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Background: In low- and middle-income countries (LMIC), 45% of deaths could be addressed by implementation of an emergency medical services (EMS) system. Prehospital care is a critical component of EMS worldwide, and basic, affordable training has been shown to improve EMS systems. However, patient outcome impact is unclear. In this study we aimed to assess the current state of prehospital care in Kigali, Rwanda, through a needs assessment, focused training intervention, and analysis of current practices and patient outcomes.Methods: We identified 30 clinicians through the prehospital medical command office and included them in the study. A prospective, nonrandomized, interrupted time-series approach was used. Data collected through closed- and open-ended questionnaires included age, sex, training, and knowledge assessment. We used the data to create a tailored, 18-hour training after which immediate and 11-month post-tests were administered. Linked prehospital and hospital care datasets allowed for evaluation of patient outcomes and prehospital process indicators that included training skill application, airway intervention, intravenous fluid administration, and glucose administration.Results: Of 30 clinicians, 18 (60%) were female, 19 were nurses, and 11 were nurse anaesthetists. Median age was 36, and median years providing care was 10 (IQR 7–11). Twenty-four (80%) participants completed immediate and post-test assessments. Mean knowledge across 12 core skills significantly improved from a pre-test mean of 59.7% (95% confidence interval [CI] 42.2–77.20) to a post-test mean of 87.8% (95% CI 74.7–100). At 11 months post-training, the score improvement maintained, with a mean score of 77.6%(95% CI 59.2–96.8). For patient outcomes, the total sample size was 572 patients; 324 of these patients were transported to the ED during the pre-training period (56.4%), while 248 were transported post-training. Prehospital oxygen administration for patients with a saturation level of

Introduction: Historically, prehospital care of trauma patients has included nearly universal use of a cervical collar (C-collar) and long spine board (LSB). Due to recent evidence demonstrating harm in using LSBs, implementation of new spinal motion restriction (SMR) protocols in the prehospital setting should reduce LSB use, even among patients with spinal cord injury. Our goal in this study was to evaluate the rates of and reasons for LSB use in high-risk patients—those with hospital-diagnosed spinal cord injury (SCI)—after statewide implementation of SMR protocols.Methods: Applying data from a state emergency medical services (EMS) registry to a state hospital discharge database, we identified cases in which a participating EMS agency provided care for a patient later diagnosed in the hospital with a SCI. Cases were then retrospectively reviewed to determine the prevalence of both LSB and C-collar use before and after agency adoption of a SMR protocol. We reviewed cases with LSB use after SMR protocol implementation to determine the motivations driving continued LSB use. We used simple descriptive statistics, odds ratios (OR) with 95% confidence intervals (CI) to describe the results.Results: We identified 52 EMS agencies in the state of Arizona with 417,979 encounters. There were 225 patients with SCI, of whom 74 were excluded. The LSBs were used in 52 pre-SMR (81%) and 49 post-SMR (56%) cases. The odds of LSB use after SMR protocol implementation was 70% lower than it had been before implementation (OR 0.297, 95% CI 0.139–0.643; P = 0.002). Use of a C-collar after SMR implementation was not significantly changed (OR 0.51, 95% CI 0.23–1.143; P = 0.10). In the 49 cases of LSB use after agency SMR implementation, the most common reasons for LSB placement were ease of lifting (63%), placement by non-transporting agency (18%), and extrication (16.3%). High suspicion of SCI was determined as the primary or secondary reason for not removing LSB after assessment in 63% of those with LSB placement, followed by multiple transfers required (20%), and critical illness (10%).Conclusion: Implementation of selective spinal motion restriction protocols was associated with a statistically significant decrease in the utilization of long spine boards among prehospital patients with acute traumatic spinal cord injury.

Background: Timely and effective pre-hospital management of penetrating neck injuries (PNI) is critical to improve patient outcomes. Pre-hospital interventions in patients with PNI can be especially challenging due to the anatomical injury site coupled with a resource-limited environment. Nationally, in the United Kingdom, no consensus statement or expert agreed guidance exists on how to best manage PNI in the pre-hospital setting. Method: We conducted a national modified e-Delphi study with subject matter experts (SMEs) from multiple professional specialities with experience in the management of PNI. Pre-identified SMEs were contacted and consented prior to participation allowing for a remotely conducted Delphi using REDCap and Microsoft Teams. In Round 1, statements drawn from the literature base were distributed to all SMEs. Round 2 comprised a facilitated and structured discussion of the statements and then an online survey provided final ratification in Round 3. Of the participating SMEs consensus was set a priori at 70%. Results: Of the 67 pre-identified SMEs, 28 participated, resulting in a response rate of 42%. From the first two rounds, 19 statements were derived with every statement achieving consensus in Round 3. Subsequently, an algorithm for the pre-hospital management of PNI was developed and agreed with SME consensus. Conclusion: Curation of national consensus statements from SMEs aims to provide principles and guidance for PNI management in a complicated patient group where pre-hospital evidence is lacking. Multi-professional national consensus on the best approach to manage these injuries alongside a novel PNI management algorithm aims to optimise time critical care and by extension improve patient outcomes. [ABSTRACT FROM AUTHOR]

We explored whether modified early warning scores (MEWS) could be used as a tool for triage in pre-hospital settings by comparing MEWS with patient triage on arrival to the emergency department (ED) and prognosis. Adult patients (=20 years old) admitted to EDs between 2016 and 2018 were enrolled from National Emergency Department Information System data in this retrospective study. A total of 8,609,955 participants were included in the analysis. EDMEWS of the dead (4.74 ± 2.51) was higher than that of admitted (1.86 ± 1.72) and discharged patients (1.18 ± 1.15) (p < 0.001). In admitted patients, non-survivors had higher EDMEWS than survivors (p<0.001), and as the level of the Korean Triage and Acquisition Scale was severe, EDMEWS increased (p<0.001) accordingly in these patients. EDMEWS had an adjusted hazard ratio (HR) of 1.164 (95% confidence interval: 1.135±1.194) for mortality (p<0.001). When an EDMEWS of 0 was used as a reference value, the HR increased with an increase in the EDMEWS. As EDMEWS increased from 1 to 7+, HR also increased from 1.115 to 2.508. EDMEWS has a positive correlation with mortality and admission rates in EDs. Moreover, admitted patients with higher EDMEWS had a longer duration of hospitalization and they had a higher mortality rate compared to patients with lower EDMEWS. MEWS can be a useful tool to provide evidence to support decision-making processes involving transportation to the ED and selection of the appropriate level of ED for pre-hospital EMS and longterm care facilities. [ABSTRACT FROM AUTHOR]

Background and Objectives Materials and Methods Results Conclusion In the setting of trauma and suspected critical bleeding, indications to commence blood transfusions remain unclear, with high rates of potentially avoidable transfusions. Prehospital blood lactate measurements could help predict the need for blood transfusions. The aim of this study was to compare measurements detected by a point‐of‐care (POC) lactate device with laboratory measured lactate levels.This was a cross‐sectional study conducted in the emergency department. Eligible patients were those with suspected major trauma and critical bleeding. Venous or arterial blood samples were collected. POC measurements of lactate levels were conducted using a StatStrip Xpress® lactate meter and compared with laboratory values.Among 70 patients, the mean difference between the POC and laboratory lactate results was −0.19 mmol/L, with limits of agreement at −1.9 and 1.5. Most measurements (n = 66; 94.3%) were within the limits of agreement. A POC lactate level of >3.3 mmol/L had >90% specificity for transfusion, whereas a level <1.4 mmol/L had 90% sensitivity to rule out a transfusion.The level of agreement of POC lactate with the laboratory lactate was high. Research on clinical decision rules for pre‐hospital transfusion that incorporate POC lactate measures is therefore feasible. [ABSTRACT FROM AUTHOR]

