Outcome following physician supervised prehospital resuscitation: a retrospective study

The Use of Prehospital Intensive Care Units in Emergencies-A Scoping Review

BACKGROUND

Amidst a rising tide of trauma-related emergencies, emergency departments worldwide grapple with the challenges of overcrowding and prolonged patient wait times. Addressing these challenges, the integration of prehospital intensive care units has appeared as a promising solution, streamlining trauma care and enhancing patient safety. Nevertheless, the feasibility of such an initiative becomes murky when considered globally. This review delves into the intricacies of prehospital intensive care units' deployment for trauma care, scrutinizing their configurations, operational practices, and the inherent challenges and research priorities.

METHODS

A scoping review was performed for eligible studies. The result was uploaded to the RAYYAN research platform, facilitating simultaneous evaluation of the studies by all researchers.

RESULTS

A total of 42 studies were initially selected. Four studies were duplicates, and 25 studies were unanimously removed as irrelevant. The remaining studies (n = 13) were included in the review, and the outcomes were categorized into diverse subgroups.

CONCLUSIONS

A country's emergency medical services must achieve specific milestones in education, competency, resource availability, and performance to effectively harness the potential of a prehospital intensive care unit. While certain nations are equipped, others lag, highlighting a global disparity in readiness for such advanced care modalities.

Exploring the Feelings of Nurses during Resuscitation—A Cross-Sectional Study

Cardiopulmonary resuscitation (CPR) is one of the most stressful situations in emergency medicine. Nurses involved in performing basic and advanced resuscitation procedures are therefore exposed to a certain amount of stress. The purpose of this study was to determine the stressors and the level of stress experienced by nurses during resuscitation. A cross-sectional quantitative study was done. The sample consisted of 457 nurses who worked in emergency units. First demographic data were collected, followed by a questionnaire regarding the effect of different situations that occur during and after resuscitation on nurses including Post-Code Stress Scale questionnaire. The most disturbing situations for respondents were resuscitation of young person (MV = 3.7, SD = 1.4), when they fail to establish an intravenous pathway (MV = 3.5, SD = 1.4), chaotic situation during resuscitation (MV = 3.4, SD = 1.4) and making decision about termination of resuscitation (MV = 3.1, SD = 1.5). Research has shown that nurses are exposed to a certain amount of stress during resuscitation, but most of them manage to compensate for stress effectively.

Organ failure, aetiology and 7-day all-cause mortality among acute adult patients on arrival to an emergency department: a hospital-based cohort study

BACKGROUND

Organ failure is both a frequent and dangerous condition among adult patients on arrival to an emergency department (ED). The risk of an unfavourable outcome could depend on the underlying aetiology. Knowledge of the relation between aetiology and prognosis could improve the risk stratification at arrival.

OBJECTIVES

To describe the relation between organ failure, aetiology and prognosis through 7-day all-cause mortality.

METHODS

An observational three-year cohort study at the ED at Odense University Hospital, Denmark, including all acute adult patients.First-measured vital signs and laboratory values were included to evaluate the presence of the following organ failures: respiratory, coagulation, hepatic, circulatory, cerebral or renal.The primary outcome was 7-day all-cause mortality. Aetiological disease categories were based on primary discharge diagnoses. We described the association between 7-day mortality, aetiology category, site of organ failures and number of patients at risk.

RESULTS

Of 40 423 patients with a first-time visit at the ED, 5883(14.6%) had an organ failure on arrival. The median age was 69 (IQR 54-80), and 50% were men. The most frequent aetiology was infection (1495, 25.4%). Seven-day all-cause mortality ranged between aetiologies from 0.0% (95% confidence interval [CI], 0.0-14.2) allergy) to 45.6% (95% CI, 41.3-50.0) (cardiac). Combining aetiology and site of organ failure, 7-day all-cause mortality was the highest in the cardiac category, from 14.8% (95% CI, 4.2-3.7) with hepatic failure to 79.2% (95% CI, 73.6-84.1) with cerebral failure. The combination of infection and respiratory failure characterised most patients (n = 949).

