaster Med 2020; 34:317-321. [PMID: 31204644 DOI: 10.1017/s1049023x19004394] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Prehospital physicians balance the need to stabilize patients prior to transport, minimizing the delay to transport patients to the appropriate level of care. Literature has focused on which interventions should be performed in the prehospital environment, with airway management, specifically prehospital intubation (PHI), being a commonly discussed topic. However, few studies have sought additional factors which influence scene time or quantify the impact of mission characteristics or therapeutic interventions on scene time.Hypothesis/Problem:The goal of this study was to identify specific interventions, patient demographics, or mission characteristics that increase scene time and quantify their impact on scene time. METHODS A retrospective, database model-building study was performed using the prehospital mission database of South Australian Ambulance Service (SAAS; Adelaide, South Australia) MedSTAR retrieval service from January 1, 2015 through August 31, 2016. Mission variables, including patient age, weight, gender, retrieval platform, physician type, PHI, arterial line placement, central line placement, and finger thoracostomy, were assessed for predictors of scene time. RESULTS A total of 506 missions were included in this study. Average prehospital scene time was 34 (SD = 21) minutes. Four mission variables significantly increased scene time: patient age, rotary wing transport, PHI, and arterial line placement increased scene time by 0.09 (SD = 0.08) minutes, 13.6 (SD = 3.2) minutes, 11.6 (SD = 3.8) minutes, and 34.4 (SD = 8.4) minutes, respectively. CONCLUSION This study identifies two mission characteristics, patient age and rotary wing transport, and two interventions, PHI and arterial line placement, which significantly increase scene time. Elderly patients are medically complex and more severely injured than younger patients, thus, may require more time to stabilize on-scene. Inherent in rotary wing operations is the time to prepare for the flight, which is shorter during ground transport. The time required to safely execute a PHI is similar to that in the literature and has remained constant over the past two years; arterial line placement took longer than envisioned. The SAAS MedSTAR has changed its clinical practice guidelines for prehospital interventions based on this study's results. Retrieval services should similarly assess the necessity and efficiency of interventions to optimize scene time, knowing that the time required to safely execute an intervention may reach a minimum duration. Defining the scene time enables mission planning, team training, and audit review with the aim of improved patient care.
Collapse
|
14
|
Cowley A, Durham M, Aldred D, Crabb R, Crouch P, Heywood A, McBride A, Williams J, Lyon R. Presence of a pre-hospital enhanced care team reduces on scene time and improves triage compliance for stab trauma. Scand J Trauma Resusc Emerg Med 2019; 27:86. [PMID: 31492193 PMCID: PMC6731599 DOI: 10.1186/s13049-019-0661-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A reduction in pre-hospital scene time for patients with penetrating trauma is associated with reduced mortality, when combined with appropriate hospital triage. This study investigated the relationship between presence of pre-hospital enhanced care teams (ECT) (Critical Care Paramedics (CCPS) or Helicopter Emergency Medical Service (HEMS)), on the scene time and triage compliance, of penetrating trauma patients in a UK ambulance service. The primary outcome was whether scene time reduces when an ECT is present. A secondary outcome was whether the presence of an ECT improved compliance with the trust's Major Trauma Decision Tree (MTDT). METHODS All suspected penetrating trauma incidents involving a patient's torso were identified from the Trust's computer-aided dispatch (CAD) system between 31st March 2017 and 1st April 2018. Only patients who sustained central penetrating trauma were included. Any incidents involving firearms were excluded due to the prolonged times that can be involved when waiting for specialist police units. Data relevant to scene time for each eligible incident were retrieved, along with the presence or absence of an ECT. The results were analysed to identify trends in the scene times and compliance with the MTDT. RESULTS One hundred seventy-one patients met the inclusion criteria, with 165 having complete data. The presence of an ECT improved the median on-scene time in central stabbing by 38% (29m50s vs. 19m0s, p = 0.03). The compliance with the trust's MTDT increased dramatically when an ECT is present (81% vs. 37%, odds ratio 7.59, 95% CI, 3.70-15.37, p < 0.0001). CONCLUSIONS The presence of an ECT at a central stabbing incident significantly improved the scene time and triage compliance with a MTDT. Ambulance services should consider routine activation of ECTs to such incidents, with subsequent service evaluation to monitor patient outcomes. Ambulance services should continue to strive to reduce scene times in the context of central penetrating trauma.
Collapse
Affiliation(s)
- Alan Cowley
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK.
- Air Ambulance Kent Surrey Sussex, Rochester Airport, Maidstone Road, Chathan, Rochester, ME5 9SD, UK.
| | - Mark Durham
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK
| | - Duncan Aldred
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK
| | - Richard Crabb
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK
- Air Ambulance Kent Surrey Sussex, Rochester Airport, Maidstone Road, Chathan, Rochester, ME5 9SD, UK
| | - Paul Crouch
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK
| | - Adam Heywood
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK
- Air Ambulance Kent Surrey Sussex, Rochester Airport, Maidstone Road, Chathan, Rochester, ME5 9SD, UK
| | - Andy McBride
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK
| | - Julia Williams
- South East Coast Ambulance Service NHS Foundation Trust (SECAmb), Nexus House, 4 Gatwick Road, Crawley, RH10 9BG, UK
| | - Richard Lyon
- Air Ambulance Kent Surrey Sussex, Rochester Airport, Maidstone Road, Chathan, Rochester, ME5 9SD, UK
- University of Surrey, Stag Hill, Guildford, GU2 7XH, UK
| |
Collapse
|
15
|
Is Prehospital Time Important for the Treatment of Severely Injured Patients? A Matched-Triplet Analysis of 13,851 Patients from the TraumaRegister DGU®. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5936345. [PMID: 31321238 PMCID: PMC6610751 DOI: 10.1155/2019/5936345] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/11/2019] [Accepted: 05/16/2019] [Indexed: 11/17/2022]
Abstract
Background The impact of time (the golden period of trauma) on the outcome of severely injured patients has been well known for a long time. While the duration of the prehospital phase has changed only slightly (average time: ~66 min) since the TraumaRegister DGU® (TR-DGU®) was implemented, mortality rates have decreased within the last 20 years. This study analyzed the influence of prehospital time on the outcome of trauma patients in a matched-triplet analysis. Material and Methods A total of 93,024 patients from the TraumaRegister DGU® were selected based on the following inclusion criteria: ISS ≥ 16, primary admission, age ≥ 16 years, and data were available for the following variables: prehospital intubation, blood pressure, mode of transportation, and age. The patients were assigned to one of three groups: group 1: 10-50 min (short emergency treatment time); group 2: 51-75 min (intermediate emergency treatment time); group 3: >75 min (long emergency treatment time). A matched-triplet analysis was conducted; matching was based on the following criteria: intubation at the accident site, rescue resources, Abbreviated Injury Scale (AIS) of the body regions, systolic blood pressure, year of the accident, and age. Results A total of 4,617 patients per group could be matched. The number of patients with a GCS score ≤8 was significantly higher in the first group (group 1: 36.6%, group 2: 33.5%, group 3: 30.3%; p < 0.001). Moreover, the number of patients who had to be resuscitated during the prehospital phase and/or upon arrival at the hospital was higher in group 1 (p = 0.010); these patients also had a significantly higher mortality (group 1: 20.4%, group 2: 18.1%, group 3: 15.9%; p ≤ 0.001). The number of measures performed during the prehospital phase (e.g., chest tube insertion) increased with treatment time. Conclusions The results suggest that survival after severe trauma is not only a matter of short rescue time but more a matter of well-used rescue time including performance of vital measures already in the prehospital setting. This also includes that rescue teams identify the severity of injuries more rapidly in the most-severely injured patients in critical condition than in less-severely injured patients and plan their interventions accordingly.
Collapse
|
16
|
Logistics of air medical transport: When and where does helicopter transport reduce prehospital time for trauma? J Trauma Acute Care Surg 2019; 85:174-181. [PMID: 29787553 DOI: 10.1097/ta.0000000000001935] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma is a time sensitive disease. Helicopter emergency medical services (HEMS) have shown benefit over ground emergency medical services (GEMS), which may be related to reduced prehospital time. The distance at which this time benefit emerges depends on many factors that can vary across regions. Our objective was to determine the threshold distance at which HEMS has shorter prehospital time than GEMS under different conditions. METHODS Patients in the Pennsylvania trauma registry 2000 to 2013 were included. Distance between zip centroid and trauma center was calculated using straight-line distance for HEMS and driving distance from geographic information systems network analysis for GEMS. Contrast margins from linear regression identified the threshold distance at which HEMS had a significantly lower prehospital time than GEMS, indicated by nonoverlapping 95% confidence intervals. The effect of peak traffic times and adverse weather on the threshold distance was evaluated. Geographic effects across EMS regions were also evaluated. RESULTS A total of 144,741 patients were included with 19% transported by HEMS. Overall, HEMS became faster than GEMS at 7.7 miles from the trauma center (p = 0.043). Helicopter emergency medical services became faster at 6.5 miles during peak traffic (p = 0.025) compared with 7.9 miles during off-peak traffic (p = 0.048). Adverse weather increased the distance at which HEMS was faster to 17.1 miles (p = 0.046) from 7.3 miles in clear weather (p = 0.036). Significant variation occurred across EMS regions, with threshold distances ranging from 5.4 to 35.3 miles. There was an inverse but non-significant relationship between urban population and threshold distance across EMS regions (ρ, -0.351, p = 0.28). CONCLUSION This is the first study to demonstrate that traffic, weather, and geographic region significantly impact the threshold distance at which HEMS are faster than GEMS. Helicopter emergency medical services was faster at shorter distances during peak traffic while adverse weather increased this distance. The threshold distance varied widely across geographic region. These factors must be considered to guide appropriate HEMS triage protocols. LEVEL OF EVIDENCE Therapeutic, level IV.