Background: Helicopter emergency services (HEMS) are widely used to bring medical assistance to individuals that cannot be reached by other means or individuals that have time‐critical medical conditions, such as chest pain, stroke or severe trauma. It is a very expensive resource whose use and importance depends on local conditions. The aim of this study was to describe flight and patient characteristics in all HEMS flights done in Iceland, a geographically isolated, mountainous and sparsely populated country, over a 5‐year course. Methods: This retrospective study included all individuals requiring HEMS transportation in Iceland during 2018–2022. The electronic database of the Icelandic Coast Guard was used to identify the individuals and register flight data. Electronic databases from Landspitali and Akureyri hospitals were used to collect clinical variables. Descriptive statistics was applied. Results: The average number of HEMS transports was 3.5/10,000 inhabitants and the median [IQR] activation time and flight times were 30 min [20–42] and 40 min [26–62] respectively. The vast majority of patients were transported to Landspitali Hospital in Reykjavik. More than half of the transports were due to trauma, the most common medical transports were due to chest pain or cardiac arrests. Advanced medical therapy was provided for 66 (10%) of individuals during primary transports, 157 (24%) of individuals were admitted to intensive care, 188 (28%) needed surgery and 53 (7.9%) needed a coronary angiography. Conclusion: In Iceland, the number of transports is lower but activation and flight times for HEMS flights are considerably longer than in other Nordic countries, likely due to geographical features and the structure of the service including utilizing helicopters both for HEMS and search and rescue operations. The transport times for some time‐sensitive conditions are not within standards set by international studies and guidelines. [ABSTRACT FROM AUTHOR]

Background: While COVID‐19 is predominantly a respiratory disease, cardiovascular complications occur and are associated with worse outcomes. Electrocardiogram (ECG) abnormalities are frequently observed in hospitalized COVID‐19 patients, some of which are associated with increased mortality. It is unclear whether ECG abnormalities occurring before hospitalization are associated with increased mortality. This quantitative systematic literature review aims to determine which ECG changes occurring before hospitalization are associated with mortality and discuss whether these findings can aid the assessment of patients and decision‐making in the pre‐hospital environment. Methods: A systematic search of the following digital databases was conducted: CINAL, PUBMED, MEDLINE, and Coronavirus Research Database. Eight cohort studies (primary papers) including COVID‐19 patients with ECGs taken in the Emergency Department before hospitalization were selected for quantitative synthesis and results were obtained for the prevalence of ECG changes among survivors compared with non‐survivors. Odds and hazard ratios for ECG abnormalities associated with mortality were also collected and compared. Results: Identification of ECG abnormalities on pre‐hospitalization ECG is associated with increased mortality in COVID‐19 patients. These ECG abnormalities include non‐sinus rhythm, QTc prolongation, left bundle branch block, axis deviation, atrial fibrillation, atrial flutter, right ventricular strain patterns, ST segment changes, T wave abnormalities, and evidence of left ventricular hypertrophy. Conclusion: Electrocardiogram assessment in the pre‐hospital environment may be beneficial when assessing COVID‐19 patients and could help identify patients at increased risk of mortality. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusions Improved understanding of the deteriorating patient in the pre‐hospital setting may result in earlier recognition and response. Considering the effects of undetected deterioration are profound, it is fundamental to report the prevalence of pre‐hospital clinical deterioration to advance our understanding. The present study investigated the prevalence of pre‐hospital clinical deterioration and adverse events (AEs) within 3 days of the pre‐hospital episode of care.This retrospective cohort study was based on pre‐hospital incidents involving adult patients attended by Queensland Ambulance Service between 1 January 2018 and 31 December 2020. Due to lacking a standardised definition of pre‐hospital clinical deterioration, established early warning scores (NEWS, MEWS and Q‐ADDS) were calculated from pre‐hospital vital signs to identify clinical deterioration. Linked hospital data were used to identify the occurrence of an AE.Some degree of physiological derangement was initially observed in over half of the patients, and pre‐hospital clinical deterioration was seen in 2.7%–4% of patients. The prevalence of AEs was 3.2%. Patients that experienced an AE were more likely to be male, elderly, suffering from a medical (non‐trauma) condition, and had a greater burden of disease. Concerningly, almost 50% of patients that suffered an AE did not meet escalation thresholds of NEWS, MEWS or Q‐ADDS.The present study found the prevalence of pre‐hospital clinical deterioration and AEs subsequent to pre‐hospital episodes of care to be low. Future research should prioritise using standardised criteria to define pre‐hospital clinical deterioration and evaluate the performance of early warning scores. [ABSTRACT FROM AUTHOR]

Background: Helicopter Emergency Medical Services (HEMS) in the United Kingdom (UK) deliver enhanced care to high-acuity, critically ill and injured patients. To enable patients to meet the HEMS team who treated them, many services within the UK have developed or are in the process of developing a Patient and Family Aftercare Service (PFAS). This study aims to evaluate whether the introduction of PFAS mitigates anxiety associated with patient aftercare visits. Methods: A service evaluation of anxiety in HEMS team members before and after patient aftercare visits were conducted. The study was carried out between 1 September 2023, and 31 October 2023, and patient visits were undertaken between March 2022 and July 2023. An electronic survey was distributed to the respondents who provided informed consent for participation. The survey comprised the validated generalised anxiety disorder anxiety scale (GAD-7) and five additional contextualised statements developed through the wider PFAS. Anonymised data were collected using REDCap, a secure electronic database and was analysed in R programming. Free-text comments were reported by content analysis, placed into themes, and discussed with a narrative to complement the quantitative analysis. Results: Of the 33 recipients, 25 completed the questionnaire. Between the pre- and post-aftercare visits, a statistically significant difference was found between scores for GAD-7 (0.004, p < 0.05) and contextualised statements (0.001, p < 0.05). In addition, six broad themes were identified through content analysis. These include the emotional impact of patient interaction, coping strategies and structural changes in the aftercare system, challenges in patient and family expectations, anxieties relating to operational commitments, memory and recall of the incident, and a positive impact on personal growth. Conclusion: Anxiety related to patient aftercare visits was reduced when measured before and after the patient visits. Following this service evaluation, we can hypothesise that within pre-hospital care, PFAS plays an important structural role. Future research should focus on affirming the correct tool to measure anxiety in multi-disciplinary teams and prospectively evaluating these methods collaboratively across multiple pre-hospital services. [ABSTRACT FROM AUTHOR]