CONCLUSION

Infection was the most prevalent aetiology, and 7-day all-cause mortality was highly associated with the site of organ failure and aetiology.

Risk factors for cancellation after dispatch of rapid response cars for prehospital emergency care: a single-center, case-control study

Aim

The objective of this study is to identify the risk factors for cancellation after dispatch of rapid response cars (RRC) for prehospital emergency care.

Methods

We retrospectively extracted data from all RRC cases dispatched from our hospital between April 2017 and March 2019. A total of 1,440 cases were included in our study and divided into either the “cancelled” group (n = 723) or the “treated” group (n = 717), based on the occurrence of cancellation. The variables obtained from the request calls for RRC included patient characteristics, distance from the hospital to the scene, and reasons for RRC request. The variables were compared between the two groups and logistic regression analysis was carried out to identify the risk factors for RRC cancellation.

Results

Multivariable analysis showed that distance from the hospital to the scene (odds ratio [OR] 1.25; 95% confidence interval (CI), 1.21–1.28), suspicion of cardiopulmonary arrest with no witness information (OR 7.61; 95% CI, 4.13–14.00), dyspnea (OR 2.22; 95% CI, 1.19–4.11), and suicide by hanging (OR 3.49; 95% CI, 1.37–8.89) were independent risk factors for cancellation.

Conclusions

In our study, a greater distance from the hospital to the scene, suspicion of cardiopulmonary arrest with no witness information, dyspnea, and suicide by hanging were identified as independent risk factors for cancellation after dispatch of RRC. Evaluating the risk factors for cancellation at individual facilities could help hospitals adjust their dispatch criteria to allocate limited medical resources more effectively.

General practitioners not available - out-of-hospital emergency patients handled by anaesthesiologist in a large Norwegian municipality

BACKGROUND

Until autumn 2018 the GPs in Bergen Municipality did not attend emergency patients outside the emergency primary care centre. The ambulance staff handled emergencies on their own or were assisted by an anaesthesiologist from the helicopter emergency medical service (HEMS). The aim of this study was to investigate procedures performed by the HEMS anaesthesiologist and to assess the level of skills needed to perform these procedures.

METHODS

This study was a retrospective assessment of data from the period 2011 to 2013 on all emergency missions in which patients were dealt with by HEMS, using a rapid-response car in Bergen Municipality. All emergency missions were sorted into three categories: No intervention, Basic or Advanced intervention. This list was made by a research group with anaesthesiologists working for Bergen HEMS and GPs with OOH experience. The list is based on curriculum found in acute medicine courses.

RESULTS

HEMS responded to 716 (2.3%) out of a total of 31,696 emergencies in Bergen Municipality during the three years. In more than two-thirds (71%) of these missions, no intervention or only a basic intervention was performed. Most advanced procedures were performed in patients with cardiac arrest.

CONCLUSION

By retrospective evaluation of HEMS missions by car in Bergen municipality, we found that nearly one-third of the patients received advanced procedures. Cardiac arrest was the medical condition in which the most advanced procedures were performed. More research is needed to evaluate procedures and the importance of clinical evaluation and physicians' experience in treating these patient groups.KEY POINTSBoth HEMS and on-call GPs are needed in emergency care, and more knowledge will be useful to highlight the level of practical skills needed in these missions.There is a need for better prioritization of when to use HEMS resources and when to use on-call GPs in emergency missions.More than two-thirds of the patients involved in emergency missions received no intervention or just a basic intervention when dealt with by HEMS.This raises the issue of whether an on-call GP could have adequately treated many of the patients in this study in terms of practical skills.

Level of vital and laboratory values on arrival, and increased risk of 7-day mortality among adult patients in the emergency department: a population-based cohort study

OBJECTIVES

The aim of the study was to provide evidence for, at which vital and laboratory values, increased risk of 7-day mortality in acute adult patients on arrival to an emergency department (ED).

DESIGN

A population-based cohort study.

SETTING

ED at Odense University Hospital, Denmark.

