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Rickenbach ON, Aldridge J, Tumin D, Greene E, Ledoux M, Longshore S. Prehospital time and mortality in pediatric trauma. Pediatr Surg Int 2024; 40:159. [PMID: 38900155 PMCID: PMC11190012 DOI: 10.1007/s00383-024-05742-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE The "Golden Hour" of transportation to a hospital has long been accepted as a central principal of trauma care. However, this has not been studied in pediatric populations. We assessed for non-linearity of the relationship between prehospital time and mortality in pediatric trauma patients, redefining the threshold at which reducing this time led to more favorable outcomes. METHODS We performed an analysis of the 2017-2018 American College of Surgeons Trauma Quality Improvement Program, including trauma patients age < 18 years. We examined the association between prehospital time and odds of in-hospital mortality using linear, polynomial, and restricted cubic spline (RCS) models, ultimately selecting the non-linear RCS model as the best fit. RESULTS 60,670 patients were included in the study, of whom 1525 died and 3074 experienced complications. Prolonged prehospital time was associated with lower mortality and fewer complications. Both models demonstrated that mortality risk was lowest at 45-60 min, after which time was no longer associated with reduced probability of mortality. CONCLUSIONS The demonstration of a non-linear relationship between pre-hospital time and patient mortality is a novel finding. We highlight the need to improve prehospital treatment and access to pediatric trauma centers while aiming for hospital transportation within 45 min.
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Affiliation(s)
- Olivia Nieto Rickenbach
- Brody School of Medicine at East, Carolina University, 600 Moye Blvd, Greenville, NC, 27858, USA.
| | - Joshua Aldridge
- ECU Health Medical Center, Greenville, NC, USA
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | | | - Matthew Ledoux
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Shannon Longshore
- Department of Surgery, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
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Maek T, Fochtmann U, Jungbluth P, Pass B, Lefering R, Schoeneberg C, Lendemans S, Hussmann B. Reality of treatment for severely injured patients: are there age-specific differences? BMC Emerg Med 2024; 24:14. [PMID: 38267869 PMCID: PMC10807120 DOI: 10.1186/s12873-024-00935-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Major trauma and its consequences are one of the leading causes of death worldwide across all age groups. Few studies have conducted comparative age-specific investigations. It is well known that children respond differently to major trauma than elderly patients due to physiological differences. The aim of this study was to analyze the actual reality of treatment and outcomes by using a matched triplet analysis of severely injured patients of different age groups. METHODS Data from the TraumaRegister DGU® were analyzed. A total of 56,115 patients met the following inclusion criteria: individuals with Maximum Abbreviated Injury Scale > 2 and < 6, primary admission, from German-speaking countries, and treated from 2011-2020. Furthermore, three age groups were defined (child: 3-15 years; adult: 20-50 years; and elderly: 70-90 years). The matched triplets were defined based on the following criteria: 1. exact injury severity of the body regions according to the Abbreviated Injury Scale (head, thorax, abdomen, extremities [including pelvis], and spine) and 2. level of the receiving hospital. RESULTS A total of 2,590 matched triplets could be defined. Traffic accidents were the main cause of severe injury in younger patients (child: 59.2%; adult: 57.9%). In contrast, low falls (from < 3 m) were the most frequent cause of accidents in the elderly group (47.2%). Elderly patients were least likely to be resuscitated at the scene. Both children and elderly patients received fewer therapeutic interventions on average than adults. More elderly patients died during the clinical course, and their outcome was worse overall, whereas the children had the lowest mortality rate. CONCLUSIONS For the first time, a large patient population was used to demonstrate that both elderly patients and children may have received less invasive treatment compared with adults who were injured with exactly the same severity (with the outcomes of these two groups being opposite to each other). Future studies and recommendations should urgently consider the different age groups.
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Affiliation(s)
- Teresa Maek
- Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Ulrike Fochtmann
- Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Pascal Jungbluth
- Department of Orthopedics and Trauma Surgery, University Hospital Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Bastian Pass
- Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Herdecke University, Ostmerheimer Straße 200, 51109, WittenCologne, Germany
| | - Carsten Schoeneberg
- Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Sven Lendemans
- Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
- University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Bjoern Hussmann
- Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany.
