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San Francisco (California USA) is a relatively compact city with a population of 884,000 and nine stroke centers within a 47 square mile area. Emergency Medical Services (EMS) transport distances and times are short and there are currently no Mobile Stroke Units (MSUs).
This study evaluated EMS activation to computed tomography (CT [EMS-CT]) and EMS activation to thrombolysis (EMS-TPA) times for acute stroke in the first two years after implementation of an emergency department (ED) focused, direct EMS-to-CT protocol entitled “Mission Protocol” (MP) at a safety net hospital in San Francisco and compared performance to published reports from MSUs. The EMS times were abstracted from ambulance records. Geometric means were calculated for MP data and pooled means were similarly calculated from published MSU data.
From July 2017 through June 2019, a total of 423 patients with suspected stroke were evaluated under the MP, and 166 of these patients were either ultimately diagnosed with ischemic stroke or were treated as a stroke but later diagnosed as a stroke mimic. The EMS and treatment time data were available for 134 of these patients with 61 patients (45.5%) receiving thrombolysis, with mean EMS-CT and EMS-TPA times of 41 minutes (95% CI, 39-43) and 63 minutes (95% CI, 57-70), respectively. The pooled estimates for MSUs suggested a mean EMS-CT time of 35 minutes (95% CI, 27-45) and a mean EMS-TPA time of 48 minutes (95% CI, 39-60). The MSUs achieved faster EMS-CT and EMS-TPA times (P <.0001 for each).
In a moderate-sized, urban setting with high population density, MP was able to achieve EMS activation to treatment times for stroke thrombolysis that were approximately 15 minutes slower than the published performance of MSUs.
Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose.
This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients’ demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded.
Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05).
The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.
Concerns have been raised about the utility of self-report assessments in predicting future suicide attempts. Clinicians in pediatric emergency departments (EDs) often are required to assess suicidal risk. The Death Implicit Association Test (IAT) is an alternative to self-report assessment of suicidal risk that may have utility in ED settings.
A total of 1679 adolescents recruited from 13 pediatric emergency rooms in the Pediatric Emergency Care Applied Research Network were assessed using a self-report survey of risk and protective factors for a suicide attempt, and the IAT, and then followed up 3 months later to determine if an attempt had occurred. The accuracy of prediction was compared between self-reports and the IAT using the area under the curve (AUC) with respect to receiver operator characteristics.
A few self-report variables, namely, current and past suicide ideation, past suicidal behavior, total negative life events, and school or social connectedness, predicted an attempt at 3 months with an AUC of 0.87 [95% confidence interval (CI), 0.84–0.90] in the entire sample, and AUC = 0.91, (95% CI 0.85–0.95) for those who presented without reported suicidal ideation. The IAT did not add significantly to the predictive power of selected self-report variables. The IAT alone was modestly predictive of 3-month attempts in the overall sample ((AUC = 0.59, 95% CI 0.52–0.65) and was a better predictor in patients who were non-suicidal at baseline (AUC = 0.67, 95% CI 0.55–0.79).
In pediatric EDs, a small set of self-reported items predicted suicide attempts within 3 months more accurately than did the IAT.
An emerging picture has seen increasing numbers of young people with mental health crisis attend paediatric emergency departments in Ireland. Following paediatric review, many are referred to in-house paediatric liaison psychiatry (PLP) services. This pilot study describes referral patterns and practice over a 1-month period across three Dublin centres.
Case notes of all referrals to PLP were reviewed to extract relevant clinical and administrative data. For those admitted, costs associated with length of stay were estimated. Clinical profile, management and intra-hospital pathway differences were explored.
Fifty-nine young people under 16 years presented to one of the three EDs with an acute MH presentation. The sample consisted of 39 females (66%) with a mean age of 13.7 years. The majority (n = 34, 58%) presented out of hours. A substantial portion of youths presenting (n = 37, 63%) were admitted, and had a mean duration of stay of 4.51 days. There were differences between hospitals in terms of frequency of presentation with self-harm, admission rates and length of stay.
Different PLP service configuration, staffing and funding streams may explain some of the differences observed across centres, although the findings should be interpreted with caution given the limited sample size. Standardisation of service provision and management is needed for PLP services. Additional community CAMHS resourcing is needed to support the development of alternative pathways for youth in need of urgent MH review.