Traumatic injury remains a significant public health problem, with the burden highest in low-middle income countries (LMICs) and rural areas.1,2 The far-western region of Nepal, which has the lowest human development index in the country, has a high burden of traumatic injuries.3-5 One hospital in the far-western district of Achham, Bayalpata Hospital, cares for the majority of patients with traumatic injuries – most of whom arrive without any pre-hospital care. The absence of a professionalized pre-hospital program, such as an established Emergency Medical Services (EMS) system, necessitates creative strategies to address this gap.6,7 In this context, implementing a trauma-training program for community health responders (CHRs) offers a promising solution, leveraging local resources to improve early-stage trauma care. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusions A 45‐min interval from injury to intubation has been proposed as a performance indicator for severe trauma patient management. In the Sydney pre‐hospital system a previous change in case identification systems was associated with activation delay. We aimed to determine if this also decreased the proportion of patients intubated within this benchmark.Retrospective cohort study of patients intubated by a helicopter emergency medical service (HEMS) over two time periods. Period 1 dispatch was via HEMS crew directly screening the computerised dispatch system, and period 2 was via paramedics in a central control room. Times from emergency call to intubation were compared.In the HEMS crew screening period 46/58 (79.31%) intubations met the target, compared with 137/314 (43.6%) in the central control period (P < 0.001). The median (interquartile range) time to intubation in the direct crew screening period was 33 (25–41) min, versus the central control period at 47 (38–60) min (P < 0.001).On multivariate modelling, distance to the scene was related to time to intubation (P < 0.001; Incident Rate Ratio = 1.018, 95% confidence interval 1.015–1.020) as was dispatch system, entrapment/access difficulty and indication for intubation (all P < 0.001).Time from emergency call to intubation was significantly shorter in the HEMS screening period where all non‐trapped cases less than 50 km distant were intubated within the 45‐min benchmark. There was no distance where intubation within 45 min could be assured for non‐trapped patients in the central control period due to dispatch delays. [ABSTRACT FROM AUTHOR]

Paramedics are exposed to many infectious diseases in their professional activities, leading to a high risk of transmitting infectious diseases to patients in out-of-hospital settings, possibly leading to health care associated infections in hospitals and the community. The COVID-19 pandemic highlighted the importance of infection prevention and control in health care and the role of paramedics in infection control is considered even more critical. Despite this, in many countries such as Australia, research into infection prevention and control research has mainly been focused on in-hospital health care professionals with limited out-of-hospital studies. This scoping review was based upon Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Literature on knowledge and awareness of infection prevention and control in paramedics in Australia and other countries was evaluated. Based upon selection criteria applied, six papers were identified for inclusion in this review. In many studies, infection prevention and control was identified as being important, however compliance with hand hygiene practices was low and most studies highlighted the need for more education and training on infectious disease for paramedics. Current evidence suggests that paramedics have poor compliance with recommended IPC practices. The profession needs to improve IPC education, training, and culture. • Overall, paramedics have poor compliance with infection prevention and control practices (IPC). • Compared with other health professions the paramedicine profession is behind on IPC practices. • There is urgent need for further research into IPC practices in paramedicine. [ABSTRACT FROM AUTHOR]

Emergency medicine (EM) globally is a new medical speciality when compared with traditional medical specialities such as surgery, obstetrics, gynaecology and internal medicine. It is a medical speciality that deals with the management of acute illnesses and injuries in a timely and result-oriented manner. The International Federation of EM defines it as a field of practice based on the knowledge and care required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury, affecting patients of all age groups with a full spectrum of episodic, undifferentiated physical and behavioural disorders. Two types of EM are recognised: the out-of-hospital emergency medical services (OHEMS) and the in-hospital emergency medical services (IHEMS). OHEMS was introduced into the country in 1998 by the Lagos state government. IHEMS had been in place for much longer, but it was practised in a heterogeneous and substandard manner. The result of the latter is a casualty department with an overwhelming burden of patients and a high mortality rate. The World Health Assembly (WHA) resolution 60.22 of 2007 mandated every member state government to establish and monitor integrated EM care systems; it is therefore expected that the emergency medical services (EMS) in the country would wear a new look. However, anecdotal reports suggest that both OHEMS and IHEMS in the country are rudimentary and there is no strong evidence to show that EM is embraced by all as a medical speciality. The objective of this study is to examine the challenges and prospects of EM as a medical speciality in Nigeria. A review of the past literature searched in Google, Google Scholar, PubMed and African Journal online was conducted. A total of 40 relevant publications in addition to the authors knowledge and exposure in EM supported the information presented in this manuscript. Our study revealed that inadequate funding and ambulance services, nonavailability of trained bystanders, limited infrastructure and skilled manpower, inadequate and inequitable distribution of health resources, lack of standard emergency department, high out-of-pocket expenses and substandard implementation of EMS policies, are factors militating against a functional EMS in the country. In line with the philosophy of WHA resolution72.16 of 2019, it is recommended that the central government should put in place a mechanism for full and sustainable implementation of the NHIA Act (2022), National Emergency Medical Services and Ambulance System (NEMSAS) and the patient's bill of rights and direct the adoption of EM as a medical speciality in all federal and state hospitals. In addition, the central government should create public awareness, improve road networks, provide funding, and establish collaboration with local and international organisations. [ABSTRACT FROM AUTHOR]

Abstract Background Timely and effective pre-hospital management of penetrating neck injuries (PNI) is critical to improve patient outcomes. Pre-hospital interventions in patients with PNI can be especially challenging due to the anatomical injury site coupled with a resource-limited environment. Nationally, in the United Kingdom, no consensus statement or expert agreed guidance exists on how to best manage PNI in the pre-hospital setting. Method We conducted a national modified e-Delphi study with subject matter experts (SMEs) from multiple professional specialities with experience in the management of PNI. Pre-identified SMEs were contacted and consented prior to participation allowing for a remotely conducted Delphi using REDCap and Microsoft Teams. In Round 1, statements drawn from the literature base were distributed to all SMEs. Round 2 comprised a facilitated and structured discussion of the statements and then an online survey provided final ratification in Round 3. Of the participating SMEs consensus was set a priori at 70%. Results Of the 67 pre-identified SMEs, 28 participated, resulting in a response rate of 42%. From the first two rounds, 19 statements were derived with every statement achieving consensus in Round 3. Subsequently, an algorithm for the pre-hospital management of PNI was developed and agreed with SME consensus. Conclusion Curation of national consensus statements from SMEs aims to provide principles and guidance for PNI management in a complicated patient group where pre-hospital evidence is lacking. Multi-professional national consensus on the best approach to manage these injuries alongside a novel PNI management algorithm aims to optimise time critical care and by extension improve patient outcomes.

Abstract Background Helicopter Emergency Medical Services (HEMS) in the United Kingdom (UK) deliver enhanced care to high-acuity, critically ill and injured patients. To enable patients to meet the HEMS team who treated them, many services within the UK have developed or are in the process of developing a Patient and Family Aftercare Service (PFAS). This study aims to evaluate whether the introduction of PFAS mitigates anxiety associated with patient aftercare visits. Methods A service evaluation of anxiety in HEMS team members before and after patient aftercare visits were conducted. The study was carried out between 1 September 2023, and 31 October 2023, and patient visits were undertaken between March 2022 and July 2023. An electronic survey was distributed to the respondents who provided informed consent for participation. The survey comprised the validated generalised anxiety disorder anxiety scale (GAD-7) and five additional contextualised statements developed through the wider PFAS. Anonymised data were collected using REDCap, a secure electronic database and was analysed in R programming. Free-text comments were reported by content analysis, placed into themes, and discussed with a narrative to complement the quantitative analysis. Results Of the 33 recipients, 25 completed the questionnaire. Between the pre- and post-aftercare visits, a statistically significant difference was found between scores for GAD-7 (0.004, p