- Department of Orthopedics and Trauma Surgery, University Hospital Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
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Ueno K, Teramoto C, Nishioka D, Kino S, Sawatari H, Tanabe K. Factors associated with prolonged on-scene time in ambulance transportation among patients with minor diseases or injuries in Japan: a population-based observational study. BMC Emerg Med 2024; 24:10. [PMID: 38185622 PMCID: PMC10773094 DOI: 10.1186/s12873-023-00927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/28/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Prolonged prehospital time is a major global problem in the emergency medical system (EMS). Although factors related to prolonged on-scene times (OSTs) have been reported in patients with trauma and critical medical conditions, those in patients with minor diseases or injuries remain unclear. We examined factors associated with prolonged OSTs in patients with minor diseases or injuries. METHODS This population-based observational study used the ambulance transportation and request call record databases of the Higashihiroshima Fire Department, Japan, between January 1, 2016, and December 31, 2022. The participants were patients with minor diseases or injuries during the study period. We performed a multivariable logistic regression analysis with robust error variance to examine the association between patient age, sex, severity, accident type, date and time of ambulance call, and the coronavirus disease 2019 (COVID-19) pandemic with prolonged OSTs. Prolonged OST was defined as ≥ 30 min from the ambulance arrival at the scene to departure. RESULTS Of the 60,309 people transported by ambulance during the study period, 20,069 with minor diseases or injuries were included in the analysis. A total of 1,241 patients (6.2%) experienced prolonged OSTs. Fire accidents (adjusted odds ratio [aOR]: 7.77, 95% confidence interval [CI]: 3.82-15.79), natural disasters (aOR: 28.52, 95% CI: 2.09-389.76), motor vehicle accidents (aOR: 1.63, 95% CI: 1.30-2.06), assaults (aOR: 2.91, 95% CI: 1.86-4.53), self-injuries (aOR: 5.60, 95% CI: 3.37-9.32), number of hospital inquiries ≥ 4 (aOR: 77.34, 95% CI: 53.55-111.69), and the COVID-19 pandemic (aOR: 2.01, 95% CI: 1.62-2.50) were associated with prolonged OSTs. Moreover, older and female patients had prolonged OSTs (aOR: 1.18, 95% CI: 1.01-1.36 and aOR: 1.12, 95% CI: 1.08-1.18, respectively). CONCLUSIONS Older age, female sex, fire accidents, natural disasters, motor vehicle accidents, assaults, self-injuries, number of hospital inquiries ≥ 4, and the COVID-19 pandemic influenced prolonged OSTs among patients with minor diseases or injuries. To improve community EMS, we should reconsider how to intervene with potentially modifiable factors, such as EMS personnel performance, the impact of the presence of allied services, hospital patient acceptance systems, and cooperation between general emergency and psychiatric hospitals.
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Affiliation(s)
- Keiko Ueno
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Floor 2, Science Frontier Laboratory, Yoshidakonoe-cho, Sakyo-ku, Kyoto-shi, 606-8315, Kyoto, Japan.
| | - Chie Teramoto
- Department of Perioperative and Critical Care Management, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Daisuke Nishioka
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Floor 2, Science Frontier Laboratory, Yoshidakonoe-cho, Sakyo-ku, Kyoto-shi, 606-8315, Kyoto, Japan
- Department of Medical Statistics, Research & Development Center, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Shiho Kino
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Floor 2, Science Frontier Laboratory, Yoshidakonoe-cho, Sakyo-ku, Kyoto-shi, 606-8315, Kyoto, Japan
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Sawatari
- Department of Perioperative and Critical Care Management, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuaki Tanabe
- Department of Perioperative and Critical Care Management, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Breeding T, Rosander A, Abella M, Martinez B, Maka P, Elkbuli A. Retrospective Study of EMS Scene Times and Mortality in Penetrating Trauma Patients: Improving Transport Standards and Patient Outcomes. Am Surg 2024; 90:46-54. [PMID: 37489560 DOI: 10.1177/00031348231191224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND This study aimed to determine the impact of emergency medical service (EMS) scene time variability on adult and pediatric trauma patient outcomes with moderate or severe penetrating injuries. METHODS This retrospective study analyzed the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) database between 2017 and 2020 to evaluate the relationship between EMS scene time on adult and pediatric patients with moderate to severe injuries. Primary outcomes included Dead on Arrival (DOA) to the Emergency Department (ED), ED mortality, 24-hour mortality, and in-hospital mortality. Multivariable logistic regression models were used to examine the association of each EMS scene time category and mortality. RESULTS Adult patients with 10-30 minutes of EMS scene time had increased odds of experiencing ED mortality, 24-hour mortality, and in-hospital mortality. Adults with >30 minutes of EMS scene time were more likely to be DOA to the ED. There was no significant association with mortality for patients with <10 minutes of EMS scene time. In the pediatric subset of patients, those with 10-30 minutes of EMS scene time were more likely to experience ED mortality and in-hospital mortality. CONCLUSION EMS scene times less than 10 minutes were associated with the greatest odds of survival, supporting the "load and go" theory for penetrating trauma. Our study suggests that even an EMS scene time of 10-30 minutes results in a significantly increased risk of mortality, and further efforts are needed to improve scene time through improved EMS and hospital policies.