Collapse
|
17
|
Weinlich M, Martus P, Blau MB, Wyen H, Walcher F, Piatek S, Schüttrumpf JP. Competitive advantage gained from the use of helicopter emergency medical services (HEMS) for trauma patients: Evaluation of 1724 patients. Injury 2019; 50:1028-1035. [PMID: 30591228 DOI: 10.1016/j.injury.2018.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of the study was to analyze helicopter emergency medical service (HEMS) in comparison to EMS, in respect to patient's mortality and morbidity. DESIGN From a cohort of traumatized patients (n = 1724) prospectively enrolled in the German trauma registry (DGU-R) at Frankfurt University Hospital from 2009 to 2013, 1646 could be analyzed for in-hospital mortality and short-term outcome (GOS) at discharge and compared between HEMS and EMS. MEASUREMENTS AND MAIN RESULTS 129 patients (7.8%) died in the hospital. Unadjusted mortality was significantly lower in the HEMS group compared to EMS (p = 0.001). In a multiple logistic regression analysis after adjustment of variables including reanimation and age as the strongest predictors, in-hospital mortality was significantly reduced in HEMS (p = 0.014, OR = 0.21). Further predictors in the multiple logistic regression analysis were GCS > = 8 (p = 0.001), RRsys (p < 0.001), ISS at Head/Neck > = 3 (p = 0.003), and total ISS > = 9 (p < 0.001). Total rescue time and on scene time were associated with mortality (p < 0.001) but not included in the multiple logistic regression model. Without adjustment, short-term outcome (GOS) was significantly improved (p = 0.014). In a linear model, after adjusting for multiple variables including age, ISS Head/Neck > = 3, ISS Extremities > = 3, GCS > = 8, and RRsys as the strongest predictors (p < 0.001), the association remained significant (p = 0.043). Further predictors in the multiple linear regression analysis were total ISS > = 9 (p = 0.002), ISS abdomen (p = 0.001), and ISS Chest (p = 0.011). CONCLUSIONS A significant improvement for in-hospital survival for HEMS could be demonstrated. Especially in Germany, with a high number of secondary call outs (about 44%) after EMS has already reached the traumatized patient, HEMS must be the first choice for severely injured trauma patients. Dispatch criteria for immediate alarm of HEMS are recommended under practical considerations.
Collapse
Affiliation(s)
- M Weinlich
- University of Magdeburg, Dept. of Trauma Surgery, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - P Martus
- University of Tübingen, Medical Center, Otfried-Müller Str. 10, 72076, Tübingen, Germany
| | - M B Blau
- University of Tübingen, Medical Center, Otfried-Müller Str. 10, 72076, Tübingen, Germany
| | - H Wyen
- University of Frankfurt, Dept. of Traumatology, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - F Walcher
- University of Magdeburg, Dept. of Trauma Surgery, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - S Piatek
- University of Magdeburg, Dept. of Trauma Surgery, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - J P Schüttrumpf
- University of Magdeburg, Dept. of Trauma Surgery, Leipziger Str. 44, 39120, Magdeburg, Germany
| |
Collapse
|
18
|
Pakkanen T, Nurmi J, Huhtala H, Silfvast T. Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome. Scand J Trauma Resusc Emerg Med 2019; 27:9. [PMID: 30691530 PMCID: PMC6350362 DOI: 10.1186/s13049-019-0590-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients. METHODS Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of ≤8) from 2005 to 2010 and 2012-2015 in two study locations were determined. Isolated TBI patients transported directly from the accident scene to the university hospital were included. A modified six-month Glasgow Outcome Score (GOS) was defined as death, unfavourable outcome (GOS 2-3) and favourable outcome (GOS 4-5) and used to assess the neurological outcomes. Binary logistic regression analysis was used to predict mortality and good neurological outcome. The following prognostic variables for TBI were available in the prehospital setting: age, on-scene GCS, hypoxia and hypotension. As per the hypothesis that treatment provided by an on-scene anaesthetist would be beneficial to TBI outcomes, physician was added as a potential predictive factor with regard to the prognosis. RESULTS The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05-1.07), lower on-scene GCS (OR 0.85 CI 0.79-0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20-2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08-14.23). In the secondary analysis lower age (OR 0.95 CI 0.94-0.96), a higher on-scene GCS (OR 1.21 CI 1.20-1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09-2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04-0.82) was associated with poor outcome. CONCLUSION Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.
Collapse
Affiliation(s)
- Toni Pakkanen
- FinnHEMS Ltd, Research and Development Unit, Vantaa, Finland. .,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and Department of Emergency Medicine, University of Helsinki, Helsinki, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Tom Silfvast
- Department of Anaesthesia and Intensive Care, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| |
Collapse
|
19
|
van Niekerk G, Welzel T, Stassen W. Clinical Interventions Account for Scene Time in a Helicopter Emergency Medical Service in South Africa. Air Med J 2018; 37:357-361. [PMID: 30424852 DOI: 10.1016/j.amj.2018.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/15/2018] [Accepted: 07/22/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Helicopter emergency medical services (HEMS) have been associated with a prolonged scene time, compromising the time benefit in an urban setting. Therefore, the clinical benefit offered through additional equipment, skills, and experience of HEMS crews must be investigated to propose the value of HEMS. This study aimed at establishing whether HEMS scene time was associated with the number of clinical interventions performed and improved patient stability. METHOD This retrospective, cross-sectional chart review included all primary HEMS cases from June 1, 2013, to May 31, 2015, from a South African helicopter service and extracted the number of clinical interventions and patient stability using the Mainz Emergency Evaluation Score (MEES). We correlated this with scene time using analysis of variance. RESULTS Five hundred fourteen clinical interventions were performed on 204 patients. A median of 2 clinical interventions per patient was performed on scene. Performing 1 additional clinical intervention was associated with an approximate 4-minute increase in on-scene time. Some improvement in patient stability was shown by a mean change in the MEES of 0.65 after on-scene intervention, but this did not reach MEES clinical cutoff measures. CONCLUSION The number of clinical interventions performed by helicopter crews can account for scene time in a South African HEMS. The clinical interventions performed by helicopter crews tend to have a positive effect on patient stability.
Collapse
Affiliation(s)
- Garth van Niekerk
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Tyson Welzel
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
20
|
Straumann GSH, Austvoll-Dahlgren A, Holte HH, Wisborg T. Effect of requiring a general practitioner at scenes of serious injury: A systematic review. Acta Anaesthesiol Scand 2018; 62:1194-1199. [PMID: 29932207 DOI: 10.1111/aas.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 05/09/2018] [Accepted: 05/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND In Norway, each municipality is responsible for providing first line emergency healthcare, and it is mandatory to have a primary care physician/general practitioner on call continuously. This mandate ensures that a physician can assist patients and ambulance personnel at the site of severe injuries or illnesses. The compulsory presence of the general practitioner at the scene could affect different parts of patient treatment, and it might save resources by obviating resources from secondary healthcare, like pre-hospital anaesthesiologists and other specialized resources. This systematic review aimed to examine how survival, time spent at the scene, the choice of transport destination, assessment of urgency, the number of admissions, and the number of cancellations of specialized pre-hospital resources were affected by the presence of a general practitioner at the scene of a suspected severe injury. METHODS We searched for published and planned systematic reviews and primary studies in the Cochrane Library, Medline, Embase, OpenGrey, GreyLit and trial registries. The search was completed in December 2017. Two individuals independently screened the references and assessed the eligibility of all potentially relevant studies. RESULTS The search for systematic reviews and primary studies identified 5981 articles. However, no studies met the pre-defined inclusion criteria. CONCLUSION No studies met our inclusion criteria; consequently, it remains uncertain how the presence of a general practitioner at the injury scene might affect the selected outcomes.