Abstract Background (Rationale/Purpose/Objective) Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporary control non-compressible truncal hemorrhage (NCTH) as bridge to definitive surgical treatment. The dependence on radiography for safe balloon positioning is one factor that limits the extended use of REBOA in civilian and military pre-hospital settings. We aimed to determine standardized sex and age-based variable-distance catheter insertion lengths for accurate REBOA placement without initial fluoroscopic confirmation. Methods Contrast enhanced CT-scans from a representative sample of a Dutch non-trauma population were retrospectively analyzed. Intravascular distances were measured from the bilateral common femoral artery access points (FAAP) to the middle of the aortic occlusion zones and accompanying boundaries. Means and 95% confidence intervals for the distances from the FAAPs to the boundaries and mid-zone III were calculated for all (combined) sex and age-based subgroups. Optimal insertion lengths and potentially safe regions were determined for these groups. Bootstrap analysis was performed in combination with a 40-mm long balloon introduction simulation to determine error-rates and REBOA placement accuracy for the general population. Results In total, 1354 non-trauma patients (694 females) were included. Vascular distances increased with age and were longer in males. The iliofemoral trajectory was 7 mm longer on the right side. The optimal zone I catheter insertion length would be 430 mm. Optimal zone III catheter insertion lengths showed up to 30 mm difference, ranging between 234 and 264 mm. Statistically significant and potentially clinically relevant differences were observed between the anatomical distances and necessary introduction depths for each subgroup. Conclusion This is the first study to compare aortic morphology and intravascular distances between combined sex and age-based subgroups. As zone III length was consistent, length variability and elongation seem to mainly originate in the iliofemoral trajectory and zone II. The optimal zone I catheter insertion length would be 430 mm. Optimal zone III catheter insertion ranged between 234 and 264 mm. These standardized variable-distance insertion lengths could facilitate safer fluoroscopy-free REBOA in austere, pre-hospital settings.

Objectives Methods Results Conclusion ‘Dirty adrenaline’ is the informal term used for a rapidly made peripheral dilute adrenaline infusion in the emergency treatment of shock, most commonly 1 mg adrenaline in 1 L 0.9% NaCl. It has long been part of the remote clinician's arsenal despite no supporting scientific literature. Remote clinics in Central Australia can be hours away from critical care support. The region's high prevalence of renal and cardiac disease means that access to early vasopressors and inotropes is a necessity for treating shock. To tackle this, remote clinicians often use ‘dirty adrenaline’. We present a review of ‘dirty adrenaline’ use in this region.Central Australian Retrieval Service's database was screened to identify cases in which a peripheral dilute adrenaline infusion was administered in a remote clinic prior to patient aeromedical retrieval. A retrospective chart review collected: patient demographics; clinical characteristics; infusion details; adverse events; hospital lengths of stay; and mortality outcomes.Fifty‐seven cases were identified. Median patient age was 50 (range: 2–96). Septic shock was the most common clinical indication (40/57). Median infusion duration was 155 min. Median systolic BP from commencement until retrieval increased from 75.5 to 91 mmHg. Survival to hospital discharge was 86% (49/57). No significant adverse events associated with ‘dirty adrenaline’ were recorded.‘Dirty adrenaline’ is safe to administer and appears to considerably improve survival when used to treat fluid‐resistant shock in remote nurse‐led clinics guided by an off‐site critical care physician. [ABSTRACT FROM AUTHOR]

Background and Aim: The importance and role of the pre-hospital emergency system as the frontline of treatment in reducing casualties and damage to patients, as well as the unknown nature of some biohazardous factors, should be considered. This study aims to investigate the prepared components of the pre-hospital emergency system in dealing with biological threats. Methods: This study is a two-stage qualitative research. The first stage used the critical review method, and the second used the guided qualitative content analysis method. The studied population at this stage consisted of 14 people who were experts in the field of biology. Data were collected and analyzed through semi-structured interviews. Results: After integrating the dimensions and components obtained from the literature review and interviews and based on the opinions of the supervisors and advisors and the summary of the research team, seven dimensions and 23 final components of pre-hospital preparedness in biothreat were extracted and finalized. The study's final findings include seven dimensions of disease warning and diagnosis, information and communication management, management, planning and evaluation, resources and equipment management, documenting and recording experiences, training and practice, and safety and security. Conclusion: The present study can be a reliable source for evaluating biological exercises and actual biological operations by identifying the components and dimensions required for biological exercise. Planning and implementing activities related to the role of the main elements of preparedness identified in this review can help improve the preparedness of emergency medical service systems in incidents. Also, the findings of this study provide valuable information to EMS educators, EMS managers, and researchers. [ABSTRACT FROM AUTHOR]

Background (Rationale/Purpose/Objective): Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporary control non-compressible truncal hemorrhage (NCTH) as bridge to definitive surgical treatment. The dependence on radiography for safe balloon positioning is one factor that limits the extended use of REBOA in civilian and military pre-hospital settings. We aimed to determine standardized sex and age-based variable-distance catheter insertion lengths for accurate REBOA placement without initial fluoroscopic confirmation. Methods: Contrast enhanced CT-scans from a representative sample of a Dutch non-trauma population were retrospectively analyzed. Intravascular distances were measured from the bilateral common femoral artery access points (FAAP) to the middle of the aortic occlusion zones and accompanying boundaries. Means and 95% confidence intervals for the distances from the FAAPs to the boundaries and mid-zone III were calculated for all (combined) sex and age-based subgroups. Optimal insertion lengths and potentially safe regions were determined for these groups. Bootstrap analysis was performed in combination with a 40-mm long balloon introduction simulation to determine error-rates and REBOA placement accuracy for the general population. Results: In total, 1354 non-trauma patients (694 females) were included. Vascular distances increased with age and were longer in males. The iliofemoral trajectory was 7 mm longer on the right side. The optimal zone I catheter insertion length would be 430 mm. Optimal zone III catheter insertion lengths showed up to 30 mm difference, ranging between 234 and 264 mm. Statistically significant and potentially clinically relevant differences were observed between the anatomical distances and necessary introduction depths for each subgroup. Conclusion: This is the first study to compare aortic morphology and intravascular distances between combined sex and age-based subgroups. As zone III length was consistent, length variability and elongation seem to mainly originate in the iliofemoral trajectory and zone II. The optimal zone I catheter insertion length would be 430 mm. Optimal zone III catheter insertion ranged between 234 and 264 mm. These standardized variable-distance insertion lengths could facilitate safer fluoroscopy-free REBOA in austere, pre-hospital settings. [ABSTRACT FROM AUTHOR]

Objective: To assess the safety and effectiveness of peripheral vasoactive drugs initiated during pre‐hospital care and retrieval missions, in Queensland, Australia. Methods: Three years of retrospective data was gathered from two sources. Medical notes were reviewed using a search for any patient having 'inotrope' recorded on an electronic medical record. Each case was reviewed to include only peripheral infusions of adrenaline or noradrenaline. Clinical Governance records were searched for adverse events related to vasoactive drugs, alerted for review to ensure complete capture. Results: A total of 418 patients received peripheral infusions of adrenaline and noradrenaline over the 3‐year period. No major complications were recorded either immediately or at Clinical Governance review. Minor complications were recorded in 4.7% of the cases, of which 3.5% occurred with peripheral vasoactives during the presence of the retrieval team. The frequency of use of peripheral vasoactives increased over the study period. Conclusions: In this retrospective data set there were no major complications of peripheral vasoactive drugs. Minor complications were similar to in‐hospital use and related to vascular access and drug delivery. [ABSTRACT FROM AUTHOR]

ABSTRACT Background While COVID‐19 is predominantly a respiratory disease, cardiovascular complications occur and are associated with worse outcomes. Electrocardiogram (ECG) abnormalities are frequently observed in hospitalized COVID‐19 patients, some of which are associated with increased mortality. It is unclear whether ECG abnormalities occurring before hospitalization are associated with increased mortality. This quantitative systematic literature review aims to determine which ECG changes occurring before hospitalization are associated with mortality and discuss whether these findings can aid the assessment of patients and decision‐making in the pre‐hospital environment. Methods A systematic search of the following digital databases was conducted: CINAL, PUBMED, MEDLINE, and Coronavirus Research Database. Eight cohort studies (primary papers) including COVID‐19 patients with ECGs taken in the Emergency Department before hospitalization were selected for quantitative synthesis and results were obtained for the prevalence of ECG changes among survivors compared with non‐survivors. Odds and hazard ratios for ECG abnormalities associated with mortality were also collected and compared. Results Identification of ECG abnormalities on pre‐hospitalization ECG is associated with increased mortality in COVID‐19 patients. These ECG abnormalities include non‐sinus rhythm, QTc prolongation, left bundle branch block, axis deviation, atrial fibrillation, atrial flutter, right ventricular strain patterns, ST segment changes, T wave abnormalities, and evidence of left ventricular hypertrophy. Conclusion Electrocardiogram assessment in the pre‐hospital environment may be beneficial when assessing COVID‐19 patients and could help identify patients at increased risk of mortality.