Training emergency department (ED) personnel in the care of victims of mass-casualty incidents (MCIs) is a highly challenging task requiring unique and innovative approaches. The purpose of this study was to retrospectively explore the value of high-fidelity simulators in an exercise that incorporates time and resource limitation as an optimal method of training health care personnel in mass-casualty care.
Mass-casualty injury patterns from an explosive blast event were simulated for 12 victims using high-fidelity computerized simulators (HFCS). Programmed outcomes, based on the nature of injuries and conduct of participants, ranged from successful resuscitation and survival to death. The training exercise was conducted five times with different teams of health care personnel (n = 42). The exercise involved limited time and resources such as blood, ventilators, and imaging capability. Medical team performance was observed and recorded. Following the exercise, participants completed a survey regarding their training satisfaction, quality of the exercise, and their prior experiences with MCI simulations. The Likert scale responses from the survey were evaluated using mean with 95% confidence interval, as well as median and inter-quartile range. For the categorical responses, the frequency, proportions, and associated 95% confidence interval were calculated.
The mean rating on the quality of experiences related trainee survey questions (n = 42) was between 4.1 and 4.6 on a scale of 5.0. The mean ratings on a scale of 10.0 for quality, usefulness, and pertinence of the program were 9.2, 9.5, and 9.5, respectfully. One hundred percent of respondents believed that this type of exercise should be required for MCI training and would recommend this exercise to colleagues. The five medical team (n = 5) performances resulted in the number of deaths ranging from two (including the expectant victims) to six. Eighty percent of medical teams attempted to resuscitate the “expectant” infant and exhausted the O- blood supply. Sixty percent of medical teams depleted the supply of ventilators. Forty percent of medical teams treated “delayed” victims too early.
A training exercise using HFCS for mass casualties and employing limited time and resources is described. This exercise is a preferred method of training among participating health care personnel.
Central venous catheter (CVC) placement is an important procedure which is frequently performed in the emergency department (ED) and can cause serious complications. The aim of this study is to introduce a simulation-based tissue model for ultrasound (US)-guided central venous access practices and to compare the effectiveness of static and dynamic US techniques through this model.
This was a prospective study on US-guided CVC placement techniques simulated with a chicken tissue model. This model is based on the principle of placing two cylindrical balloons filled with colored water (red for arterial and blue for venous) between a raw chicken breast and wrapping the formed structure with plastic wrap. The study was conducted in an academic tertiary care hospital with Emergency Medicine (EM) residents who have received basic US training, including vascular access procedures. All participants performed simulated CVC placement procedures with both static and dynamic US techniques. At the end of the study, the practitioners were asked to rate usefulness of these techniques between one and ten (one was the lowest and ten was the highest score).
A total of 32 EM residents were included in the study. Their median age was 29 (IQR = 27 - 31) years and 72% of them were male. Their median duration in ED was 19 (IQR = 12 - 34) months. According to the results of simulated CVC placement procedures, there was no significant difference between the static and dynamic US techniques in terms of puncture numbers, procedure durations, and success rates. However, according to the usefulness scores given by the practitioners, the dynamic US technique was found to be more useful (P < .001).
The chicken tissue model is a convenient tool for simulating US-guided CVC placement procedures. The dynamic US technique is considered to be more useful in this field than the static technique, but the results of practitioner-dependent practices may not always support this generalization.
Emergency Medical Services (EMS) providers are trained to place endotracheal tubes (ETTs) in the prehospital setting when indicated. Endotracheal tube cuffs are traditionally inflated with 10cc of air to provide adequate seal against the tracheal lumen. There is literature suggesting that many ETTs are inflated well beyond the accepted safe pressures of 20-30cmH2O, leading to potential complications including ischemia, necrosis, scarring, and stenosis of the tracheal wall. Currently, EMS providers do not routinely check ETT cuff pressures. It was hypothesized that the average ETT cuff pressure of patients arriving at the study site who were intubated by EMS exceeds the safe pressure range of 20-30cmH2O.
While ETT cuff inflation is necessary to close the respiratory system, thus preventing air leaks and aspiration, there is evidence to suggest that over-inflated ETT cuffs can cause long-term complications. The purpose of this study is to characterize the cuff pressures of ETTs placed by EMS providers.