Collapse
Affiliation(s)
| | | | - H. H. Holte
- Norwegian Institute of Public Health; Oslo Norway
| | - T. Wisborg
- Norwegian National Advisory Unit on Trauma; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo Norway
- Anaesthesia and Critical Care Research Group; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
- Department of Anaesthesiology and Intensive Care; Finnmark Health Trust; Hammerfest Hospital; Hammerfest Norway
| |
Collapse
|
21
|
Pre-hospital rescue times and interventions in severe trauma in Germany and the Netherlands: a matched-pairs analysis. Eur J Trauma Emerg Surg 2018; 45:1059-1067. [DOI: 10.1007/s00068-018-0978-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/03/2018] [Indexed: 11/25/2022]
|
22
|
A Protocol for Helicopter In-Cabin Intubation. Air Med J 2018; 37:306-311. [PMID: 30322633 DOI: 10.1016/j.amj.2018.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 05/07/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The gold standard for prehospital intubation is to avoid intubating in confined spaces. For our helicopter service, this is not always realistic. Operating in a rural region with a subarctic, cold climate, our crews are frequently forced to intubate inside ambulances or in our helicopter. This article describes a protocol for in-cabin intubation and compares it with standard open space conditions. METHODS Fourteen prehospital physicians were randomized to solve a simplified clinical scenario during which they were to intubate a mannequin either inside the helicopter, in accordance with our in-cabin protocol, or outside on an ambulance stretcher. Participants scored intubating conditions using a visual analog scale (VAS) and the Cormack-Lehane classification. The number of intubation attempts was recorded. Three timing end points were also measured. RESULTS All intubations were successful on the first attempt. All participants reported an optimal glottic view of Cormack-Lehane 1 in both scenario conditions. Participants perceived in-cabin intubation to be less difficult than intubating outdoors. (VAS 1 vs. VAS 2, P = .02). We found no difference in the duration of intubation. Scene time was 53.5 seconds (P = .04) shorter in the in-cabin group. In-cabin intubation delayed the establishment of a secure airway by 63 seconds (P = .01). CONCLUSION Our study suggests that protocolized in-cabin intubation can be performed in a timely manner under conditions that are equal to or better than when intubating outside on a stretcher with 360-degree patient access. Although delaying the establishment of a secure airway, in-cabin intubation may reduce scene times.
Collapse
|
23
|
Igarashi Y, Yokobori S, Yamana H, Nagakura K, Hagiwara J, Masuno T, Yokota H. Overview of doctor-staffed ambulance use in Japan: a nationwide survey and 1-week study. Acute Med Surg 2018; 5:316-320. [PMID: 30338076 PMCID: PMC6167388 DOI: 10.1002/ams2.347] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/24/2018] [Indexed: 11/06/2022] Open
Abstract
Aim In Japan, standard prehospital care is provided by emergency medical services teams. Doctor-staffed ambulances play a role in facilitating the immediate treatment of critically ill patients to increase the survival rates. However, little is known about their activities. We revealed the present situation of doctor-staffed ambulances in Japan. Methods First, we surveyed all the fire departments in Japan and determined whether a doctor-staffed ambulance was present within their district boundary. Second, we surveyed hospitals that operate doctor-staffed ambulances in their system to list their activities during a 1-week period. Results Of 133 hospitals that operated a doctor-staffed ambulance, 73 (55%) replied to our questionnaire. Only 26 (36%) of them provided 24-h ambulance deployment. Additionally, 51 (70%) of hospitals bore the operational costs of ambulances. Within 1 week, 345 doctor-staffed ambulances were dispatched, but 97 (28%) were cancelled. In total, 62 patients (28%) were diagnosed with cardiac arrest, 48 (19%) with trauma or burns, 36 (15%) with stroke, and 22 (9%) with acute coronary syndrome; 159 (58%) were transferred to a tertiary emergency medical center. Conclusions Doctor-staffed ambulances have the advantage of deployment at night and in urban areas compared to doctor-staffed helicopters. Among the 73 hospitals that responded to the questionnaire, doctor-staffed ambulances were dispatched almost as frequently as doctor-staffed helicopters. However, doctor-staffed ambulances did not receive adequate funding. Future data collection is necessary to determine the efficacy of doctor-staffed ambulances among hospitals that operate this service.
Collapse
Affiliation(s)
- Yutaka Igarashi
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Hidetoshi Yamana
- Emergency Department Tsukuba Medical Center Hospital Tsukuba Japan
| | | | - Jun Hagiwara
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| |
Collapse
|
24
|
Duke M, Tatum D, Sexton K, Stuke L, Robertson R, Sutherland M, Tyroch A, Agrawal V, Duchesne J. When Minutes Fly by: What is the True “Golden Hour” for Air Care? Am Surg 2018. [DOI: 10.1177/000313481808400633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Air transport was developed to hasten patient transport based on the “golden hour” belief that delayed care leads to poorer outcome. The primary aim of our study was to identify the critical inflection point of increased nonsurvivors on total prehospital time. This was a multicenter review of adult trauma patients transported by air between November 2014 and August 2015. Primary outcome of interest was all-cause inhospital mortality. Total helicopter emergency medical services times of nonsurvivors were plotted to visualize the distribution of prehospital time. Of 636 patients included, 71 per cent were male and 86 per cent suffered blunt trauma. Among non-survivors, mortality doubled once total helicopter emergency medical services time exceeded 30 minutes (P < 0.001). Nonsurvivors presented with significantly lower median [interquartile range (IQR)] Glasgow Coma Score compared with survivors [3 (3–13) vs 15 (12–15), respectively; P < 0.001] as well as a significantly higher median (IQR) Injury Severity Score [26 (19–41) vs 12 (5–22); P < 0.001], increased incidence of penetrating mechanism of injury [21 vs 8%; P = 0.002], and higher median (IQR) shock index [0.84 (0.63–1.06) vs 0.71 (0.6–0.87); P = 0.023]. We identified an inflection point of doubling in mortality after 30 minutes. This suggests a possible threshold effect between time and mortality in severely injured patients. Revised field criteria for determining which injured patients would most benefit from helicopter transport are needed.
Collapse
Affiliation(s)
| | - Danielle Tatum
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
| | - Kevin Sexton
- University of Arkansas Medical Center, Little Rock, Arkansas
| | - Lance Stuke
- Louisiana State University Medical Center, New Orleans, Louisiana
| | | | | | - Alan Tyroch
- Texas Tech University Health Science Center, Lubbock, Texas
| | | | | |
Collapse
|
25
|
Gałązkowski R, Farkowski MM, Rabczenko D, Marciniak-Emmons M, Darocha T, Timler D, Sterliński M. Additional data from clinical examination on site significantly but marginally improve predictive accuracy of the Revised Trauma Score for major complications during Helicopter Emergency Medical Service missions. Arch Med Sci 2018; 14:865-870. [PMID: 30002706 PMCID: PMC6040125 DOI: 10.5114/aoms.2016.61884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The Revised Trauma Score (RTS) accurately identifies trauma patients at high risk of adverse events or death. Less is known about its usefulness in the general population and non-trauma recipients of Helicopter Emergency Medical Service (HEMS). The RTS is a simple tool and omits a lot of other data obtained during clinical evaluation. The aim was to assess the role of the RTS to identify patients at risk of major complications (death, cardiopulmonary resuscitation, defibrillation, intubation) in the general population of HEMS patients. Clinical factors beyond the RTS were analyzed to identify additional prognostic factors for predicting major complications. MATERIAL AND METHODS A retrospective analysis of medical records of adult patients routinely collected during HEMS missions in the years 2011-2014 was performed. RESULTS The analysis included 19 554 HEMS missions. Patients were 55 ±20 years old and 68% were male. The most common indication for HEMS was diseases of the circulatory system - 41%. Major complications occurred in 2072 (10.6%) cases. In the general population of HEMS patients, the RTS accurately identified individuals at risk of major complications at a cut-off value of 10.5 and area under the curve (AUC) of 93.5%. In multivariate analysis, additional clinical data derived from clinical examination (ECG; skin, pupil and breathing examination) significantly but marginally improved the accuracy of RTS assessment: AUC 95.6% (p < 0.001 for the difference). CONCLUSIONS The Revised Trauma Score accurately identifies individuals at risk of major complications during HEMS missions regardless of the indication. Additional clinical data significantly but marginally improved the accuracy of RTS in the general population of HEMS patients.
Collapse
Affiliation(s)
- Robert Gałązkowski
- Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
| | - Michał M. Farkowski
- Second Department of Coronary Artery Disease, Institute of Cardiology, Warsaw, Poland
| | - Daniel Rabczenko
- Department for Monitoring and Analysis of Population Health Status, National Institute of Public Health – National Institute of Hygiene, Warsaw, Poland
| | | | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, John Paul II Hospital, Medical College Jagiellonian University, Krakow, Poland
- Polish Medical Air Rescue, Krakow, Poland
| | - Dariusz Timler
- Department of Emergency Medicine and Disaster Medicine, Medical University of Lodz, Lodz, Poland
| | - Maciej Sterliński
- Second Department of Coronary Artery Disease, Institute of Cardiology, Warsaw, Poland
| |
Collapse
|
26
|
Abstract
IntroductionAccording to Ontario, Canada's Basic Life Support Patient Care Standards, Emergency Medical Services (EMS) on-scene time (OST) for trauma calls should not exceed 10 minutes, unless there are extenuating circumstances. The time to definitive care can have a significant impact on the morbidity and mortality of trauma patients. This is the first Canadian study to investigate why this is the case by giving a voice to those most involved in prehospital care: the paramedics themselves. It is also the first study to explore this issue from a complex, adaptive systems approach which recognizes that OSTs may be impacted by local, contextual features.ProblemResearch addressed the following problem: what are the facilitators and barriers to achieving 10-minute OSTs? METHODS This project used a descriptive, qualitative design to examine facilitators and barriers to achieving 10-minute OSTs on trauma calls, from the perspective of paramedics. Paramedics from a regional Emergency Services organization were interviewed extensively over the course of one year, using qualitative interviewing techniques developed by experts in that field. All interviews were recorded, transcribed, and entered into NVivo for Mac (QSR International; Victoria, Australia) software that supports qualitative research, for ease of data analysis. Researcher triangulation was used to ensure credibility of the data. RESULTS Thirteen percent of the calls had OSTs that were less than 10 minutes. The following six categories were outlined by the paramedics as impacting the duration of OSTs: (1) scene characteristics; (2) the presence and effectiveness of allied services; (3) communication with dispatch; (4) the paramedics' ability to effectively manage the scene; (5) current policies; and (6) the quantity and design of equipment. CONCLUSION These findings demonstrate the complexity of the prehospital environment and bring into question the feasibility of the 10-minute OST standard. LevitanM, LawMP, FerronR, Lutz-GraulK. Paramedics' perspectives on factors impacting on-scene times for trauma calls. Prehosp Disaster Med. 2018;33(3):250-255.