Exploring inequalities in ambulance and pre-hospital demand is important to improve service equity and reduce wider health inequalities. Maternity incidents amongst ambulance demand are a key area of focus because of the specialized care that is needed for patients, as well as the impact of wider determinants of health on pregnancy outcomes. Since there are spatial inequalities amongst pregnant patients who call for an ambulance, the aim of this study is to assess the underlying factors associated with pregnancy related ambulance complaints, to determine why maternity patients utilize the ambulance service. Local indicators of spatial autocorrelation were used to identify clusters of ambulance maternity demand within Greater London (UK). A negative binomial regression model was used to explore associations between socioeconomic, environmental, accessibility and demographic variables. Our results reveal that neighborhoods with low adult skills (i.e. qualifications/English language abilities) have a higher rate of demand. Moreover, our results imply that the demand for ambulance services may not be directly tied to health outcomes; rather, it might be more closely associated with patients' reasons for calling an ambulance, irrespective of the actual necessity. The benefits of identifying factors that drive demand in ambulance services are not just linked to improving equity, but also to reducing demand, ultimately relieving pressure on services if alternative options are identified or underlying causes addressed. Doing so can improve health inequalities by firstly, improving ambulance care equity by directly supporting a better allocation of resources within ambulance systems to target patterns in demand.

Abstract Introduction Pre-hospital ambulance service is the most important part of healthcare service. Client satisfaction with the service indicates the degree of adaptation to the appropriate quality and quantity of services. Patients’ dissatisfaction with the service can affect their expectations of the overall services that they will receive later in the definitive care facility. However, it is not a well-addressed area in developing countries, including Ethiopia. Objective This study aimed to identify the ambulance service satisfaction level and associated factors among service users in Addis Ababa, Ethiopia. Methods A cross-sectional study was conducted in five governmental hospitals in Addis Ababa city. A face-to-face exit interview technique was employed on a total of 410 consecutively selected participants using a pretested tool developed from similar sources. The cleaned data was entered into the Epi-Data Manager 4.6 version and then exported to SPSS version 26 for analysis. The dependent variable was dichotomized into satisfied and unsatisfied to compute bivariate logistic regression. In the multivariate logistic regression model, predictors with a p-value

Abstract Background Efficient resource distribution is important. Despite extensive research on response timings within ambulance services, nuances of time from unit dispatch to becoming available still need to be explored. This study aimed to identify the determinants of the duration between ambulance dispatch and readiness to respond to the next case according to the patients’ transport decisions. Methods Time from ambulance dispatch to availability (TDA) analysis according to the patients’ transport decision (Transport versus Non-Transport) was conducted using R-Studio™ for a data set of 93,712 emergency calls managed by a Middle Eastern ambulance service from January to May 2023. Log-transformed Hazard Ratios (HR) were examined across diverse parameters. A Cox regression model was utilised to determine the influence of variables on TDA. Kaplan–Meier curves discerned potential variances in the time elapsed for both cohorts based on demographics and clinical indicators. A competing risk analysis assessed the probabilities of distinct outcomes occurring. Results The median duration of elapsed TDA was 173 min for the transported patients and 73 min for those not transported. The HR unveiled Significant associations in various demographic variables. The Kaplan–Meier curves revealed variances in TDA across different nationalities and age categories. In the competing risk analysis, the ‘Not Transported’ group demonstrated a higher incidence of prolonged TDA than the ‘Transported’ group at specified time points. Conclusions Exploring TDA offers a novel perspective on ambulance services’ efficiency. Though promising, the findings necessitate further exploration across diverse settings, ensuring broader applicability. Future research should consider a comprehensive range of variables to fully harness the utility of this period as a metric for healthcare excellence.

Abstract Background Severity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm. Methods We conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets. Results After exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023). Conclusions Based on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.

Abstract Purpose Emergency Medical Services (EMS) in Alberta are facing critical challenges. This qualitative study aims to describe and understand the frontline perspective regarding system level issues and propose provider-informed policy recommendations. Methods 19 semi-structured one-on- one interviews were conducted with Primary or Advanced Care Paramedics (PCP/ACP) across Alberta. Participants were asked to share their perspectives, experiences and recommendations in relation to EMS response times and the working environment. Interviews were analyzed using thematic analysis to identify themes and subthemes. Results Two core themes were identified as areas of concern: poor response times and the EMS working environment, which each influence and impact the other. Within response times, paramedics highlighted specific difficulties with ED offloading, a lack of resources, low-acuity calls, and rural challenges. In terms of the EMS working environment, four subthemes were apparent including attrition, unhealthy culture, organizational barriers and the need for paramedic empowerment. Providers made many recommendations including creating and expanding emergency mobile integrated health (MIH) branches, sharing 811 and 911 responses, and enforcing ED target offload times amongst other suggestions. Conclusions While response times are a key and highly visible problem, there are many critical factors like the EMS working environment that degrade patient care and cause concern amongst frontline practitioners. Multifaceted policy changes are to be explored to reduce disfunction within EMS services, enhance the well-being of the workforce and deliver improved patient care. Specific EMS-oriented policies are important for moving forward to reduce transfers to EDs, but the broader health system which is over capacity is causing downstream effects into EMS must be addressed by government and health administrators.

Introduction: Hypothermia is a well‐recognised finding in trauma patients, which can occur even in warmer climates. It is an independent predictor of increased morbidity and mortality. It is associated with pre‐hospital intubation, although the reasons for this are likely to be multifactorial. Core temperature drop after induction of anaesthesia is a well‐known phenomenon in the context of elective surgery, and the mechanisms of this are well established. Methods: We conducted a prospective observational study to examine the behaviour of core temperature in patients undergoing pre‐hospital anaesthesia for traumatic injuries. Results: Between 2017 and 2021 data were collected on 48 patients. The data from 40 of these were included in the final analysis. Discussion: Our data do not show a decrease in the core temperatures of patients who receive pre‐hospital anaesthesia, unlike patients who are anaesthetised without pre‐warming, in operating theatres. The lack of a change could relate to patient, anaesthetic or environmental factors. [ABSTRACT FROM AUTHOR]