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Affiliation(s)
- Tessa Breeding
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Abigail Rosander
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA
| | | | - Brian Martinez
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Piueti Maka
- John A. Burns School of Medicine, Honolulu, HI, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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Burdick KJ, Perez Coulter A, Tirabassi M. Prehospital Transport Time and Outcomes for Pediatric Trauma: A National Study. J Surg Res 2023; 292:144-149. [PMID: 37619499 DOI: 10.1016/j.jss.2023.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 07/19/2023] [Accepted: 07/23/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Historically, emergency medical services have aimed to deliver trauma patients to definitive care within the 60 min (min) "Golden Hour" to optimize survival. There is little evidence to support or refute this for pediatric trauma. The objective of this investigation was to describe national trends in prehospital transport time, in relation to the "Golden Hour," and pediatric trauma outcomes. METHODS Retrospective cohort study of patients (<15 y old) receiving emergency medical services trauma transport between 2017 and 2019. Transport time (less than or greater than 60 min) was the exposure variable, and analyses were adjusted for injury severity score (ISS). Continuous variables with a normal distribution were compared by t-test was and skewed variables were compared by Mann-Whitney U-test. Categorical variables were compared by Chi-Square test. RESULTS 54,489 patients met our criteria: 49,628 blunt and 4861 penetrating. Most patients (62.2%) had transport times less than 60 min: 30,389 (61.2%) blunt and 3479 (71.6%) penetrating. The overall mortality rate was 1.6%, 1.2% for blunt and 5.5% for penetrating. For blunt trauma, mortality was higher for transport times less than 60 min (1.5%). For penetrating trauma, mortality was lower for transport times less than 60 min (0.7%). Mean ISS was greater for blunt (7.9) compared to penetrating trauma (7.1), and greater for both trauma types with transport times less than 60 min. For both trauma types, mean length of stay was significantly longer for transport times greater than 60 min, when adjusting for ISS (P < 0.001). CONCLUSIONS We did not find evidence that prehospital transport within the "Golden Hour" had a substantial association with survival, though it may be associated with length of stay. There are many factors contributing to trauma outcomes, so efforts should continue to expand access and pediatric readiness.
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Affiliation(s)
- Kendall J Burdick
- T.H. Chan School of Medicine, Worcester, Massachusetts; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
| | - Aixa Perez Coulter
- Department of Surgery, Baystate Medical Center, Springfield, Massachusetts
| | - Michael Tirabassi
- T.H. Chan School of Medicine, Worcester, Massachusetts; Department of Surgery, Baystate Medical Center, Springfield, Massachusetts
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Hirschhorn RM, Huggins RA, Kerr ZY, Mensch JM, Dompier TP, Rudisill C, Yeargin SW. Access to Athletic Trainers and Emergency Medical Services Activations for Sport-Related Injuries. J Athl Train 2023; 58:387-392. [PMID: 37523419 DOI: 10.4085/234.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
CONTEXT Having athletic trainers (ATs) employed at secondary schools is associated with improved preparedness for sport-related emergencies. The use of emergency medical services (EMS) in settings with different access to athletic training services remains unknown. OBJECTIVE To compare the incidence of EMS activations for patients with sport-related injuries among zip codes with various levels of access to athletic training services. DESIGN Descriptive epidemiology study. SETTING Data were obtained from the National EMS Information System and the Athletic Training Location and Services Project. PATIENTS OR OTHER PARTICIPANTS Zip codes where 911 EMS activations for sport-related injuries among individuals 13 to 18 years old occurred. MAIN OUTCOME MEASURE(S) Incidence of EMS activations, athletic training service level (no ATs employed [NONE], less than full-time employment [PARTIAL], all ATs employed full time [FULL]), and athletic training employment model (independent contractor [IC], medical or university facility [MUF], school district [SD], mixed employment models [MIX]) for each zip code. RESULTS The EMS activations were 2.8 ± 3.6 per zip code (range = 1-81, N = 4923). Among zip codes in which at least 1 AT was employed (n = 2228), 3.73% (n = 83) were IC, 38.20% (n = 851) were MUF, 27.24% (n = 607) were SD, and 30.83% (n = 687) were MIX. Compared with SD, MUF had a 10.8% lower incidence of EMS activations (incidence rate ratio [IRR] = 0.892; 95% CI = 0.817, 0.974; P = .010). The IC (IRR = 0.920; 95% CI = 0.758, 1.118; P = .403) and MIX (IRR = 0.996; 95% CI = 0.909, 1.091; P = .932) employment models were not different from the SD model. Service level was calculated for 3834 zip codes, with 19.5% (n = 746) NONE, 46.2% (n = 1771) PARTIAL, and 34.4% (n = 1317) FULL. Compared with NONE, FULL (IRR = 1.416; 95% CI = 1.308, 1.532; P < .001) and PARTIAL (IRR = 1.368; 95% CI = 1.268, 1.476; P < .001) had higher incidences of EMS activations. CONCLUSIONS Local access to athletic training services was associated with an increased use of EMS for sport-related injuries among secondary school-aged individuals, possibly indicating improved identification and triage of sport-related emergencies in the area. The difference in EMS use among employment models may reflect different policies and procedures for sport-related emergencies.