Collapse
|
27
|
Thomas SH, Blumen I. Helicopter Emergency Medical Services Literature 2014 to 2016: Lessons and Perspectives, Part 1-Helicopter Transport for Trauma. Air Med J 2018; 37:54-63. [PMID: 29332779 DOI: 10.1016/j.amj.2017.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/30/2017] [Indexed: 11/30/2022]
|
28
|
Cardoso RG, Francischini CF, Ribera JM, Vanzetto R, Fraga GP. Helicopter emergency medical rescue for the traumatized: experience in the metropolitan region of Campinas, Brazil. Rev Col Bras Cir 2016; 41:236-44. [PMID: 25295983 DOI: 10.1590/0100-69912014004003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 12/20/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze the profile of patients served by the air medical rescue system in the Metropolitan Region of Campinas, evaluating: triage and mobilization criteria; response time; on-site care and transport time; invasive procedures performed in the Pre-Hospital Care (PHC); severity of patients; morbidity and mortality. METHODS We conducted a prospective, descriptive study in which we analyzed medical records of patients rescued between July 2010 and December 2012. During this period, 242 victims were taken to the HC-Unicamp. Of the 242 patients, 22 were excluded from the study. RESULTS of the 220 cases evaluated, 173 (78.6%) were male, with a mean age of 32 years. Blunt trauma was the most prevalent (207 cases - 94.1%), motorcycle accidents being the most common mechanisms of injury (66 cases - 30%), followed by motor vehicle collisions (51 cases - 23.2%). The average response time was 10 ± 4 minutes and the averaged total pre-hospital time was 42 ± 11 minutes. The mean values of the trauma indices were: RTS = 6.2 ± 2.2; ISS = 19.2 ± 12.6; and TRISS = 0.78 ± 0.3. Tracheal intubation in the pre-hospital environment was performed in 77 cases (35%); 43 patients (19.5%) had RTS of 7.84 and ISSd"9, being classified as over-triaged. Of all patients admitted, the mortality was 15.9% (35 cases). CONCLUSION studies of air medical rescue in Brazil are required due to the investments made in the pre-hospital care in a country without an organized trauma system. The high rate of over-triage found highlights the need to improve the triage and mobilization criteria.
Collapse
Affiliation(s)
| | | | | | | | - Gustavo Pereira Fraga
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| |
Collapse
|
29
|
On-scene Times for Inter-facility Transport of Patients with Hypoxemic Respiratory Failure. Prehosp Disaster Med 2016; 31:267-71. [PMID: 27018912 DOI: 10.1017/s1049023x16000315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Introduction Inter-facility transport of critically ill patients is associated with a high risk of adverse events, and critical care transport (CCT) teams may spend considerable time at sending institutions preparing patients for transport. The effect of mode of transport and distance to be traveled on on-scene times (OSTs) has not been well-described. Problem Quantification of the time required to package patients and complete CCTs based on mode of transport and distance between facilities is important for hospitals and CCT teams to allocate resources effectively. METHODS This is a retrospective review of OSTs and transport times for patients with hypoxemic respiratory failure transported from October 2009 through December 2012 from sending hospitals to three tertiary care hospitals. Differences among the OSTs and transport times based on the mode of transport (ground, rotor wing, or fixed wing), distance traveled, and intra-hospital pick-up location (emergency department [ED] vs intensive care unit [ICU]) were assessed. Correlations between OSTs and transport times were performed based on mode of transport and distance traveled. RESULTS Two hundred thirty-nine charts were identified for review. Mean OST was 42.2 (SD=18.8) minutes, and mean transport time was 35.7 (SD=19.5) minutes. On-scene time was greater than en route time for 147 patients and greater than total trip time for 91. Mean transport distance was 42.2 (SD=35.1) miles. There were no differences in the OST based on mode of transport; however, total transport time was significantly shorter for rotor versus ground, (39.9 [SD=19.9] minutes vs 54.2 [SD=24.7] minutes; P <.001) and for rotor versus fixed wing (84.3 [SD=34.2] minutes; P=0.02). On-scene time in the ED was significantly shorter than the ICU (33.5 [SD=15.7] minutes vs 45.2 [SD=18.8] minutes; P <.001). For all patients, regardless of mode of transportation, there was no correlation between OST and total miles travelled; although, there was a significant correlation between the time en route and distance, as well as total trip time and distance. CONCLUSIONS In this cohort of critically ill patients with hypoxemic respiratory failure, OST was over 40 minutes and was often longer than the total trip time. On-scene time did not correlate with mode of transport or distance traveled. These data can assist in planning inter-facility transports for both the sending and receiving hospitals, as well as CCT services. Wilcox SR , Saia MS , Waden H , McGahn SJ , Frakes M , Wedel SK , Richards JB . On-scene times for inter-facility transport of patients with hypoxemic respiratory failure. Prehosp Disaster Med. 2016;31(3):267-271.
Collapse
|
30
|
Rubenson Wahlin R, Ponzer S, Lövbrand H, Skrivfars M, Lossius HM, Castrén M. Do male and female trauma patients receive the same prehospital care?: an observational follow-up study. BMC Emerg Med 2016; 16:6. [PMID: 26787192 PMCID: PMC4717583 DOI: 10.1186/s12873-016-0070-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 01/06/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Trauma-related mortality can be lowered by efficient prehospital care. Less is known about whether gender influences the prehospital trauma care provided. The aim of this study was to explore gender-related differences in prehospital trauma care of severely injured trauma patients, with a special focus on triage, transportation, and interventions. METHODS We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County, Sweden. A total of 383 trauma patients (279 males and 104 females) > 15 years of age with an Injury Severity Score (ISS) of > 15 transported to emergency care hospitals in the Stockholm area were included. RESULTS Male patients had a 2.75 higher odds ratio (95 % CI, 1.2-6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. No significant difference between genders was detected regarding other aspects of the prehospital care provided. CONCLUSIONS This study indicated that prehospital prioritization among severely injured late adolescent and adult trauma patients differs between genders. Knowledge of a more diffuse presentation of symptoms in female trauma patients despite severe injury may help to adapt and improve prehospital trauma care for this group.
Collapse
Affiliation(s)
- Rebecka Rubenson Wahlin
- />Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, SE-118 83 Stockholm, Sweden
- />Department of Anesthesia and Intensive Care, Södersjukhuset, SE-118 83 Stockholm, Sweden
| | - Sari Ponzer
- />Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, SE-118 83 Stockholm, Sweden
| | - Hanna Lövbrand
- />Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, SE-118 83 Stockholm, Sweden
| | - Markus Skrivfars
- />Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hans Morten Lossius
- />Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, SE-118 83 Stockholm, Sweden
- />Field of Prehospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, NO-4036 Stavanger, Norway
| | - Maaret Castrén
- />Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, SE-118 83 Stockholm, Sweden
- />Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
31
|
Galvagno Jr SM, Sikorski R, Hirshon JM, Floccare D, Stephens C, Beecher D, Thomas S. Helicopter emergency medical services for adults with major trauma. Cochrane Database Syst Rev 2015; 2015:CD009228. [PMID: 26671262 PMCID: PMC8627175 DOI: 10.1002/14651858.cd009228.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured people derive the greatest benefit. OBJECTIVES To determine if helicopter emergency medical services (HEMS) transport, compared with ground emergency medical services (GEMS) transport, is associated with improved morbidity and mortality for adults with major trauma. SEARCH METHODS We ran the most recent search on 29 April 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE (OvidSP), EMBASE Classic + EMBASE (OvidSP), CINAHL Plus (EBSCOhost), four other sources, and clinical trials registers. We screened reference lists. SELECTION CRITERIA Eligible trials included randomized controlled trials (RCTs) and nonrandomized intervention studies. We also evaluated nonrandomized studies (NRS), including controlled trials and cohort studies. Each study was required to have a GEMS comparison group. An Injury Severity Score (ISS) of at least 15 or an equivalent marker for injury severity was required. We included adults age 16 years or older. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and assessed the risk of bias of included studies. We applied the Downs and Black quality assessment tool for NRS. We analyzed the results in a narrative review, and with studies grouped by methodology and injury type. We constructed 'Summary of findings' tables in accordance with the GRADE Working Group criteria. MAIN RESULTS This review includes 38 studies, of which 34 studies examined survival following transportation by HEMS compared with GEMS for adults with major trauma. Four studies were of inter-facility transfer to a higher level trauma center by HEMS compared with GEMS. All studies were NRS; we found no RCTs. The primary outcome was survival at hospital discharge. We calculated unadjusted mortality using data from 282,258 people from 28 of the 38 studies included in the primary analysis. Overall, there was considerable heterogeneity and we could not determine an accurate estimate of overall effect.Based on the unadjusted mortality data from six trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS. Twenty-one studies used multivariate regression to adjust for confounding. Results varied, some studies found a benefit of HEMS while others did not. Trauma-Related Injury Severity Score (TRISS)-based analysis methods were used in 14 studies; studies showed survival benefits in both the HEMS and GEMS groups as compared with MTOS. We found no studies evaluating the secondary outcome, morbidity, as assessed by quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). Four studies suggested a small to moderate benefit when HEMS was used to transfer people to higher level trauma centers. Road traffic and helicopter crashes are adverse effects which can occur with either method of transport. Data regarding safety were not available in any of the included studies. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria. AUTHORS' CONCLUSIONS Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, we could not determine an accurate composite estimate of the benefit of HEMS. Although some of the 19 multivariate regression studies indicated improved survival associated with HEMS, others did not. This was also the case for the TRISS-based studies. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their nonrandomized design. The question of which elements of HEMS may be beneficial has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximize the potential utility of results. Large, multicenter studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.