The goal of emergency medical services (EMS) is to provide urgent medical care and stabilization prior to patient transport to a healthcare facility for definitive treatment. The number and variety of interventions performed in the field by EMS providers continues to grow as early management of severe injuries and critical illness in the pre-hospital setting has been shown to improve patient outcomes. The sequela of many field interventions, including those associated with airway management, emergent vascular access, cardiopulmonary resuscitation (CPR), patient immobilization, and hemorrhage control may be appreciated on emergency department admission imaging. Attention to these imaging findings is important for the emergency radiologist, who may be the first to identify a malpositioned device or an iatrogenic complication arising from pre-hospital treatment. Recognition of these findings may allow for earlier corrective action to be taken in the acute care setting. This review describes common EMS interventions and their imaging findings. [ABSTRACT FROM AUTHOR]

Background: The interest in re‐introducing whole blood (WB) transfusion for the management of traumatic major haemorrhage is increasing. However, due to the current leucodepletion filters used in the UK a WB component was not readily available. Instead, an alternative but similar component, leucocyte depleted red cell and plasma (LD‐RCP), which provided a unique experience in assessing the feasibility of a WB component was used whilst a WB component was being manufactured. Study Design and Methods: Between November 2018 and October 2020, LD‐RCP replaced RBC as standard of care for all trauma patients with major haemorrhage in London. The aims of the study were to assess (a) deliverability, (b) component wastage and (c) safety. Results: Over the study period a total of 1208 LD‐RCP units were delivered, of which 96.5% were delivered 'On Time In Full' (OTIF). Of the 1208 units, 733 (60.68%) were transfused and 475 (39.3%) units were wasted. Component wastage reduced significantly throughout the study (p = 0.001). A total of 177 patients had a blood group recorded, 86 were group O and 91 were non‐group O. There was no statistically significantly difference between haemoglobin (p = 0.422), or bilirubin levels (p = 0.084) between group O and non‐group O patients. Discussion: It was feasible for NHS Blood and Transplant to deliver LD‐RCP on time in full, however component wastage was high due to short shelf life and limited use of the component. Low titre group O LD‐RCP units were not associated with clinical evidence of haemolysis. [ABSTRACT FROM AUTHOR]

Background. Cardiovascular disease is a major health issue for Māori that requires timely and effective first-response care. Māori report culturally unsafe experiences in health care, resulting in poor health outcomes. Research in the pre-hospital context is lacking. This study aimed to explore experiences of cultural (un)safety for Māori and their whānau who received acute pre-hospital cardiovascular care from paramedics. Methods. Utilising a qualitative descriptive methodology and Kaupapa Māori Research (KMR), in-depth semi-structured interviews were undertaken with 10 Māori patients and/or whānau, and a general inductive approach was used for analysis. Results. Three key themes were identified: (1) interpersonal workforce skills, (2) access and service factors and (3) active protection of Māori. Participants described paramedics' clinical knowledge and interpersonal skills, including appropriate communication and ability to connect. Barriers to accessing ambulance services included limited personal and community resources and workforce issues. The impact of heart health on communities and desire for better preventative care highlighted the role of ambulance services in heart health. Conclusion. Māori experience culturally unsafe pre-hospital care. Systemic and structural barriers were found to be harmful despite there being fewer reports of interpersonal discrimination than in previous research. Efforts to address workforce representation, resource disparities and cultural safety education (focussing on communication, partnership and connection) are warranted to improve experiences and outcomes for Māori. [ABSTRACT FROM AUTHOR]

Introduction: Pre-hospital ambulance service is the most important part of healthcare service. Client satisfaction with the service indicates the degree of adaptation to the appropriate quality and quantity of services. Patients' dissatisfaction with the service can affect their expectations of the overall services that they will receive later in the definitive care facility. However, it is not a well-addressed area in developing countries, including Ethiopia. Objective: This study aimed to identify the ambulance service satisfaction level and associated factors among service users in Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted in five governmental hospitals in Addis Ababa city. A face-to-face exit interview technique was employed on a total of 410 consecutively selected participants using a pretested tool developed from similar sources. The cleaned data was entered into the Epi-Data Manager 4.6 version and then exported to SPSS version 26 for analysis. The dependent variable was dichotomized into satisfied and unsatisfied to compute bivariate logistic regression. In the multivariate logistic regression model, predictors with a p-value < 0.05 at the 95% CI were considered to have a significant association. Result: A total of 410 respondents were included in the study. The mean of participants' responses regarding ambulance personnel, call operator, treatment on the scene, and ambulance subscale was 3.64, 3.48, 3.40, and 3.43, respectively. The study found that only 21.5% of participants were satisfied by the ambulance service they received. There was a statistically significant association between ambulance service satisfaction and age (AOR = 3.52, 95% CI: 1.01–12.36), monthly income (AOR = 3.13, 95% CI: 1.41–6.94), ambulance response time (AOR = 10.33, 95% CI: 2.09–51.06), type of ambulance used (AOR = 4.55, 95% CI: 2.19–9.43), and previous ambulance usage (AOR = 2.33, 95% CI: 1.34–4.05). Conclusion: The study found a low level of satisfaction among ambulance users. The findings suggest that ambulance personnel performance is a key determinant of user satisfaction, while treatment at the scene and in the ambulances, and call operator areas require improvement. Age, monthly income, ambulance response time, type of ambulance, and previous ambulance use also influenced satisfaction. Improving the quality of services, reducing response time, and ensuring call operators are trained are vital steps to enhance satisfaction. [ABSTRACT FROM AUTHOR]

Playing with a child is one of the easiest and most effective ways to establish communication. However, illness or injury can lead to negative emotions and stress in a child, making it challenging for them to adapt to treatment during pre-hospital care. The use of therapeutic communication and play in pre-hospital settings facilitates the identification of the patient's current conditions, the assessment of identified situations, and the implementation of pre-hospital care approaches based on these evaluations. The paramedic program included 40 students in the first grade and 40 students in the second grade. The second-grade students received 16 hours of theoretical and 16 hours of practical therapeutic play training from a play therapist. The second-grade students who participated in the training applied therapeutic play techniques in communication with children. Then, The Medical Procedure Fear Scale was administered to all students during their internships in emergency services or ambulance settings with children aged 4-9. The data obtained in the research were analyzed using SPSS 22.0 statistical software. Paramedic students who received therapeutic play training and used therapeutic play in communication with children had lower fear scale scores compared to those who did not receive therapeutic play training and did not use therapeutic play in communication with children. The study concluded that gender and the applied field of the scale did not affect the scale scores, while age was identified as an influential factor. The entire healthcare team, especially paramedics working in emergency health services, should have sufficient knowledge, skills, and experience about children's developmental periods, therapeutic play, and its types. [ABSTRACT FROM AUTHOR]