PARTICIPANTS

All patients ≥18 years with a first-time contact within the study period, 1 April 2012 to 31 March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was 7-day all-cause mortality.Variables were first recorded vital and laboratory values included in risk stratification scores; respiratory frequency, blood pressure, heart rate, Glasgow Coma Scale, temperature, saturation, creatinine, PaO₂, platelet count and bilirubin. The association between values and mortality was described using a restricted cubic spline. A predefined 7-day mortality of 2.5% was chosen as a relevant threshold.

RESULTS

We included 40 423 patients, 52.5% women, median age 57 (IQR 38-74) years and 7-day mortality 2.8%. Seven-day mortality of 2.5% had thresholds of respiratory frequency <12 and >18/min, systolic blood pressure <112 and >192 mm Hg, heart rate <54 and >102 beats/min, temperature <36.0°C and >39.8°C, saturation <97%, Glasgow Coma Scale score <15, creatinine <41 and >98 µmol/L for PaO₂ <9.9 and >12.3 kPa, platelet count <165 and >327×10⁹/L and bilirubin >12 µmol/L.

CONCLUSION

Vital values on arrival, outside the normal ranges for the measures, are indicative of increased risk of short-term mortality, and most of the value thresholds are included in the lowest urgency level in triage and risk stratification scoring systems.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Etiology of Shock in the Emergency Department: A 12-Year Population-Based Cohort Study

Introduction:

The knowledge of the etiology and associated mortality of undifferentiated shock in the emergency department (ED) is limited. We aimed to describe the etiology-based proportions and incidence rates (IR) of shock, as well as the associated mortality in the ED.

Methods:

Population-based cohort study at a University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. Patients aged ≥18 years living in the ED-catchment area (N = 225,000) with a first-time ED presentation with shock (n = 1,553) defined as hypotension (systolic blood pressure ≤100 mm Hg) and ≥1 organ failures were included. Discharge diagnoses defined the etiology and were grouped as follows: distributive septic shock (SS), distributive non-septic shock (NS), cardiogenic shock (CS), hypovolemic shock (HS), obstructive shock (OS), and other conditions (OC). Outcomes were etiology-based characteristics, annual IR per 100,000 person-years at risk (95% confidence intervals [CIs]), mortality at 0 to 7-, and 0 to 90 days (95% CIs) and hazard rates (HR) at 0 to 7, 8 to 90 days (95% CIs). Poisson and Cox regression models were used for analyses.

Results:

Among 1,553 shock patients: 423 (27.2%) had SS, 363 (23.4%) NS, 217 (14.0%) CS, 479 (30.8%) HS, 14 (0.9%) OS, and 57 (3.7%) OC. The corresponding IRs were 16.2/100,000 (95% CI: 14.8–17.9), 13.9/100,000 (95% CI: 12.6–15.4), 8.3/100,000 (95% CI: 7.3–9.5), 18.4/100,000 (95% CI: 16.8–20.1), 0.5/100,000 (95% CI: 0.3–0.9), and 2.2/100,000 (95% CI: 1.7–2.8). SS IR increased from 8.4 to 28.5/100,000 during the period 2000 to 2011. Accordingly, the 7-, and 90-day mortalities of SS, NS, CS, and HS were 30.3% (95% CI: 25.9–34.7) and 56.2% (95% CI: 50.7–61.5), 12.7% (95% CI: 9.2–16.1) and 22.6% (95% CI: 18.1–27.7), 34.6% (95% CI: 28.2–40.9) and 52.3% (95% CI: 44.6–59.8), 19.2% (95% CI: 15.7–22.7), and 36.8% (95% CI: 33.3–43.3). SS (HR = 1.46 [95% CI: 1.03–2.07]), and CS (HR = 2.15 [95% CI: 1.47–3.13]) were independent predictors of death within 0 to 7 days, whereas SS was a predictor within 8 to 90 days (HR = 1.66 [95% CI: 1.14–2.42]).