Collapse
Affiliation(s)
- Samuel M Galvagno Jr
- University of Maryland School of Medicine, Division of Trauma Anesthesiology, Program in Trauma, R Adams Cowley Shock Trauma CenterDepartment of AnesthesiologyBaltimoreMDUSA21201
| | - Robert Sikorski
- University of Maryland School of Medicine, Division of Trauma Anesthesiology, Program in Trauma, R Adams Cowley Shock Trauma CenterDepartment of AnesthesiologyBaltimoreMDUSA21201
| | - Jon M Hirshon
- University of Maryland School of MedicineDepartment of Emergency MedicinePaca‐Pratt Building110 S. Paca Street, 4S‐127BaltimoreMarylandUSA21201‐1559
| | - Douglas Floccare
- Maryland Institute for Emergency Medical Services Systems653 W Pratt StreetBaltimoreMDUSA21201
| | - Christopher Stephens
- R. Adams Cowley Shock Trauma Center, University of MarylandTrauma AnaesthesiologyDepartment of AnesthesiologyBaltimoreMDUSA21201
| | - Deirdre Beecher
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupKeppel StreetLondonUKWC1E 7HT
| | - Stephen Thomas
- Hamad General Hospital & Weill Cornell Medical College in QatarDepartment of Emergency MedicineDohaQatar
| | | |
Collapse
|
32
|
PAKKANEN T, VIRKKUNEN I, SILFVAST T, RANDELL T, HUHTALA H, YLI-HANKALA A. One-year outcome after prehospital intubation. Acta Anaesthesiol Scand 2015; 59:524-30. [PMID: 25790242 DOI: 10.1111/aas.12483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 01/05/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of physician staffed emergency medical services (EMS) is to supplement other EMS units in the care of prehospital patients. The need for advanced airway management in critical prehospital patients can be considered as one indicator of the severity of the patient's condition. Our primary aim was to study the long-term outcome of critically ill patients (excluding cardiac arrest) who were intubated by EMS physicians in the prehospital setting. METHODS Data of 845 patients, whose airways were secured by the EMS physicians during a 5-year (2007-2011) period, were retrospectively evaluated. After exclusions, the outcome of 483 patients (8.9% of all patients treated by EMS) was studied. Evaluation was based on hospital patient records 1 year after the incident. For assessment of neurological outcome, a modified Glasgow Outcome Score (GOS) was used. Time and cause of death were recorded. RESULTS 55.3% of the study patients had a good neurological recovery (GOS 4-5) with independent life 1 year after the event. The overall 1-year mortality (GOS 1) was 35.0%. Poor neurological outcome (GOS 2-3) was found in 9.7% of the patients. Patients with intoxication or convulsions survived best, while those with suspected intracranial pathology had the worst prognosis. Of all survivors, 85% recovered well. CONCLUSION The majority of the study patients had a favourable neurological recovery with independent life at 1 year after the incident. More than 80% of all deaths occurred within 30 days of the incident.
Collapse
Affiliation(s)
- T. PAKKANEN
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
- Tays Emergency Medical Service; Tampere University Hospital; Tampere Finland
| | - I. VIRKKUNEN
- Tays Emergency Medical Service; Tampere University Hospital; Tampere Finland
| | - T. SILFVAST
- Department of Anaesthesia and Intensive Care; Helsinki University Hospital; University of Helsinki; Helsinki Finland
| | - T. RANDELL
- Department of Anaesthesia and Intensive Care; Helsinki University Hospital; University of Helsinki; Helsinki Finland
| | - H. HUHTALA
- School of Health Sciences; University of Tampere; Tampere Finland
| | - A. YLI-HANKALA
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
- Medical School; University of Tampere; Tampere Finland
| |
Collapse
|
33
|
Harmsen AMK, Giannakopoulos GF, Moerbeek PR, Jansma EP, Bonjer HJ, Bloemers FW. The influence of prehospital time on trauma patients outcome: a systematic review. Injury 2015; 46:602-9. [PMID: 25627482 DOI: 10.1016/j.injury.2015.01.008] [Citation(s) in RCA: 233] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/05/2015] [Accepted: 01/07/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the 'golden hour', the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients. METHODS A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality. RESULTS Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury. CONCLUSION Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.
Collapse
Affiliation(s)
- A M K Harmsen
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands.
| | | | - P R Moerbeek
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands
| | - E P Jansma
- Medical Library, VU university Medical Center, Amsterdam, The Netherlands
| | - H J Bonjer
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands
| | - F W Bloemers
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
34
|
Andrew E, de Wit A, Meadley B, Cox S, Bernard S, Smith K. Characteristics of Patients Transported by a Paramedic-staffed Helicopter Emergency Medical Service in Victoria, Australia. PREHOSP EMERG CARE 2015; 19:416-24. [PMID: 25689322 DOI: 10.3109/10903127.2014.995846] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The optimal staffing of helicopter emergency medical services (HEMS) is uncertain. An intensive care paramedic-staffed HEMS has operated in the state of Victoria, Australia for over 28 years, with paramedics capable of performing advanced procedures, including rapid sequence intubation, decompression of tension pneumothorax, and cricothyroidotomy. Administration of a wide range of vasoactive, anesthetic, and analgesic medications is also permitted. We sought to explore the characteristics of patients transported by HEMS in Victoria, and describe paramedic utilization of their skill set in the prehospital environment. METHODS A retrospective data review was conducted of patients transported by the HEMS between 1 July 2012 and 30 June 2013. Data were sourced from the Ambulance Victoria data warehouse and the Victorian State Trauma Registry. Interhospital transfers were excluded. RESULTS HEMS attended 1,519 cases during the study period. A total of 825 primary transport cases were included in analyses. Most patients were male (69.5%) and the majority of cases involved trauma (86.1%). Rapid sequence intubation (RSI) was performed in 36.8% of pediatric and 29.9% of adult major trauma patients, with a procedural success rate of 100%. Ketamine was administered to 18.5% of all trauma patients. The proportion of patients with a severe pain score (≥7) decreased from 33.8 to 3.2% (p < 0.001) between initial and final paramedic assessments. A clinically significant pain reduction of ≥2 points was achieved by 87.0% (95% CI 82.9-90.4%) of adult trauma patients who had an initial pain score >2 points and a valid final pain score. In-hospital mortality following major-trauma was 7.6% (95% CI 5.0-11.0%). CONCLUSIONS The skill set of HEMS intensive care paramedics in Victoria is broad, including a large number of prehospital critical care procedures commonly utilized by physician-staffed HEMS in other jurisdictions. A high RSI procedural success rate was observed across the study period, as were significant improvements in patient physiological parameters and pain scores.
Collapse
|
35
|
Stewart CL, Metzger RR, Pyle L, Darmofal J, Scaife E, Moulton SL. Helicopter versus ground emergency medical services for the transportation of traumatically injured children. J Pediatr Surg 2015; 50:347-52. [PMID: 25638635 DOI: 10.1016/j.jpedsurg.2014.09.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS). METHODS We queried trauma registries of two level 1 pediatric trauma centers for children 0-17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time. RESULTS We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%-53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS<10 and hospitalization<1 day. CONCLUSIONS HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children.