Background: This study assesses how ambulance paramedics using the modified HEART-score with a point-of-care cardiac troponin (cTn) compare to the emergency physicians using the modified HEART-score with a high-sensitive cTn (hs-cTn) in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS), focusing on interobserver agreement and diagnostic performance. Methods: In this prospective multicenter cohort, we compare four cTn testing strategies (serial point of care and hs-cTn cTn measurement) with and without the HEART-score. Outcomes include the HEART-score's interobserver agreement, NSTE-ACS at discharge, major adverse cardiovascular events (MACE) after 30 days, and diagnostic accuracy of the different strategies. Conclusion: The POPular HEART study aims to improve NSTE-ACS diagnostic pathways, promoting pre-hospital detection and ruling out of NSTE-ACS to minimize unnecessary hospitalizations and associated costs. Clinical Trial Registration:NCT04851418 (ClinicalTrials.gov) Many people visit the emergency department (ED) due to chest pain, often worried about the possibility of a heart attack. While acute heart attacks can often be detected through an electrocardiogram (ECG; a test of the heart's electrical activity), a significant number of patients with a heart attack have a normal ECG. These patients require further testing to measure cardiac troponin (cTn; an indicator of heart damage) in the hospital to rule out a heart attack, known as non-ST-elevation acute coronary syndrome (NSTE-ACS). To improve diagnosis and care for these patients, we compared two approaches: ambulance paramedics using a quick bedside cTn test and the HEART-score, versus hospital doctors using a more sensitive cTn test with the HEART-score. The HEART score combines factors like the patient's medical history, ECG results, age, risk factors, and cTn levels to assess the risk of heart problems. In this comparison, the key difference lies in how cTn levels are measured – either through a quick finger prick test in an ambulance using a point-of-care device or a more detailed analysis in a hospital laboratory. We focused on patients visited by emergency medical services for chest pain suspected of a heart attack and transported to the hospital. We assessed the quick bedside test by paramedics and the detailed hospital test by doctors, alongside the use of the HEART score in both settings. Our evaluation looked at the agreement between these methods and their effectiveness in identifying or excluding an NSTE-ACS. Our research, known as the POPular HEART study, seeks to simplify the early identification or rule-out of an NSTE-ACS in patients with chest pain directly by ambulance. This approach aims to decrease unnecessary hospital admissions and reduce healthcare costs. We're exploring innovative methods to safely identify patients with a very low risk of NSTE-ACS in individuals with chest pain outside the hospital. Our objective is to safely minimize hospital admissions that may not be necessary, thereby saving resources. By doing so, we aim to alleviate the pressure on EDs and contribute to more cost-effective healthcare. Article highlights Background The study investigates the use of the HEART-score with point-of-care (POC) cTn testing by ambulance paramedics compared with HEART-score assessments with high-sensitive cTn (hs-cTn) by emergency physicians in patients suspected of having non-ST-elevation acute coronary syndrome (NSTE-ACS). Focuses on evaluating the interobserver agreement and diagnostic performance using the (modified) HEART-score. Methods A prospective, multicenter cohort study design. Comparison of four cTn testing strategies involving serial POC and hs-cTn measurements, with and without the modified HEART score. Including patients presenting with chest pain, visited by an ambulance, and transported to a hospital under a working diagnosis of NSTE-ACS. Primary outcomes measured were the HEART-score's interobserver agreement, the final diagnosis of NSTE-ACS at discharge, major adverse cardiovascular events (MACE) within 30 days, and the diagnostic accuracy of the testing methods. Conclusion The POPular HEART study aims to refine the diagnostic approach for NSTE-ACS, allowing for the early detection and exclusion of NSTE-ACS in the pre-hospital phase. The study seeks to reduce unnecessary hospital admissions and associated healthcare costs by improving the accuracy and reliability of NSTE-ACS diagnosis in the pre-hospital setting. Key findings The use of POC troponin testing by paramedics, when combined with the HEART score, can potentially streamline the diagnostic process for NSTE-ACS in the pre-hospital setting. High interobserver agreement suggests that the modified HEART-score is a reliable tool for assessing NSTE-ACS risk both pre-hospital and in-hospital. Early identification and exclusion of NSTE-ACS could significantly reduce unnecessary hospital stays, promoting more efficient use of healthcare resources. Implications for practice Implementing POC cTn testing and the HEART-score assessment in ambulance services could enhance the early diagnosis and management of NSTE-ACS. This approach may lead to a shift in how patients with suspected NSTE-ACS are triaged and managed, emphasizing the importance of accuracy and speed in the diagnostic process. Healthcare systems could see a reduction in the burden on emergency departments and in the overall costs associated with the care of patients with chest pain. Future directions Further research is needed to explore the scalability of implementing POC cTn testing and the HEART-score in diverse healthcare settings. Long-term studies could evaluate the impact of these diagnostic strategies on patient outcomes, healthcare costs, and system efficiency. Innovation in POC testing technology, reimbursement by health insurers and training for pre-hospital care providers will be critical to the widespread adoption of these strategies. [ABSTRACT FROM AUTHOR]

Background: Efficient resource distribution is important. Despite extensive research on response timings within ambulance services, nuances of time from unit dispatch to becoming available still need to be explored. This study aimed to identify the determinants of the duration between ambulance dispatch and readiness to respond to the next case according to the patients' transport decisions. Methods: Time from ambulance dispatch to availability (TDA) analysis according to the patients' transport decision (Transport versus Non-Transport) was conducted using R-Studio™ for a data set of 93,712 emergency calls managed by a Middle Eastern ambulance service from January to May 2023. Log-transformed Hazard Ratios (HR) were examined across diverse parameters. A Cox regression model was utilised to determine the influence of variables on TDA. Kaplan–Meier curves discerned potential variances in the time elapsed for both cohorts based on demographics and clinical indicators. A competing risk analysis assessed the probabilities of distinct outcomes occurring. Results: The median duration of elapsed TDA was 173 min for the transported patients and 73 min for those not transported. The HR unveiled Significant associations in various demographic variables. The Kaplan–Meier curves revealed variances in TDA across different nationalities and age categories. In the competing risk analysis, the 'Not Transported' group demonstrated a higher incidence of prolonged TDA than the 'Transported' group at specified time points. Conclusions: Exploring TDA offers a novel perspective on ambulance services' efficiency. Though promising, the findings necessitate further exploration across diverse settings, ensuring broader applicability. Future research should consider a comprehensive range of variables to fully harness the utility of this period as a metric for healthcare excellence. [ABSTRACT FROM AUTHOR]

Background: Severity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm. Methods: We conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets. Results: After exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023). Conclusions: Based on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement. [ABSTRACT FROM AUTHOR]

Purpose: Emergency Medical Services (EMS) in Alberta are facing critical challenges. This qualitative study aims to describe and understand the frontline perspective regarding system level issues and propose provider-informed policy recommendations. Methods: 19 semi-structured one-on- one interviews were conducted with Primary or Advanced Care Paramedics (PCP/ACP) across Alberta. Participants were asked to share their perspectives, experiences and recommendations in relation to EMS response times and the working environment. Interviews were analyzed using thematic analysis to identify themes and subthemes. Results: Two core themes were identified as areas of concern: poor response times and the EMS working environment, which each influence and impact the other. Within response times, paramedics highlighted specific difficulties with ED offloading, a lack of resources, low-acuity calls, and rural challenges. In terms of the EMS working environment, four subthemes were apparent including attrition, unhealthy culture, organizational barriers and the need for paramedic empowerment. Providers made many recommendations including creating and expanding emergency mobile integrated health (MIH) branches, sharing 811 and 911 responses, and enforcing ED target offload times amongst other suggestions. Conclusions: While response times are a key and highly visible problem, there are many critical factors like the EMS working environment that degrade patient care and cause concern amongst frontline practitioners. Multifaceted policy changes are to be explored to reduce disfunction within EMS services, enhance the well-being of the workforce and deliver improved patient care. Specific EMS-oriented policies are important for moving forward to reduce transfers to EDs, but the broader health system which is over capacity is causing downstream effects into EMS must be addressed by government and health administrators. [ABSTRACT FROM AUTHOR]