Conclusion:

HS and SS are frequent etiological characteristics followed by NS and CS, whereas OS is a rare condition. We confirm the increasing trend of SS, as previously reported. Seven-day mortality ranged from 12.7% to 34.6%, while 90-day mortality ranged from 22.6% to 56.2%. The underlying etiology was an independent predictor of mortality.

Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review

INTRODUCTION

The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data.

OBJECTIVE

This systematic review aims to identify barriers and facilitators to health data harmonization-including data sharing and linkage-by a comparative analysis of studies from Denmark and Switzerland.

METHODS

Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization.

RESULTS

Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported.

CONCLUSION

This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.

Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study

OBJECTIVES

The aim was to describe population-based incidence and emergency department-based prevalence and 1-year all-cause mortality of patients with new organ failure present at arrival.

DESIGN

This was a population-based cohort study of all citizens in four municipalities (population of 230 000 adults).

SETTING

Emergency department at Odense University Hospital, Denmark.

PARTICIPANTS

We included all adult patients who arrived from 1 April 2012 to 31 March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Organ failure was defined as a modified Sequential Organ Failure Assessment score≥2 within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic and coagulation.The primary outcome was prevalence of organ failure, and secondary outcomes were 0-7 days, 8-30 days and 31-365 days all-cause mortality.

RESULTS

We identified in total 175 278 contacts, of which 70 399 contacts were further evaluated for organ failure. Fifty-two per cent of these were women, median age 62 (IQR 42-77) years. The incidence of new organ failure was 1342/100 000 person-years, corresponding to 5.2% of all emergency department contacts.The 0-7-day, 8-30-day and 31-365-day mortality was 11.0% (95% CI: 10.2% to 11.8%), 5.6% (95% CI: 5.1% to 6.2%) and 13.2% (95% CI: 12.3% to 14.1%), respectively, if the patient had one or more new organ failures at first contact in the observation period, compared with 1.4% (95% CI: 1.3% to 1.6%), 1.2% (95% CI: 1.1% to 1.3%) and 5.2% (95% CI: 5.0% to 5.4%) for patients without. Seven-day mortality ranged from hepatic failure, 6.5% (95% CI: 4.9% to 8.6%), to cerebral failure, 33.8% (95% CI: 31.0% to 36.8%), the 8-30-day mortality ranged from cerebral failure, 3.9% (95% CI: 2.8% to 5.3%), to hepatic failure, 8.6% (95% CI: 6.6% to 10.8%) and 31-365-day mortality ranged from cerebral failure, 9.3% (95% CI: 7.6% to 11.2%), to renal failure, 18.2% (95% CI: 15.5% to 21.1%).

CONCLUSIONS

The study revealed an incidence of new organ failure at 1342/100 000 person-years and a prevalence of 5.2% of all emergency department contacts. One-year all-cause mortality was 29.8% among organ failure patients.

The effect of prehospital critical care on survival following out-of-hospital cardiac arrest: A prospective observational study

AIM

To examine the effect of prehospital critical care on survival following OHCA, compared to routine advanced life support (ALS) care.

METHODS

We undertook a prospective multi-centre cohort study including two ambulance services and six prehospital critical care services in the United Kingdom (UK), between September 2016 and October 2017. Inclusion criteria were adult patients with non-traumatic OHCA treated by either prehospital critical care teams or ALS paramedics. Patients who received prehospital critical care were matched to those receiving ALS using propensity score matching. Primary outcome was survival to hospital discharge; secondary outcome was survival to hospital admission.

RESULTS

The primary analysis included 658 patients with OHCA receiving prehospital critical care and 1847 patients receiving ALS care. Rates of survival to hospital discharge (primary outcome) were 11.9% in both groups; rates of survival to hospital admission (secondary outcome) were 34.4% and 27.7% in the prehospital critical care and ALS group, respectively. The corresponding odds ratios for survival to hospital discharge and survival to hospital admission with prehospital critical care were 1.06 (95% confidence interval 0.75-1.49) and 1.39 (95% confidence interval 1.10-1.75), respectively. Results were consistent across subgroups and sensitivity analyses.