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Affiliation(s)
| | | | - Zachary Y Kerr
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - James M Mensch
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia
| | - Thomas P Dompier
- School of Health Professions, Lebanon Valley College, Annville, PA
| | - Caroline Rudisill
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia
| | - Susan W Yeargin
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia
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Population-Based Assessment of Urban Versus Rural Child Fatalities From Firearms in a Midwestern State. J Surg Res 2023; 283:52-58. [PMID: 36370682 DOI: 10.1016/j.jss.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/22/2022] [Accepted: 10/15/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Several studies have evaluated differences in firearm injury patterns among children based on regionalization. However, many of these studies exclude patients who die before arriving at a trauma center. We therefore hypothesize that important population-based differences in pediatric firearm injuries may be uncovered with the inclusion of both prehospital firearm mortalities and patients treated at a tertiary children's hospital. METHODS Patients less than 15 y of age who sustained a firearms-related injury/death between the years 2012 and 2018 were identified in: (1) death certificates from the Office of Vital Statistics State of Indiana and (2) Riley Hospital for Children at Indiana University Health Trauma Registry. Counties of injury were classified as either urban, midsized, or rural based on the National Center for Health Statistic's population data. Significant variables in univariate analysis were then assessed using multivariate logistic regression models. RESULTS A total of 222 patients were identified. Median age of firearm injury survivors was 13 (interquartile range 7-14), while the median age of nonsurvivors was 14 (interquartile range 11-15), P = 0.040. The proportion of suicide was significantly higher in rural counties (P < 0.001). When controlling for shooter intent, patients from a rural or midsized county had statistically significant higher odds of dying before reaching a hospital than their urban counterpart (rural odds ratio [OR] 5.67 [95% confidence interval {CI} 2.23, 14.38]; midsized OR 6.53 [95% CI 2.43, 17.46]; P < 0.001). CONCLUSIONS Important differences exist between pediatric firearm injuries based on where they occur. Public health initiatives aimed at reducing pediatric firearm injury and death should not exclude rural pediatrics patients.
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Burdick KJ, Lee LK, Mannix R, Monuteaux MC, Hirsh MP, Fleegler EW. Racial and Ethnic Disparities in Access to Pediatric Trauma Centers in the United States: A Geographic Information Systems Analysis. Ann Emerg Med 2023; 81:325-333. [PMID: 36328848 DOI: 10.1016/j.annemergmed.2022.08.454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Injury is the leading cause of death and disability for children, making access to pediatric trauma centers crucial to pediatric trauma care. Our objective was to describe the pediatric population with timely access to a pediatric trauma center by demographics and geography in the United States. METHODS Level 1, 2, and 3 pediatric trauma center locations were provided by the American Trauma Society. Geographic information systems road network and rotor wing analysis determined US Census Block Groups with the ground and/or air access to a pediatric trauma center within a 60-minute transport time. We then described, at the national and state levels, the 2020 pediatric population (< 15 years old) with and without pediatric trauma center access by ground and air, stratified by race, ethnicity, and urbanicity. RESULTS There were 157 pediatric trauma centers (82 Level 1, 64 Level 2, 11 Level 3). Of the 2020 US pediatric population, 33,352,872 (54.5%) had timely access to Level 1-3 pediatric trauma centers by ground and 45,431,026 (74.1%) by air. The percentage of children with access by race and ethnicity were (by ground, by air): American Indian/Alaskan Native (31.0%, 43.5%), White (48.7%, 71.3%), Native Hawaiian/Pacific Islander (59.3%, 61.0%), Hispanic (60.2%, 76.9%), Black (64.2%, 78.0%), and Asian (76.5%, 89.5%). Only 48.2% of children living in rural block groups had access, compared with 83.6% in urban block groups. CONCLUSION Significant disparities in current access to pediatric trauma centers exist by race and ethnicity, and geography, leaving some children at risk for poor trauma outcomes.