The centralisation of trauma services in western countries has led to an improvement in patient outcomes. Effective trauma systems include a pre‐hospital trauma system. Delivery of high‐level pre‐hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs) and timely transport to definitive care. Globally, many nations endorse nationwide pre‐hospital major trauma triage guidelines, to ensure a universal approach to patient care. This paper examined clinical guidelines from all 10 EMS in Australia and Aotearoa/New Zealand. All relevant trauma guidelines were included, and key information was extracted. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care. The identification of major trauma patients varied between all 10 EMS, with no universal criteria. The most common approach to trauma triage included a three‐step assessment process: physiological criteria, identified injuries and mechanism of injury. Disparity between physiological criteria, injuries and mechanism was found when comparing guidelines. All 10 EMS had fundamental LSI included in their trauma guidelines. Fundamental LSI included haemorrhage control (arterial tourniquets, pelvic binders), non‐invasive airway management (face mask ventilation, supraglottic airway devices) and pleural wall needle decompression. Variation in more advanced LSI was evident between EMS. Optimising trauma triage guidelines is an important aspect of a robust and evidence driven trauma system. The lack of consensus in trauma triage identified in the present study makes benchmarking and comparison of trauma systems difficult. Effective trauma systems include a pre‐hospital trauma system. Delivery of high‐level pre‐hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs), and timely transport to definitive care. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care, and identified variations between all systems included in the present study. [ABSTRACT FROM AUTHOR]

Aim: The management of cardiorespiratory arrest in a diving bell presents multiple clinical, technical, and environmental considerations that standard resuscitation algorithms do not address, and no situation-specific algorithm exists. The development and testing of an algorithm to guide the management of cardiorespiratory arrest in a bell is described. Methods: An iterative approach to algorithm development was used. Phase 1 involved a small multidisciplinary group and took place in a simulation centre and a decommissioned diving bell. The algorithm was then refined in a purpose-build simulation complex with repeated simulation by a group of divers, and with input from industry experts. ALS principles were followed unless contextual or technical factors necessitated deviation. Results: Clinical and technical aspects of the resuscitation are addressed. Key priorities that conflict with standard ALS principles are: prioritisation of rescue breaths; use of mechanical CPR when available; and the provision of CPR with the casualty in a seated position where necessary. Conclusion: This is the first algorithm to guide the delivery of resuscitation in a diving bell. It incorporates adapted ALS principles and available data concerning compression technique effectiveness, and was informed by industry and clinical expertise. It provides guiding principles that can be adapted to setting-specific needs, and we would encourage its industry-wide international adoption.

Introduction: The use of extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest is increasing globally. However, providing equity of access to all patients is challenging, and to date, access has been limited to inner city areas surrounding major hospitals. To increase the availability of ECPR in our jurisdiction, we sought to train pre-hospital physicians with no experience in extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR). To enable this, we sort to develop and teach a syllabus that would provide novice ECPR providers the skill to perform ECPR safely and effectively in the pre-hospital environment. Methods: This training programme consisted of 11 pre-hospital physicians and six critical care paramedics. All participants had no prior hospital experience instituting or managing ECPR patients. The training programme was multimodal utilising a porcine model of heart failure to teach time pressured dynamic physiological troubleshooting, cadaver labs to teach cannulation, didactic teaching and simulation. Key knowledge and skill domains were identified. Each learning framework was built upon with a final focus on integrating all skill domains required to successfully initiate ECPR. Results: The training program was completed from February 2022 to August 2023. Knowledge progression was assessed at key stages via written and practical examination. Each participant demonstrated clear knowledge and skill progression at the key stages of the training programme. At the end of the training programme, participants met the pre-defined standards to progress to ECPR provision in the pre-hospital environment. Conclusion: We present a training program for novice ECPR providers performing ECPR in the pre-hospital setting. The outcomes of this training program can provide a training framework for both novices, low volume ECMO centres and pre-hospital clinicians.

Out-of-hospital cardiac arrest (OHCA) is a time-sensitive medical emergency that needs immediate interventions. COVID-19 affected the performance of the emergency medical service (EMS) system in pre-hospital care, including the management of cardiac arrest. This study aimed to identify the impact of the COVID-19 pandemic on pre-hospital management of out-of-hospital cardiac arrest and its outcome in Qom City, Iran. In this descriptive-analytical study, the data were collected from the electronic registration system of the EMS center in Qom, Iran. All OHCA patients who received resuscitation during COVID-19 and before COVID-19 were enrolled in the study. Data consisted of the characteristics of OHCA patients, EMS interventions and response times, and the outcome of OHCA. A P-value of

Abstract Background Tourniquets (TQ) have been increasingly adopted in pre-hospital settings recently. This study examined the effectiveness and safety of applying TQ in the pre-hospital settings for civilian patients with traumatic vascular injuries to the extremities. Materials and methods We systematically searched the Ovid Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from their inception to June 2023. We compared pre-hospital TQ (PH-TQ) use to no PH-TQ, defined as a TQ applied after hospital arrival or no TQ use at all, for civilian vascular extremity trauma patients. The primary outcome was overall mortality rate, and the secondary outcomes were blood product use and hospital stay. We analyzed TQ-related complications as safety outcomes. We tried to include randomized controlled trials (RCTs) and non-randomized studies (including non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and case-control studies), if available. Pooled odds ratios (ORs) were calculated and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Results Seven studies involving 4,095 patients were included. In the primary outcome, pre-hospital TQ (PH-TQ) use significantly decrease mortality rate in patients with extremity trauma (odds ratio [OR], 0.48, 95% confidence interval [CI] 0.27–0.86, I 2 = 47%). Moreover, the use of PH-TQ showed the decreasing trend of utilization of blood products, such as packed red blood cells (mean difference [MD]: -2.1 [unit], 95% CI: -5.0 to 0.8, I 2 = 99%) or fresh frozen plasma (MD: -1.0 [unit], 95% CI: -4.0 to 2.0, I 2 = 98%); however, both are not statistically significant. No significant differences were observed in the lengths of hospital and intensive care unit stays. For the safety outcomes, PH-TQ use did not significantly increase risk of amputation (OR: 0.85, 95% CI: 0.43 to 1.68, I 2 = 60%) or compartment syndrome (OR: 0.94, 95% CI: 0.37 to 2.35, I 2 = 0%). The certainty of the evidence was very low across all outcomes. Conclusion The current data suggest that, in the pre-hospital settings, PH-TQ use for civilian patients with vascular traumatic injury of the extremities decreased mortality and tended to decrease blood transfusions. This did not increase the risk of amputation or compartment syndrome significantly.

Abstract Background Quality measurement as part of quality improvement in healthcare is integral for service delivery and development. This is particularly pertinent for health services that deliver care in ways that differ from traditional practice. Community Emergency Medicine (CEM) is a novel and evolving concept of care delivered by services in parts of the UK and Ireland. This scoping review aims to provide a broad overview of how quality may be measured within services delivering CEM. Methods and analysis The methodology follows both the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). It is guided by recognised work of Arksey and O’Malley and the guidelines developed by the Joanna Briggs Institute. Several databases will be searched: MEDLINE, EMbase, EMcare, CINAHL, Scopus, the Cochrane Library and grey literature. Search terms have been developed by representatives within Community Emergency Medicine services. Two reviewers will independently screen eligible studies for final study selection. Results will be collected and analysed in descriptive and tabular form to illustrate the breadth of quality indicators that may be applicable to CEM services. This scoping review protocol has been registered with the Open Science Framework platform (osf.io/e7qxg). Discussion This is the first stage of a larger research study aimed at developing national quality indicators for CEM. The purpose of this scoping review is to provide a comprehensive review of quality indicators that could be used within CEM. The results will be mapped using a framework and identify gaps in the literature to help guide future-focused research.

Abstract Background Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse. Methods A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥ 70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥ 50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥ 10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site. Results Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS. Conclusions Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decision-making. Further assessment of unintended consequences, benefits and harm is required. Trial registration. ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333