CONCLUSIONS

Despite a positive association with the secondary outcome of survival to hospital admission, prehospital critical care was not associated with increased rates of survival to hospital discharge following OHCA.

Quality measurement in physician-staffed emergency medical services: a systematic literature review

PURPOSE

Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS.

DATA SOURCES

The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus.

STUDY SELECTION

The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool.

DATA EXTRACTION

The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well.

RESULTS OF DATA SYNTHESIS

In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were 'Adherence to medical protocols', 'Provision of advanced interventions', 'Response time' and 'Adverse events'.

CONCLUSION

The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

Patients in prehospital transport to the emergency department: a cohort study of risk factors for 7-day mortality

BACKGROUND

Ambulance transfer is the first contact with the healthcare system for many patients in emergency conditions.We aimed to identify prognostic risk factors accessible in the prehospital phase that indicate an increased risk of 7-day mortality.

PATIENTS AND METHODS

We included patients aged 18 years or older, transferred by ambulance to the emergency department at Odense University Hospital, from 1 April 2012 to 30 September 2014. We carried out multivariate logistic regressions, adjusted for age and sex, to describe the relationship between vital sign values recorded in the prehospital setting and 7-day mortality.

RESULTS

A total of 32 076 ambulance transfers were recorded. Of these, 20 328 were first-time transfers, including 2692 that received assistance from a physician-staffed mobile emergency care unit (MECU). The 7-day mortality was 5.3% [95% confidence interval (CI): 5.0-5.6]. The risk of death increased with age. The odds ratios (ORs) were 2.0 (95% CI: 1.1-3.5) for ages 30-44 years and 7.3 (95% CI: 4.5-11) for ages 45-69 years compared with the 18-29-year-olds. All abnormal vital sign values were associated with increased 7-day mortality. Glasgow Coma Score of less than 14 had the strongest association (OR: 17, 95% CI: 14.7-19.7). MECU assistance showed an adjusted OR of 5.3 (95% CI: 4.6-6.1).

CONCLUSION

The overall 7-day mortality was 5.3%, but differed in the two subgroups, with 15.4% in the MECU-assisted ambulance transfers and 3.8% in non-MECU-assisted transfers. Older age and Glasgow Coma Scores below 14 were the strongest of factors associated significantly with 7-day mortality.

Difference of achievements between physicians from public hospitals and emergency medical center in prehospital emergency

The benefit gained by replacing physicians in the prehospital service is still controversial. The present study compared the difference of achievements of pre-hospital emergency between the physicians from public hospitals and those from the Emergency Medical Center.We included prehospital emergency patients who were sent to the hospital by ambulance after emergency calls from February 1 to May 31, 2016, in Shanghai (24,250,000 inhabitants). Cohort characteristics and diagnoses were described, and the data were analyzed using the Shanghai Emergency Medical Center's database software. We determined whether the physicians from public hospitals were associated with greater success rate of cardiopulmonary resuscitation (CPR) and examined the diseases category and the number of patients with cardiac arrest in prehospital emergency patients.During February 1, 2016, to May 31, 2016, the total turnout of ambulances in the urban area of Shanghai was 107,341 times, among which, first aid was 55,053 times. The number of patients with cardiac arrest was 3012, the 3 principal causes for cardiac arrest were Unknown diagnosis (45.19%), Cardiovascular disease (28.02%) and Respiratory diseases (11.09%), and the successful rate of CPR was 1.56%. The number of critically ill patients, encountered by the physicians from public hospitals, was 10.33% as compared to those from the Emergency Medical Center, which was 11.77% (P < .001). Although the success rate of CPR of the physicians from public hospitals was lower than that of the physicians from the Emergency Medical Center (1.22-1.58%), it did not achieve statistical significance (P > .05).Transferring the physicians from public hospitals to work in Emergency Medical Center showed no improvement in the success rates of resuscitation.