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Affiliation(s)
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
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Maek T, Fochtmann U, von Loewenich A, Jungbluth P, Zimmermann W, Lefering R, Lendemans S, Hussmann B. Is prehospital intubation of severely injured children in accordance with guidelines? BMC Emerg Med 2022; 22:194. [PMID: 36474145 PMCID: PMC9724279 DOI: 10.1186/s12873-022-00750-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The current German S3 guideline for polytrauma lists five criteria for prehospital intubation: apnea, severe traumatic brain injury (GCS ≤8), severe chest trauma with respiratory failure, hypoxia, and persistent hemodynamic instability. These guideline criteria, used in adults in daily practice, have not been previously studied in a collection of severely injured children. The aim of this study was to assess the extent to which the criteria are implemented in clinical practice using a multivariate risk analysis of severely injured children. METHODS Data of 289,698 patients from the TraumaRegister DGU® were analyzed. Children meeting the following criteria were included: Maximum Abbreviated Injury Scale 3+, primary admission, German-speaking countries, years 2008-2017, and declaration of intubation. Since children show age-dependent deviating physiology, four age groups were defined (years old: 0-2; 3-6; 7-11; 12-15). An adult collective served as a control group (age: 20-50). After a descriptive analysis in the first step, factors leading to prehospital intubation in severely injured children were analyzed with a multivariate regression analysis. RESULTS A total of 4489 children met the inclusion criteria. In this cohort, young children up to 2 years old had the significantly highest injury severity (Injury Severity Score: 21; p ≤ 0.001). Falls from both high (> 3 m) and low heights (< 3 m) were more common in children than in adults. The same finding applied to the occurrence of severe traumatic brain injury. When at least one intubation criterion was formally present, the group up to 6 years old was least likely to actually be intubated (61.4%; p ≤ 0.001). Multivariate regression analysis showed that Glasgow Coma Scale score ≤ 8 in particular had the greatest influence on intubation (odds ratio: 26.9; p ≤ 0.001). CONCLUSIONS The data presented here show for the first time that the existing criteria in the guideline for prehospital intubation are applied in clinical practice (approximately 70% of cases), compared to adults, in the vast majority of injured children. Although severely injured children still represent a minority of all injured patients, future guidelines should focus more on them and address them in a specialized manner.
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Affiliation(s)
- Teresa Maek
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Ulrike Fochtmann
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Anna von Loewenich
- grid.410718.b0000 0001 0262 7331Department of Pediatrics 1, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Pascal Jungbluth
- grid.14778.3d0000 0000 8922 7789Department of Orthopedics and Trauma Surgery, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Werner Zimmermann
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Rolf Lefering
- grid.412581.b0000 0000 9024 6397Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimer Straße 200, 51109 Cologne, Germany
| | - Sven Lendemans
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany ,grid.5718.b0000 0001 2187 5445University of Duisburg-Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Bjoern Hussmann
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany ,grid.14778.3d0000 0000 8922 7789Department of Orthopedics and Trauma Surgery, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
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Farcas AM, Joiner AP, Rudman JS, Ramesh K, Torres G, Crowe RP, Curtis T, Tripp R, Bowers K, von Isenburg M, Logan R, Coaxum L, Salazar G, Lozano M, Page D, Haamid A. Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review. PREHOSP EMERG CARE 2022; 27:1058-1071. [PMID: 36369725 DOI: 10.1080/10903127.2022.2142344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/25/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care. OBJECTIVE We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group. METHODS We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach. RESULTS One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting. CONCLUSIONS Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.