This project was a single center, prospective observational study. Endotracheal tube cuff pressures were measured and recorded for adult patients intubated by EMS providers prior to arrival at a large, urban, tertiary care center over a nine-month period. All data were collected by respiratory therapists utilizing a cuff pressure measurement device which had a detectable range of 0-100cmH2O and was designed as a syringe. Results including basic patient demographics, cuff pressure, tube size, and EMS service were recorded.
In total, 45 measurements from six EMS services were included with ETT sizes ranging from 6.5-8.0mm. Mean patient age was 52.2 years (67.7% male). Mean cuff pressure was 81.8cmH2O with a range of 15 to 100 and a median of 100. The mode was 100cmH2O; 40 out of 45 (88.9%) cuff pressures were above 30cmH2O. Linear regression showed no correlation between age and ETT cuff pressure or between ETT size and cuff pressure. Two-tailed T tests did not show a significant difference in the mean cuff pressure between female versus male patients.
An overwhelming majority of prehospital intubations are associated with elevated cuff pressures, and cuff pressure monitoring education is indicated to address this phenomenon.
Agitated behaviors are frequently encountered in the prehospital setting and require emergent treatment to prevent harm to patients and prehospital personnel. Chemical sedation with ketamine works faster than traditional pharmacologic agents, though it has a higher incidence of adverse events, including intubation. Outcomes following varying initial doses of prehospital intramuscular (IM) ketamine use have been incompletely described.
To determine whether using a lower dose IM ketamine protocol for agitation is associated with more favorable outcomes.
This study was a pre-/post-intervention retrospective chart review of prehospital care reports (PCRs). Adult patients who received chemical sedation in the form of IM ketamine for agitated behaviors were included. Patients were divided into two cohorts based on the standard IM ketamine dose of 4mg/kg and the lower IM dose of 3mg/kg with the option for an additional 1mg/kg if required. Primary outcomes included intubation and hospital admission. Secondary outcomes included emergency department (ED) length of stay, additional chemical or physical restraints, assaults on prehospital or ED employees, and documented adverse events.
The standard dose cohort consisted of 211 patients. The lower dose cohort consisted of 81 patients, 17 of whom received supplemental ketamine administration. Demographics did not significantly differ between the cohorts (mean age 35.14 versus 35.65 years; P = .484; and 67.8% versus 65.4% male; P = .89). Lower dose subjects were administered a lower ketamine dose (mean 3.24mg/kg) compared to the standard dose cohort (mean 3.51mg/kg). There was no statistically significant difference between the cohorts in intubation rate (14.2% versus 18.5%; P = .455), ED length of stay (14.31 versus 14.88 hours; P = .118), need for additional restraint and sedation (P = .787), or admission rate (26.1% versus 25.9%; P = .677). In the lower dose cohort, 41.2% (7/17) of patients who received supplemental ketamine doses were intubated, a higher rate than the patients in this cohort who did not receive supplemental ketamine (8/64, 12.5%; P <.01).
Access to effective, fast-acting chemical sedation is paramount for prehospital providers. No significant outcomes differences existed when a lower dose IM ketamine protocol was implemented for prehospital chemical sedation. Patients who received a second dose of ketamine had a significant increase in intubation rate. A lower dose protocol may be considered for an agitation protocol to limit the amount of medication administered to a population of high-risk patients.
Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years.
The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years.
A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study.
The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients’ sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital.
The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.
Emergency Medical Services (EMS) are designed to respond to and manage patients experiencing life-threatening emergencies; however, not all emergency calls are necessarily emergent and of high acuity. Emergency responses to low-acuity patients affect not only EMS, but other areas of the health care system. However, definitions of low-acuity calls are vague and subjective; therefore, it was necessary to provide a clear description of the low-acuity patient in EMS.
The goal of this study was to develop descriptors for “low-acuity EMS patients” through expert consensus within the EMS environment.
A Modified Delphi survey was used to develop call-out categories and descriptors of low acuity through expert opinion of practitioners within EMS. Purposive, snowball sampling was used to recruit 60 participants, of which 29 completed all three rounds. An online survey tool was used and offered both binary and free-text options to participants. Consensus of 75% was accepted on the binary options while free text offered further proposals for consideration during the survey.