Patient-tailored triage decisions by anaesthesiologist-staffed prehospital critical care teams: a retrospective descriptive study

OBJECTIVES

The primary objective was to estimate the incidence of patients in the Central Denmark Region triaged to bypass the local emergency department without being part of a predefined fast-track protocol. The secondary objective was to describe these triage decisions in more detail with regard to the most common diagnoses, incidence of direct referral sorted by the prehospital critical care team (PHCCT) and the destination hospital.

DESIGN

Retrospective descriptive study.

SETTING AND PARTICIPANTS

The emergency medical service in the Central Denmark Region primarily consists of emergency medical technician (EMT)-staffed ambulances and anaesthesiologist-EMT-staffed PHCCTs. Patients treated by the nine ground-based PHCCTs in the region constituted the study population. The inclusion criteria were all patients treated by the PHCCTs during 2013 and 2014. The exclusion criteria were interhospital transfers, and patients with ST-segment elevation myocardial infarction, stroke or were in active labour.

ENDPOINTS

Incidence of prehospital critical care anaesthesiologist-initiated direct referral, prehospital tentative diagnoses and transport destination.

RESULTS

During the study period, the PHCCTs treated 39 396 patients and diverted 989 (2.5%) patients not covered by a predefined fast-track protocol to a specialised hospital department. 'Resuscitated from cardiac arrest' (n=143), 'treatment and observations following road traffic accident' (n=105) and 'observation and treatment for an unspecified disease/condition' (n=78) were the most common prehospital tentative diagnoses, accounting for 33.0% of all diverted patients. In total, 943 (95.3%) of the PHCCT-diverted patients were diverted to a department at Aarhus University Hospital.

CONCLUSION

Our results demonstrate that in 1 out of 40 patient contacts, the anaesthesiologist-staffed PHCCTs in the Central Denmark Region divert critically ill and injured patients directly to a specialised hospital department, bypassing local emergency departments and potentially reducing time to definitive care for these patients. There may be a potential for increased referral of patients with no predefined fast-track directly to specialised departments in the Central Denmark Region.

Secure IoT-Based, Incentive-Aware Emergency Personnel Dispatching Scheme with Weighted Fine-Grained Access Control

Emergency response times following a traffic accident are extremely crucial in reducing the number of traffic-related deaths. Existing emergency vehicle dispatching systems rely heavily on manual assignments. Although some technology-assisted emergency systems engage in emergency message dissemination and path planning, efficient emergency response is one of the main factors that can decrease traffic-related deaths. Obviously, effective emergency response often plays a far more important role in a successful rescue. In this article, we propose a secure IoT-based and incentive-aware emergency personnel dispatching scheme (EPDS) with weighted fine-grained access control. Our EPDS can recruit available medical personnel on-the-fly, such as physicians driving in the vicinity of the accident scene. An appropriate incentive, such as paid leave, can be offered to encourage medical personnel to join rescue missions. Furthermore, IoT-based devices are installed in vehicles or wearable on drivers to gather biometric signals from the driver, which can be used to decide precisely which divisions or physicians are needed to administer the appropriate remedy. Additionally, our scheme can cryptographically authorize the assigned rescue vehicle to control traffic to increase rescue efficacy. Our scheme also takes advantage of adjacent roadside units to organize the appropriate rescue personnel without requiring long-distance communication with a trusted traffic authority. Proof of security is provided and extensive analyses, including qualitative and quantitative analyses and simulations, show that the proposed scheme can significantly improve rescue response time and effectiveness. To the best of our knowledge, this is the first work to make use of medical personnel that are close by in emergency rescue missions.

Anaphylaxis in an emergency care setting: a one year prospective study in children and adults

Background

Current data on anaphylaxis is based on retrospective and register based studies. The objective of this study was to describe the epidemiology of anaphylaxis in a 1 year prospective study at the emergency care setting, Odense University Hospital, Denmark (2013–2014).