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Affiliation(s)
- Andra M Farcas
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Anjni P Joiner
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jordan S Rudman
- Harvard Affiliated Emergency Medicine Residency, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Karthik Ramesh
- School of Medicine, University of California San Diego, San Diego, California
| | | | | | | | - Rickquel Tripp
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karen Bowers
- Atlanta Fire Rescue Department; Department of Emergency Medicine, University of Tennessee-Chattanooga, Chattanooga, Tennessee
| | - Megan von Isenburg
- Duke University Medical Center Library, Duke University, Durham, North Carolina
| | - Robert Logan
- San Diego Fire - Rescue Department, San Diego, California
| | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Michael Lozano
- Division of Emergency Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - David Page
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ameera Haamid
- Section of Emergency Medicine, University of Chicago School of Medicine, Chicago, Illinois
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Ito S, Asai H, Kawai Y, Suto S, Ohta S, Fukushima H. Factors associated with EMS on-scene time and its regional difference in road traffic injuries: a population-based observational study. BMC Emerg Med 2022; 22:160. [PMID: 36109716 PMCID: PMC9479253 DOI: 10.1186/s12873-022-00718-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The outcome of road traffic injury (RTI) is determined by duration of prehospital time, patient’s demographics, and the type of injury and its mechanism. During the emergency medical service (EMS) prehospital time interval, on-scene time should be minimized for early treatment. This study aimed to examine the factors influencing on-scene EMS time among RTI patients.
Methods
We evaluated 19,141 cases of traffic trauma recorded between April 2014 and March 2020 in the EMS database of the Nara Wide Area Fire Department and the prehospital database of the emergency Medical Alliance for Total Coordination of Healthcare (e-MATCH). To examine the association of the number of EMS phone calls until hospital acceptance, age ≥65 years, high-risk injury, vital signs, holiday, and nighttime (0:00–8:00) with on-scene time, a generalized linear mixed model with random effects for four study regions was conducted.
Results
EMS phone calls were the biggest factor, accounting for 5.69 minutes per call, and high-risk injury accounted for an additional 2.78 minutes. Holiday, nighttime, and age ≥65 years were also associated with increased on-scene time, but there were no significant vital sign variables for on-scene time, except for the level of consciousness. Regional differences were also noted based on random effects, with a maximum difference of 2 minutes among regions.
Conclusions
The number of EMS phone calls until hospital acceptance was the most significant influencing factor in reducing on-scene time, and high-risk injury accounted for up to an additional 2.78 minutes. Considering these factors, including regional differences, can help improve the regional EMS policies and outcomes of RTI patients.
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12
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Profile and Outcome of Victims of an Earthquake in an Aging Society: A Population-Based Descriptive Study of the Earthquake in Osaka, Japan, on June 18, 2018. Disaster Med Public Health Prep 2022; 17:e149. [PMID: 35414369 DOI: 10.1017/dmp.2022.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study is to reveal the characteristics and outcomes of patients injured in a major earthquake and who were transported to a hospital by ambulance. METHODS This study was a retrospective descriptive epidemiological study including all patients who were injured after a major earthquake struck Osaka Prefecture on June 18, 2018, and were transported to a hospital by ambulance. The main outcome was the prognosis at each hospital's emergency department. RESULTS In total, 214 patients were included in the analysis. Their median age was 74 years (IQR, 54-82); 53 (24.8%) were men and 161 (75.2%) were women. The median time from ambulance call to arrival at the scene was 10 min (IQR, 7-15), and the median time from ambulance call to the hospital arrival was 37 min (IQR, 30-51). Ninety-seven patients (45.3%) were admitted to a hospital, 114 patients (53.3%) were discharged home to and from the emergency department, and 3 patients (1.4%) died. Among the patients discharged to home from the emergency department, the most common pathological condition was head bruising in 16 patients. CONCLUSIONS This study revealed the profile of injured patients transported by ambulances after an earthquake that struck an aging society.
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13
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Disparities Among Trauma Patients and Interventions to Address Equitable Health Outcomes. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00224-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Moafa HN, van Kuijk SM, Moukhyer ME, Alqahtani DM, Haak HR. Variation in on-scene time of emergency medical services and the extent of the difference of on-scene time between genders: a retrospective population-based registry study in Riyadh Province, Saudi Arabia. BMJ Open 2022; 12:e052481. [PMID: 35296475 PMCID: PMC8928325 DOI: 10.1136/bmjopen-2021-052481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To identify the intergender variation of on-scene time (OST) for highly urgent emergency cases conveyed by emergency medical services (EMS) in Saudi Arabia and to assess other predictors of OST and hypothesise for possible factors delaying OST. DESIGN A retrospective population-based registry study. SETTING Riyadh Province is the largest province in terms of population and the second in terms of geographical area. PARTICIPANTS All highly urgent transported patients from the scene to emergency departments, be they medical emergencies or trauma emergencies during 2018. OUTCOME MEASURE OST difference between men and women transported by EMS. RESULTS In total, 21 878 patients were included for analysis: 33.9% women and 66.1% men. The median OST for women was 22 min (IQR 15-30) and 18 min (IQR 11-26) for men (p<0.001); for medical cases, median OST was 23 min (IQR 16-31) for women compared with 20 min (IQR 13 - 29) for men (p<0.001); for trauma cases, the median OST of both sexes was equal. We found the following additional predictors of OST: factors of emergency type, sex, age category, geographical areas, type of ambulance vehicle and hospital type were all significantly associated with OST in the crude or adjusted analyses. Factors of emergency type, sex, age category, geographical areas, type of ambulance vehicle and hospital type were also significantly associated with the odds of OST of more than 15 min in the crude and adjusted regression analyses. CONCLUSIONS The median OST was longer than 15 min for more than half of transported cases. For medical cases, women had a longer median OST than men. Additional predictors associated with prolonged OST were the patient's age, area (ie, urban vs rural), type of ambulance vehicle and season. These findings are hypothesis generating and require further studies.