Collapse
Affiliation(s)
- Camille L Stewart
- University of Colorado School of Medicine, Department of Surgery, 12631 E. 17th Ave, C302, Aurora, CO 80045; Children's Hospital Colorado, Division of Pediatric Surgery, 13123 E. 16th Ave, B232, Aurora, CO 80045.
| | - Ryan R Metzger
- Primary Children's Hospital, Division of Pediatric Surgery, 100 N Mario Capecchi Dr, Suite 2600, Salt Lake City, UT 84113.
| | - Laura Pyle
- University of Colorado School of Medicine, Department of Pediatrics, 13001 E. 17th Place, C290, Aurora, CO 80045.
| | - Joe Darmofal
- Children's Hospital Colorado, Department of Transport & EMS Outreach and Education, 13123 E. 16th Ave, B245, Aurora, CO 80045.
| | - Eric Scaife
- Primary Children's Hospital, Division of Pediatric Surgery, 100 N Mario Capecchi Dr, Suite 2600, Salt Lake City, UT 84113.
| | - Steven L Moulton
- University of Colorado School of Medicine, Department of Surgery, 12631 E. 17th Ave, C302, Aurora, CO 80045; Children's Hospital Colorado, Division of Pediatric Surgery, 13123 E. 16th Ave, B232, Aurora, CO 80045.
| |
Collapse
|
36
|
Mohan HM, Mullan D, McDermott F, Whelan RJ, O'Donnell C, Winter DC. Saving lives, limbs and livelihoods: considerations in restructuring a national trauma service. Ir J Med Sci 2014; 184:659-66. [PMID: 25481642 DOI: 10.1007/s11845-014-1234-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 11/22/2014] [Indexed: 01/11/2023]
Abstract
STUDY HYPOTHESIS Level 1 trauma centers reduce mortality and improve functional outcomes in major trauma. Despite this, many countries, including Ireland, do not have officially designated major trauma centers (MTC). This study aimed to examine international trauma systems, and determine how to "best fit" trauma care in a small country (Ireland) to international models. METHODS The literature was reviewed to examine international models of trauma systems. An estimate of Irish trauma burden and distribution was made using data from the Road Safety Authority (RSA) on serious or fatal RTAs. Models of a restructured trauma service were constructed and compared with international best practice. RESULTS Internationally, a major trauma center surrounded by a regional trauma network has emerged as the gold standard in trauma care. In Ireland, there are no nationally coordinated trauma networks and care is provided by 26 acute hospitals with a mean distance to hospital from RTAs of 20.6 km ± 15.6. Based on our population, Ireland needs two Level 1 MTCs (in the two areas of major population density in the east and south), with robust surrounding trauma networks including Level 2 or 3 trauma centers. With this model, the estimated mean number of cases per Level 1 MTC per year would be 628, with a mean distance to MTC of 80.5 ± 59.2 km, (maximum distance 263.5 km). CONCLUSION Clearly designated and adequately resourced MTCs with trauma networks are needed to improve trauma outcomes, with concomitant investment in pre-hospital infrastructure.
Collapse
Affiliation(s)
- H M Mohan
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, 4, Ireland,
| | | | | | | | | | | |
Collapse
|
37
|
Timm A, Maegele M, Lefering R, Wendt K, Wyen H. Pre-hospital rescue times and actions in severe trauma. A comparison between two trauma systems: Germany and the Netherlands. Injury 2014; 45 Suppl 3:S43-52. [PMID: 25284234 DOI: 10.1016/j.injury.2014.08.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to compare the effect of national pre-hospital rescue strategies on the status of severely injured patients at the time of admission to a Trauma Center (TC) in Germany or the Netherlands. PATIENTS AND METHODS This retrospective database analysis based on the TraumaRegister DGU(®) (TR-DGU) of the German Trauma Society compares the pre-hospital trauma system of Germany with three Trauma Centers (TCs) from the Netherlands. It comprises trauma patients from 2009 to 2012 admitted to a Level I TC, all patients aged 16-80 years primarily admitted with an ISS ≥ 16 and data available for mode of transport, pre-hospital measures and total pre-hospital time. Additionally three subgroups were formed by mode of transportation and involved personnel: Ambulance/Physician, Helicopter/Physician, Ambulance/EMT. Primary endpoint is the patient's status at the time of admission to the trauma room. Secondary endpoint is hospital mortality. RESULTS A total of 12,168 patients met the inclusion criteria. Major differences in the injury patterns, pre-hospital rescue time, transport strategy and actions are documented. The mean ISS in the German overall group was 28.6 ± 12.2 compared to 27.4 ± 12.8 in the Dutch overall group. In the subgroups the highest injury severity with 29.8 ± 12.7 for German patients and 31.0 ± 14.6 for Dutch patients was found in the Helicopter/Physician subgroups and the lowest in patients transported by ambulance under emergency medical technician (EMT) care i.e. 24.2 ± 8.9 for German patients and 23.6 ± 10.3 for Dutch patients. The mean total pre-hospital time for patients admitted to Dutch TCs of 53.8 ± 28.7 min was 15.1 min shorter than for patients transported to German TCs 68.7 ± 28.6 min. The overall mean pre-hospital volume replacement of 1103 ± 821 ml for German patients was about twice as high as for Dutch patients (541 ± 700 ml). In physician led subgroups in the Netherlands higher rates of intubation, catecholamine administration and chest tubes are recorded. The basic vital signs from on-scene to hospital admission did not show relevant changes. Additional parameters available in the trauma room revealed a lower mean Base Excess (BE) for Dutch patients and a diminished mean prothrombin ratio for German patients. No reliable evidence was found that differences in the mortality analysis resulted from different national pre-hospital strategy. CONCLUSIONS Many differences in the national pre-hospital strategy were demonstrated but the effect on patient's status at the time of admission to trauma room remains unclear. A follow-up study, which mitigates the now known injury patterns has to be initiated to further substantiate the findings of this study.
Collapse
Affiliation(s)
- Alexander Timm
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre (CMMC), Ostmerheimer Str. 200, 51109 Cologne, Germany.
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre (CMMC), Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostermerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Klaus Wendt
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Hendrik Wyen
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | | |
Collapse
|
38
|
Abstract
INTRODUCTION The aim of this study was to determine the effect of prehospital time and advanced trauma life support interventions for trauma patients transported to an Iranian Trauma Center. METHODS This study was a retrospective study of trauma victims presenting to a trauma center in central Iran by Emergency Medical Services (EMS) and hospitalized more than 24 hours. Demographic and injury characteristics were obtained, including accident location, damaged organs, injury mechanism, injury severity score, prehospital times (response, scene, and transport), interventions and in-hospital outcome. RESULTS Two thousand patients were studied with an average age of 36.3 (SD = 20.8) years; 83.1% were male. One hundred twenty patients (6.1%) died during hospitalization. The mean response time, at scene time and transport time were 6.6 (SD = 3), 11.1 (SD = 5.2) and 12.8 (SD = 9.4), respectively. There was a significant association of longer transport time to worse outcome (P = .02). There was a trend for patients with transport times >10 minutes to die (OR: 0.8; 95% CI, 0.1-6.59). Advanced Life Support (ALS) interventions were applied for patients with severe injuries (Revised Trauma Score ⩽7) and ALS intervention was associated with more time on scene. There was a positive association of survival with ALS interventions applied in suburban areas (P = .001). CONCLUSION In-hospital trauma mortality was more common for patients with severe injuries and long prehospital transport times. While more severely injured patients received ALS interventions and died, these interventions were associated with positive survival trends when conducted in suburban and out-of-city road locations with long transport times.
Collapse
|
39
|
Gries A, Lenz W, Stahl P, Spiess R, Luiz T. [On-scene times for helicopter services. Influence of central dispatch center strategy]. Anaesthesist 2014; 63:555-62. [PMID: 24962365 DOI: 10.1007/s00101-014-2340-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 04/17/2014] [Accepted: 04/27/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Previous studies have suggested that when using several emergency systems and air rescue prehospital and on-scene times are extended, depending on the dispatch strategy. Emergency medical services (EMS) in Germany are delivered by ambulances (AMB) staffed by paramedics alone or with physicians (EMD) and by helicopter emergency medical services (HEMS) always staffed by both. The advantages of HEMS in countries with short transport distances and high hospital density are controversial. The best dispatching strategy for HEMS has not been determined OBJECTIVE The BoLuS study in the German state of Hessen was designed to evaluate the influence of dispatch strategy on prehospital times for responses involving both HEMS and EMS. METHODS Rescue responses involving HEMS were prospectively evaluated in 12 regions of Hessen from July 2010 to September 2011. Although all regions had access to HEMS, only one had its own service. Data from both central dispatch centers and helicopter services were collected and combined to calculate the on-scene time (OST) and correlate it with dispatch strategy. RESULTS A total of 2111 emergency interventions were evaluated. Internal medicine emergencies accounted for 42.9 % of cases and trauma for 36.7 %. Just one patient was involved in 87.9 % of rescues. Two services were involved in 65.3 % of rescues and three or more in 31.5 %. The most common dispatch categories were initial dispatch of EMS and HEMS (50.6 %), initial dispatch of EMS with later request for HEMS (19.7 %) and initial dispatch of both EMS and EMD with later request for HEMS (17.4 %). The OST for these categories were 31.0 ± 13.7 min, 43.7 ± 16.2 min and 54.6 ± 21.3 min (p < 0.01), respectively. CONCLUSION OST varies significantly depending on the number of EMS involved and the dispatch strategy. Sequential dispatching of ground and later HEMS wastes time. Getting an emergency physician to the scene as quickly as possible, reducing transport time to an appropriate hospital and caring for more complex emergencies are the main indications for HEMS. If HEMS appears likely to be needed, it should be dispatched immediately.