Methods

Prospective study at the emergency care setting, Odense University Hospital, Denmark (2013–2014). To identify anaphylaxis cases, records from all patients with clinical suspicion on anaphylaxis or a related diagnosis according to the International Classification of Diseases 10 and from patients treated at the emergency care setting or at prehospital level with adrenaline, antihistamines or glucocorticoids were reviewed daily. The identified cases were referred to the Allergy Center, where a standardized interview regarding the anaphylactic reaction was conducted. International guidelines were applied for the assessment of anaphylaxis and its pharmacological treatment. Severity of the anaphylactic reaction was evaluated according to Sampson’s severity score.

Results

We identified 180 anaphylactic patients. Anaphylaxis represented 0.3%–0.4% of all contacts in the emergency care setting with an incidence rate of 26.8 cases per 100,000 person years (95% CI: 14.3–45.8) in children and 40.4 cases per 100,000 person years (95% CI: 32.8–49.3) in adults. Moderate to severe anaphylaxis was registered in 96% of the cases. Skin (96%) and respiratory (79%) symptoms were the most frequent registered, but 7% of cases in adults occurred without skin manifestations. The most common elicitor in children was food (61%), while drugs (48%) and venom (24%) were the main suspected elicitors in adults. Adrenaline was administered in 25% of the cases and it was significantly less administered than glucocorticoids (83%) and antihistamines (91%). The mortality rate during our study period was 0.3 cases per 100,000 person years.

Discussion

This is one of the first prospective studies on the epidemiology of anaphylaxis in children and adults, where the patients are identified not only based on diagnosis codes but also on history, symptoms and treatment and thereafter classified according to international diagnosis criteria for anaphylaxis.

A limitation of this study is that only patients who gave consent to participate in the study were included. Furthermore, patients may have attended other hospitals during the study period. Therefore, the estimates are minimum figures.

Conclusion

The prospective study design with a broad search profile yield a higher incidence than previously reported. Adrenaline was administered in a low proportion of the patients with moderate to severe anaphylaxis. Standardized diagnosis criteria among physicians treating anaphylaxis are needed.

Prehospital prognosis is difficult in patients with acute exacerbation of chronic obstructive pulmonary disease

Background

Patients with acute exacerbation of chronic obstructive pulmonary disease often require prehospital emergency treatment. This enables patients who are less ill to be treated on-site and to avoid hospital admission, while severely ill patients can receive immediate ventilatory support in the form of intubation. The emergency physician faces difficult treatment decisions, however, and prognostic tools that could assist in determining which patients would benefit from intubation and ventilator support would be helpful. The aim of the current study was to identify prehospital clinical variables associated with mortality from acute exacerbation of chronic obstructive pulmonary disease. As part of the study, we estimated the 30-day mortality for patients with this prehospital diagnosis.

Methods

A retrospective study was performed using data collected by the mobile emergency care unit in Odense, Denmark, combined with data from the patients’ medical records. Patients with the tentative diagnosis of acute exacerbation of chronic obstructive pulmonary disease between 1st July 2011 and 31st December 2013 were included in the study.

Results

Based on data from 530 patients, we found no statistically significant associations between prehospital clinical variables and mortality, apart from a minor association between older age and higher mortality. The overall 30-day mortality was 10%, while that for patients admitted to the intensive care unit was 30%.

Conclusion

No specific prehospital prognostic factors for mortality were identified. Prognostic assessment and the decision to withhold treatment for acute exacerbation of chronic obstructive pulmonary disease seem inadvisable in the prehospital setting.

Impact of rapid response car system on ECMO in out-of-hospital cardiac arrest: A retrospective cohort study

INTRODUCTION

Extracorporeal life support (ECLS) has been reported to be more effective than conventional cardiopulmonary resuscitation (CPR). In ECLS, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO) time was predicted to be associated with better survival rates. This study aimed to examine the impact of the physician-based emergency medical services (P-EMS) using a rapid response car (RRC) on door-to-ECMO time in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

In this retrospective cohort study, adult patients with OHCA who were admitted to a Japanese tertiary care hospital from April 2012 to December 2016 and underwent venoarterial ECMO were included. Patients were either transferred by emergency medical service (EMS only group) or RRC (RRC group). Primary outcome was door-to-ECMO time. Wilcoxon rank-sum test was used to compare the outcome between the two groups.