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Affiliation(s)
- Hassan N Moafa
- Health Services Management, Jazan University Faculty of Public Health and Tropical Medicine, Jazan, Saudi Arabia
- Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sander Mj van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Mohammed E Moukhyer
- Emergency Medical Services, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
- Public Health Programmes, School of Medicine, University of Limerick, Limerick, Ireland
| | - Dhafer M Alqahtani
- Saudi Red Crescent Authority, Department of Innovation and Development, Saudi Arabia Ministry of Health, Riyadh, Saudi Arabia
| | - Harm R Haak
- Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Faculty of Health Medicine and Life Sciences, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Internal Medicine, Maxima Medical Centre, Eindhoven, The Netherlands
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15
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Newman PC, Vernon TM, Bresz KE, Schwartz JAT. Location of Injury and Other Factors Associated With Increased Survival Among Severely Injured Geriatric Trauma Patients. Am Surg 2021; 88:613-617. [PMID: 34787509 DOI: 10.1177/00031348211050578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with a Trauma Injury Severity Score (TRISS) < .5 are termed "unexpected survivors." There is scarce information published on this subset of geriatric patients whose survival is an anomaly. METHODS This is a retrospective case-control study examining all geriatric patients (age ≥65) not expected to survive (TRISS<.5) in the Pennsylvania Trauma Outcome Study (PTOS) database from 2013 to 2017. Primary outcome was survival to discharge. We selected 10 clinically important variables for logistic regression analysis as possible factors that may improve survival. RESULTS 1336 patients were included, 395 (29.6%) were unexpected survivors. Factors that improved survival odds are the following: Place of injury: street/highway (AOR:0.51; 95% CI: .36-.73, P < .001) and residential institution (AOR:0.46; 95% CI: .21-.98, P = .043); and presence of Benzodiazepines (AOR:0.49; 95% CI: .31-.77, P = .002) or ethanol (AOR:0.57; 95% CI: .34-.97, P = .040). Factors that decreased survival odds are the following: Hypotension (AOR: 8.59; 95% CI: 4.33-17.01, P < .001) and hypothermia (AOR: 1.58; 95% CI: 1.10-2.28, P = .014). Gender, race/ethnicity, blood transfusion in first 24 hours, shift of presentation to Emergency Department, place of injury (farm, industrial, recreational, or public building), use of Tetrahydrocannabinol, amphetamines or opioids, and level of trauma activation did not impact survival. DISCUSSION Location of injury (street/highway and residential institution) and ethanol or benzodiazepine use led to a significant increased survival in severely injured geriatric patients. Hypotension and hypothermia led to decreased survival. Future studies should determine possible reasons these factors lead to survival (and identify additional factors) to focus efforts in these areas to improve outcomes in geriatric trauma.