Collapse
Affiliation(s)
- A Gries
- Zentrale Notaufnahme/Notaufnahmestation, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland,
| | | | | | | | | | | |
Collapse
|
40
|
Al-Thani H, El-Menyar A, Latifi R. Prehospital versus Emergency Room Intubation of Trauma Patients in Qatar: A-2-year Observational Study. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2014; 6:12-8. [PMID: 24678471 PMCID: PMC3938867 DOI: 10.4103/1947-2714.125855] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The impact of prehospital intubation (PHI) in improving outcome of trauma patients has not been adequately evaluated in the developing countries. Aims: The present study analyzed the outcome of PHI versus emergency room intubation (ERI) among trauma patients in Qatar. Materials and Methods: Data were retrospectively reviewed for all intubated trauma patients between 2010 and 2011. Patients were classified according to location of intubation (PHI: Group-1 versus ERI: Group-2). Data were analyzed and compared. Results: Out of 570 intubated patients; 482 patients (239 in group-1 and 243 in group-2) met the inclusion criteria with a mean age of 32 14.6 years Head injury (P = 0.003) and multiple trauma (P = 0.004) were more prevalent in group-1, whereas solid organ injury predominated in group-2 (P = 0.02). Group-1 had significantly higher mean injury severity scoring (ISS), lower Glasgow coma scale (GCS), greater head abbreviated injury score and longer activation, response, scene and total emergency medical services times. The mortality was higher in group-1 (53% vs. 18.5%; P = 0.001). Multivariate analysis showed that GCS [odds ratio (OR) 0.78, P = 0.005) and ISS (OR 1.12, P = 0.001) were independent predictors of mortality. Conclusions: PHI is associated with high mortality when compared with ERI. However, selection bias cannot be ruled out and therefore, PHI needs further critical assessment in Qatar.
Collapse
Affiliation(s)
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Rifat Latifi
- Department of Surgery, Hamad General Hospital, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar ; Department of Surgery, Arizona University, Tucson, Arizona, USA
| |
Collapse
|
41
|
Falk AC, Alm A, Lindström V. Has increased nursing competence in the ambulance services impacted on pre-hospital assessment and interventions in severe traumatic brain-injured patients? Scand J Trauma Resusc Emerg Med 2014; 22:20. [PMID: 24641814 PMCID: PMC3994652 DOI: 10.1186/1757-7241-22-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 03/07/2014] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Trauma is one of the most common causes of morbidity and mortality in modern society, and traumatic brain injuries (TBI) are the single leading cause of mortality among young adults. Pre-hospital acute care management has developed during recent years and guidelines have shown positive effects on the pre-hospital treatment and outcome for patients with severe traumatic brain injury. However, reports of impacts on improved nursing competence in the ambulance services are scarce. Therefore, the aim of this study was to investigate if increased nursing competence level has had an impact on pre-hospital assessment and interventions in severe traumatic brain-injured patients in the ambulance services. METHOD A retrospective study was conducted. It included all severe TBI patients (>15 years of age) with a Glasgow Coma Score (GCS) of less than eight measured on admission to a level one trauma centre hospital, and requiring intensive care (ICU) during the years 2000-2009. RESULTS 651 patients were included, and between the years 2000-2005, 395 (60.7%) severe TBI patients were injured, while during 2006-2009, there were 256 (39.3%) patients. The performed assessment and interventions made at the scene of the injury and the mortality in hospital showed no significant difference between the two groups. However, the assessment of saturation was measured more frequently and length of stay in the ICU was significantly less in the group of TBI patients treated between 2006-2009. CONCLUSION Greater competence of the ambulance personnel may result in better assessment of patient needs, but showed no impact on performed pre-hospital interventions or hospital mortality.
Collapse
Affiliation(s)
- Ann-Charlotte Falk
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, III, 141 83 Huddinge, Stockholm, Sweden
| | - Annika Alm
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, III, 141 83 Huddinge, Stockholm, Sweden
| | - Veronica Lindström
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Academic EMS in Stockholm, Stockholm, Sweden
| |
Collapse
|
42
|
Blom MC, Aspelin L, Ivarsson K. Propensity for performing interventions in pre-hospital trauma management - a comparison between physicians and non-physicians. J Trauma Manag Outcomes 2014; 8:3. [PMID: 24502224 PMCID: PMC3942262 DOI: 10.1186/1752-2897-8-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 02/04/2014] [Indexed: 11/26/2022]
Abstract
Background In 2005, the Advanced Life Support (ALS) teams delivering pre-hospital care in RegionSkane in southern Sweden received additional support by physicians, who were part of “Pre-hospital acute teams” (PHAT). The study objective is to compare the incidence of pre-hospital medical interventions for trauma-patients cared for by conventional ALS teams and patients who received additional support by PHAT. Methods Trauma patients with Injury Severity Score (ISS) >9 were identified retrospectively in the national quality registry KVITTRA at three hospitals in RegionSkane, for the time period October 2005 to December 2008. Interventions include e.g. tracheal intubation, administration of i.v. fluids, neck immobilization and spine board usage. Confounding effects from trauma severity, trauma mechanism, vital parameters, age and sex were addressed in multivariate models. Results Data from 202 cases was included. 9 pre-hospital interventions were assessed. The incidence of endotracheal intubation and immobilisation of extremities was higher among patients in the PHAT-group compared to the ALS-only group (16.3% vs. 6.9%, p = 0.034) and (12.8% vs. 4.3%, p = 0.027) respectively. PHATs presence remained a significant predictor of these interventions also after taking confounding factors into account (OR 5.5, CL 1.5-19.7) and (OR 3.2 CI 1.0-9.8). PHAT was involved in a greater proportion of cases with <50.0% of survival (19.8% vs. 12.1%, p = 0.134). The average ISS was higher among cases receiving PHAT support in strata ISS 16-24 and ISS > 24 than cases in corresponding strata cared for by ALS teams alone (ISS 20.0 vs. 17.0, p = 0.048 and ISS 34.0 vs. 29.0, p = 0.019). Conclusions The incidence of endotracheal intubation and immobilization of extremities was greater among patients supported by PHAT, compared to patients cared for by ALS teams alone. This finding has to be interpreted in the light of a selection-bias where PHAT support was directed to more severely injured patients.
Collapse
Affiliation(s)
- Mathias C Blom
- IKVL, Medicine, Lund University, IKVL/Avd för medicin, Hs 32, EA-blocket, plan 2, Universitetssjukhuset, Lund SE 221 85, Sweden.
| | | | | |
Collapse
|
43
|
McQueen C, Crombie N, Perkins GD, Wheaton S. Impact of introducing a major trauma network on a regional helicopter emergency medicine service in the UK. Emerg Med J 2013; 31:844-50. [PMID: 23851129 DOI: 10.1136/emermed-2013-202756] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION In the West Midlands region of the UK, the delivery of prehospital trauma care has recently been remodelled through the introduction of a regionalised major trauma network (MTN). Helicopter emergency medical services (HEMS) are integral to the network, providing means of delivering highly skilled specialist teams to scenes of trauma and rapid transfer of patients to major trauma centres. This study reviews the impact of introducing the West Midlands MTN on the operation of one its regional HEMS units. METHODS Retrospective review of the Midlands Air Ambulance clinical database for the 6 months after the launch of the West Midlands MTN. The corresponding period for the previous year was reviewed for comparison. The contribution of trauma cases to overall workload, mission outcome data and the number of interventions performed at the scene were compared. RESULTS The proportion of HEMS activations for trauma cases was similar in both cohorts (70.84% before MTN vs 71.57% after MTN). The proportion of mission cancellations was significantly lower after the launch of the network (23.71% vs 19.03%). Significantly more scene attendances resulted in interventions by HEMS crews after the MTN launch (44.66% vs 56.92%). CONCLUSIONS Since the introduction of the West Midlands MTN, tasking of HEMS assets appears to be better targeted to cases involving significant injury, and a reduction in mission cancellations has been observed. There is a need for more detailed evaluation of patient outcomes to identify strategies for optimising the utilisation of HEMS assets within the regional network.