RESULTS

A total of 34 patients were included in this study, and outcome data were available for all patients. The door-to-ECMO time was significantly shorter in the RRC group than in the EMS only group (median, 23min vs. 36min; P=0.006). Additionally, the RRC was also associated with earlier successful intubation and intravenous adrenaline administration.

CONCLUSION

The physician-based RRC system was associated with a shorter door-to-ECMO time and successful advanced procedures in prehospital settings. Combination of the RRC system with ECLS may lead to better outcomes in patients with OHCA.

Characteristics and prognoses of patients treated by an anaesthesiologist-manned prehospital emergency care unit. A retrospective cohort study

OBJECTIVE

When planning and dimensioning an emergency medical system, knowledge of the population serviced is vital. The amount of literature concerning the prehospital population is sparse. In order to add to the current body of literature regarding prehospital treatment, thus aiding future public health planning, we describe the workload of a prehospital anaesthesiologist-manned mobile emergency care unit (MECU) and the total population it services in terms of factors associated with mortality.

PARTICIPANTS

The study is a register-based study investigating all missions carried out by a MECU operating in a mixed urban/rural area in Denmark from 1 May 2006 to 31 December 2014. Information on missions was extracted from the local MECU registry and linked at the individual level to the Danish population-based databases, the National Patient Registry and the Civil Registration System.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were number of missions and number of patient contacts. Secondary patient variables were mortality and association between mortality and age, sex, comorbidity, prior admission to hospital and response time.

RESULTS

The MECU completed 41 513 missions (mean 13.1 missions/day) having 32 873 patient contacts, corresponding to 19.2 missions and 15.2 patient encounters per 1000 patient years. Patient variables: the median age was 57 years (range 0-108 years), 42.8% (42.3% to 43.4%) were women. For patients admitted to hospital alive, 30-day mortality was 5.7% (5.4% to 6.0%); 90-day mortality was 8.1% (7.8% to 8.5%) while 2-year mortality was 16.4% (16.0% to 16.8%). Increasing age, male sex, comorbidity and prior admission to hospital but not response time were associated with mortality.

CONCLUSIONS

Mortality following an incident requiring the assistance of a MECU was high in the first 2 years following the incident. MECU response time assessed as a continuous parameter was not associated with patient outcome.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.

MATERIAL AND METHODS

In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.

RESULTS

Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation.

CONCLUSION

This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

Shock in the emergency department; a 12 year population based cohort study

Background

The knowledge of the frequency and associated mortality of shock in the emergency department (ED) is limited. The aim of this study was to describe the incidence, all-cause mortality and factors associated with death among patients suffering shock in the ED.

Methods

Population-based cohort study at an University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. All patients aged ≥18 years living in the hospital catchment area with a first time ED presentation with shock (n = 1646) defined as hypotension (systolic blood pressure (SBP) ≤100 mmHg)) and ≥1 organ failures. Outcomes were annual incidence per 100,000 person-years at risk (pyar), all-cause mortality at 0–7, and 8–90 days and risk factors associated with death.

Results

We identified 1646 of 438,191 (0.4 %) ED patients with shock at arrival. Incidence of shock increased from 53.8 to 80.6 cases per 100,000 pyar. The 7-day, and 90-day mortality was 23.1 % (95 % CI: 21.1–25.1) and 40.7 % (95 % CI: 38.3–43.1), respectively. Independent predictors of 7-day mortality were: age (adjusted HR 1.03 (95 % CI: 1.03–1.04), and number of organ failures (≥3 organ failures; adjusted HR 3.13 95 % CI: 2.28–4.30). Age, comorbidity level and number of organ failure were associated with 90-day mortality.

Conclusion

Shock is a frequent and critical finding in the ED, carrying a 7- and, 90- day mortality of 23.1 and 40.7 %, respectively. Age and number of organ failures are independent prognostic factors for death within 7 days, whereas age, comorbidity and organ failures are of significance within 8–90 days.