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Affiliation(s)
- Paige C Newman
- Department of Trauma and Acute Care Surgery, 6569Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Tawnya M Vernon
- Department of Trauma and Acute Care Surgery, 6569Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Kellie E Bresz
- Department of Trauma and Acute Care Surgery, 6569Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Jennifer A T Schwartz
- Department of Trauma and Acute Care Surgery, 6569Penn Medicine Lancaster General Health, Lancaster, PA, USA
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16
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Popp LM, Ashburn NP, McGinnis HD, Stopyra JP. Prehospital Cross-Sectional Study of Drowning Patients Across the United States. Wilderness Environ Med 2021; 32:271-277. [PMID: 34183233 PMCID: PMC9052871 DOI: 10.1016/j.wem.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/26/2021] [Accepted: 03/03/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Every year drowning is responsible for 7% of injury-related deaths worldwide, making it the third leading cause of unintentional injury-related death. However, in the United States, little is known regarding the prehospital presentation and management of these patients. The purpose of this study was to describe the drowning population in the United States, with a focus on prehospital time intervals, transport, and cardiac arrest frequency. METHODS A retrospective cross-sectional study was performed querying records from emergency medical services encounters across the United States over 30 mo (January 2016 to July 2018) using the ESO (Austin, TX) national emergency medical services data registry. Patients with a dispatch or chief complaint of drowning were included. Descriptive statistics, binomial proportion tests, and general linear and logistic regression models were used. RESULTS There were 1859 encounters that met the study criteria. Median age was 18 y (n=1855, LQ-UQ 4-46). Pediatric patients accounted for 50% (n=919, 95% CI 47-52). Cardiac arrest occurred in 29% (n=537, 95% CI 27-31), and return of spontaneous circulation occurred in 37% (n=186, 95% CI 32-41). Times were 8±5, 19±17, and 15±10 min (mean±SD) for arrival, on-scene, and transport times, respectively. CONCLUSIONS This national prehospital drowning study demonstrated that despite an 18% fatality rate in drowning encounters, patients were more likely to have return of spontaneous circulation when compared to the overall prehospital national average, with rates higher in pediatric patients. Future studies with outcomes data should focus on identifying factors that improve cardiopulmonary resuscitation success rates.
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Affiliation(s)
- Lucas M Popp
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Henderson D McGinnis
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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17
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Finlay E, Palmer S, Abes B, Abo B, Fishe JN. Clinical, Operational, and Socioeconomic Analysis of EMS Bypass of the Closest Facility for Pediatric Asthma Patients. West J Emerg Med 2021; 22:972-978. [PMID: 35353998 PMCID: PMC8328167 DOI: 10.5811/westjem.2021.4.50382] [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: 10/22/2020] [Accepted: 04/13/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Pediatric hospital care is becoming increasingly regionalized, with fewer facilities providing inpatient care for common conditions such as asthma. That trend has major implications for emergency medical services (EMS) medical care and operations because EMS historically transports patients to the closest facility. This study describes EMS transport patterns of pediatric asthma patients in greater depth, including an analysis of facility bypass rates and the association of bypass with demographics and clinical outcomes. Methods This was a retrospective study of pediatric asthma patients ages 2–18 years transported by Lee County, FL EMS between March 1, 2018 – December 31, 2019. A priori, we defined bypass as greater than five minutes extra transport time. We performed geospatial analysis and mapping of EMS pediatric asthma encounters. We used the Pediatric Destination Tree (PDTree) project’s tiered approach to characterize receiving hospital facility pediatric capability. We analyzed incidence and characteristics of bypass, and bypass and non-bypass patient characteristics including demographics, emergency department (ED) clinical outcomes, and socioeconomic disadvantage (SED). Results From the study period, there were a total of 262 encounters meeting inclusion criteria, 254 (96.9%) of which could be geocoded to EMS incident and destination locations. Most encounters (72.8%) bypassed at least one facility, and the average number of facilities bypassed per encounter was 1.52. For all 185 bypass encounters, there was a median additional travel time of 13.5 minutes (interquartile range 7.5 – 17.5). Using the PDTree’s classification of pediatric capability of destination facilities, 172 of the 185 bypasses (93%) went to a Level I facility. Bypass incidence varied significantly by age, but not by minority status, asthma severity, or by the area deprivation index of the patient’s home address. Overall, the highest concentrations of EMS incidents tended to occur in areas of greater SED. With regard to ED outcomes, ED length of stay did not vary between bypass and non-bypass patients (P = 0.54), and neither did hospitalization (P = 0.80). Conclusion We found high rates of bypass for pediatric EMS encounters for asthma exacerbations, and that bypass frequency was significantly higher in younger age groups. With national trends pointing toward increasing pediatric healthcare regionalization, bypass has significant implications for EMS operations.
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Affiliation(s)
- Erik Finlay
- University of Florida Geoplan Center, Gainesville, Florida
| | - Sam Palmer
- University of Florida Geoplan Center, Gainesville, Florida
| | - Benjamin Abes
- Lee County Emergency Medical Services, Fort Myers, Florida
| | - Benjamin Abo
- Lee County Emergency Medical Services, Fort Myers, Florida
| | - Jennifer N Fishe
- University of Florida College of Medicine - Jacksonville, Pediatric Emergency Department, Jacksonville, Florida
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