Collapse
Affiliation(s)
- Carl McQueen
- Academic Department of Anaesthesia, Critical Care, Pain & Resuscitation, Birmingham Heartlands Hospital, Birmingham, West Midlands, UK Midlands Air Ambulance, Unit 16 Enterprise Trading Estate, Birmingham, West Midlands, UK
| | - Nick Crombie
- Midlands Air Ambulance, Unit 16 Enterprise Trading Estate, Birmingham, West Midlands, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Steve Wheaton
- West Midlands Ambulance Service NHS Foundation Trust, Birmingham, West Midlands, UK
| |
Collapse
|
44
|
Andruszkow H, Lefering R, Frink M, Mommsen P, Zeckey C, Rahe K, Krettek C, Hildebrand F. Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R124. [PMID: 23799905 PMCID: PMC4056624 DOI: 10.1186/cc12796] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 06/21/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Physician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive. METHODS Traumatized patients (Injury Severity Score; ISS≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score. RESULTS A total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n=8,231) were transported by GEMS and 37.7% (n=4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P<0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P<0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P<0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P<0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P<0.001) resulting in an increased length of ICU treatment and in-hospital time (P<0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862). CONCLUSIONS Although HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.
Collapse
|
45
|
Morrison JJ, Oh J, DuBose JJ, O'Reilly DJ, Russell RJ, Blackbourne LH, Midwinter MJ, Rasmussen TE. En-route care capability from point of injury impacts mortality after severe wartime injury. Ann Surg 2013; 257:330-4. [PMID: 23291661 DOI: 10.1097/sla.0b013e31827eefcf] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study is to characterize modern point-of-injury (POI) en-route care platforms and to compare mortality among casualties evacuated with conventional military retrieval (CMR) methods to those evacuated with an advanced medical retrieval (AMR) capability. BACKGROUND Following a decade of war in Afghanistan, the impact of en-route care capabilities from the POI on mortality is unknown. METHODS Casualties evacuated from POI to one level III facility in Afghanistan (July 2008-March 2012) were identified from UK and US trauma registries. Groups comprised those evacuated by a medically qualified provider-led, AMR and those by a medic-led CMR capability. Outcomes were compared per incremental Injury Severity Score (ISS) bins. RESULTS Most casualties (n = 1054; 61.2%) were in the low-ISS (1-15) bracket in which there was no difference in en-route care time or mortality between AMR and CMR. Casualties in the mid-ISS bracket (16-50) (n = 583; 33.4%) experienced the same median en-route care time (minutes) on AMR and CMR platforms [78 (58) vs 75 (93); P = 0.542] although those on AMR had shorter time to operation [110 (95) vs 117 (126); P < 0.001]. In this mid-ISS bracket, mortality was lower in the AMR than in the CMR group (12.2% vs 18.2%; P = 0.035). In the high-ISS category (51-75) (n = 75; 4.6%), time to operation was lower in the AMR than the CMR group (66 ± 77 vs 113 ± 122; P = 0.013) but there was no difference in mortality. CONCLUSIONS This study characterizes en-route care capabilities from POI in modern combat. Conventional platforms are effective in most casualties with low injury severity. However, a definable injury severity exists for which evacuation with an AMR capability is associated with improved survival.
Collapse
Affiliation(s)
- Jonathan J Morrison
- United States Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Hoogervorst EM, van Beeck EF, Goslings JC, Bezemer PD, Bierens JJLM. Developing process guidelines for trauma care in the Netherlands for severely injured patients: results from a Delphi study. BMC Health Serv Res 2013; 13:79. [PMID: 23452394 PMCID: PMC3621215 DOI: 10.1186/1472-6963-13-79] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 02/14/2013] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In organised trauma systems the process of care is the key to quality. Nevertheless, the optimal process of trauma care remains unclear due to lack of or inconclusive evidence. Because monitoring and improving the performance of a trauma system is complex, this study aimed to develop consensus-based process guidelines for trauma care in the Netherlands for severely injured patients. METHODS A five-round Delphi study was conducted with 141 participants that represent all professions involved in trauma care. Sensitivity analyses were carried out to evaluate whether consensus extended across all professions and to detect possible bias. RESULTS Consensus was reached on 21 guidelines within 4 categories: timeliness, actions, competent teams and interdisciplinary process. Timeliness guidelines set specific critical limits and definitions for 10 time intervals in the time period from an emergency call until the patient leaves the trauma room. Action guidelines reflect aspects of appropriate care and strongly rely on the international Advanced Trauma Life Support principles. Competence guidelines include flow charts to assess the competence of prehospital and emergency department teams. Essential to competent teams are education and experience of all team members. The interdisciplinary process guideline focuses on cooperation, communication and feedback within and between all professions involved. Consensus was extended across all professions and no bias was detected. CONCLUSIONS In this Delphi study, a large expert panel agreed on a set of guidelines describing the optimal process of care for severely injured trauma patients in the Netherlands. In addition to time intervals and appropriate actions, these guidelines emphasise the importance of team competence and interdisciplinary processes in trauma care. The guidelines can be seen as a description of a best practice and a new field standard in the Netherlands. The next step is to implement the guidelines and monitor the performance of the Dutch trauma system based on the guidelines.
Collapse
|
47
|
Hoogerwerf N, Valk JP, Houmes RJ, Christiaans HM, Geeraedts LMG, Schober P, de Lange-de Klerk ESM, Van Lieshout EMM, Scheffer GJ, Den Hartog D. Benefit of Helicopter Emergency Medical Services on trauma patient mortality in the Netherlands? Injury 2013; 44:274-5. [PMID: 22877790 DOI: 10.1016/j.injury.2012.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 04/13/2012] [Accepted: 05/12/2012] [Indexed: 02/02/2023]
|
48
|
Sherren PB, Hayes-Bradley C, Reid C, Burns B, Habig K. Are physicians required during winch rescue missions in an Australian helicopter emergency medical service? Emerg Med J 2013; 31:229-32. [PMID: 23353665 DOI: 10.1136/emermed-2012-201879] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND A helicopter emergency medical service (HEMS) capable of winching offers several advantages over standard rescue operations. Little is known about the benefit of physician winching in addition to a highly trained paramedic. OBJECTIVE To analyse the mission profiles and interventions performed during rescues involving the winching of a physician in the Greater Sydney Area HEMS (GSA-HEMS). METHODS All winch missions involving a physician from August 2009 to January 2012 were identified from the prospectively completed GSA-HEMS electronic database. A structured case sheet review for a predetermined list of demographic data and physician-only interventions (POIs) was conducted. RESULTS We identified 130 missions involving the winching of a physician, of which 120 case sheets were available for analysis. The majority of patients were traumatically injured (90%) and male (85%) with a median age of 37 years. Seven patients were pronounced dead at the scene. A total of 63 POIs were performed on 48 patients. Administration of advanced analgesia was the most common POI making up 68.3% of interventions. Patients with abnormal RTSc(2) scores were more likely to receive a POI than those with normal RTSc(2) (84.8% vs 15.2%; p=0.03). The performance of a POI had no effect on median scene times (45 vs 43 min; p=0.51). CONCLUSIONS Our high POI rate of 40% (48/120) coupled with long rescue times and the occasional severe injuries support the argument for winching Physicians. Not doing so would deny a significant proportion of patients time-critical interventions, advanced analgesia and procedural sedation.
Collapse
Affiliation(s)
- Peter Brendon Sherren
- Department of Pre-hospital Care, Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS), , Sydney, New South Wales, Australia
| | | | | | | | | |
Collapse
|
49
|
Wyen H, Lefering R, Maegele M, Brockamp T, Wafaisade A, Wutzler S, Walcher F, Marzi I. The golden hour of shock - how time is running out: prehospital time intervals in Germany--a multivariate analysis of 15, 103 patients from the TraumaRegister DGU(R). Emerg Med J 2012; 30:1048-55. [PMID: 23258373 DOI: 10.1136/emermed-2012-201962] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Although prehospital treatment algorithms have changed over the past years, the prehospital time of multiple trauma patients of some 70 min and the on-scene-treatment time (OST) of some 30 min have not changed since 1993. The aim of this study was to critically assess specific interventions and conditions at the scene in relation to their impact on prehospital rescue intervals. METHODS We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST. RESULTS 15 103 datasets were included in this study. Based on the mean OST of 32.7 (± 18.6) min and a constant absolute term of 16.2 (± 1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3 ± 0.8 min) and being a car occupant (8.0 ± 0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale ≤ 8 (-4.5 ± 0.7 min) and cardiopulmonary resuscitation (-2.8 ± 1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0 ± 24.6 min) compared with Level I (70.0 ± 28.5 min) and II (66.8 ± 27.4 min) trauma centres. CONCLUSIONS This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results.
Collapse
Affiliation(s)
- Hendrik Wyen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of the Johann Wolfgang Goethe-University, , Frankfurt, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Garner AA, Lee A, Weatherall A. Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew - case identification rates and effect on the Sydney paediatric trauma system. Scand J Trauma Resusc Emerg Med 2012; 20:82. [PMID: 23244708 PMCID: PMC3571886 DOI: 10.1186/1757-7241-20-82] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 12/16/2012] [Indexed: 11/10/2022] Open
Abstract
Background Severe paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC. Methods Paediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS) > 15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available. Results Ninety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p = 0.011), and shorter times to PTC (67 vs 261mins, p = 0.015) and length of intensive care unit stays (2 vs 0 days, p = 0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P < 0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P < 0.01). Conclusions Physician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival.
Collapse
Affiliation(s)
- Alan A Garner
- CareFlight, PO Box 159, Barden St, Northmead, NSW 2145, Australia.
| | | | | |
Collapse
|