On completion of round two, consensus was obtained on 45% (70/155) of the descriptors, and a further 30% (46/155) consensus was obtained in round three. Experts felt that respiratory distress, unconsciousness, chest pain, and severe hemorrhage cannot be considered low acuity. For other emergency response categories, specific descriptors were offered to denote a case as low acuity.
Descriptors of low acuity in EMS are provided in both medical and trauma cases. These descriptors may not only assist in the reduction of unnecessary response and transport of patients, but also assist in identifying the most appropriate response of EMS resources to call-outs. Further development and validation are required of these descriptors in order to improve accuracy and effectiveness within the EMS dispatch environment.
This study was aimed to assess if combining the evaluation of blood glucose level (BGL) and the Triage Revised Trauma Score (T-RTS) may result in a more accurate prediction of the actual clinical outcome, both in general adult population and in elderly patients with trauma.
This is a retrospective cohort study, conducted in the emergency department (ED) of an urban teaching hospital, with an average ED admission rate of 75,000 patients per year. Those excluded: known diagnosis of diabetes, age <18 years old, pregnancy, and mild trauma (classified as isolate trauma of upper or lower limb, in absence of exposed fractures). A combined Revised Trauma Score Glucose (RTS-G) score was obtained adding to T-RTS: two for BGL <160mg/dL (8.9mmol/L); one for BGL ≥160mg/dL and < 200mg/dL (11.1mmol/L); and zero for BGL ≥ 200mg/dL. The primary outcome was a composite of patient’s death in ED or admission to intensive care unit (ICU). Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the overall performance of T-RTS and of the combined RTS-G score.
Among a total of 68,933 traumas, 9,436 patients (4,407 females) were enrolled, aged from 18 to 103 years; 4,288 were aged ≥65 years. A total of 577 (6.1%) met the primary endpoint: 38 patients died in ED (0.4%) and 539 patients were admitted to ICU. The T-RTS and BGL were independently associated to primary endpoint at multivariate analysis. The cumulative RTS-G score was significantly more accurate than T-RTS and reached the best accuracy in elderly patients. In general population, ROC area under curve (AUC) for T-RTS was 0.671 (95% CI, 0.661 - 0.680) compared to RTS-G ROC AUC 0.743 (95% CI, 0.734 - 0.752); P <.001. In patients ≥65 years, T-RTS ROC AUC was 0.671 (95% CI, 0.657 - 0.685) compared to RTS-G ROC AUC 0.780 (95% CI, 0.768 - 0.793); P <.001.
Results showed RTS-G could be used effectively at ED triage for the risk stratification for death in ED and ICU admission of trauma patients, and it could reduce under-triage of approximately 20% compared to T-RTS. Comparing ROC AUCs, the combined RTS-G score performs significantly better than T-RTS and gives best results in patients ≥65 years.
Many studies from around the world, especially NAP4 in the UK, have demonstrated that airway management in critically ill patients, whether in the intensive care unit, emergency department or general wards, is fraught with danger. Serious morbidity or mortality may be 50-fold more common than in anaesthetic practice. This chapter describes the essential features of airway management specific to critical care intubation. The importance of an intubation bundle approach is emphasised, such as the UK’s Difficult Airway Society guidelines for tracheal intubation in the critically ill adult. Components include: (i) deliberate and thoughtful application of human factors science to optimise team performance and sharing the airway plan; (ii) assessment of potential difficulty based on the MACOCHA scoring system; (iii) pre-oxygenation using continuous positive airway pressure (CPAP) or non-invasive ventilation, high flow nasal oxygen, or a combination of these; (iv) a modified rapid sequence induction with continuous peroxygenation; (v) optimising laryngoscopy and intubation with early videolaryngoscopy by a trained operator; (vi) airway rescue with an amalgamated Plan B/C, borrowing from the Vortex approach; (vii) use of second generation supraglottic airways (SGAs); (viii) priming for front of neck airway (FONA) and (ix) a scalpel-bougie-tube cricothyroidotomy when managing cannot intubate, cannot oxygenate (CICO).
The main objective was to study different clinical presentations and outcomes of patients after acute industrial chlorine gas exposure in Oman with evaluation of overall incident management to help develop a chemical exposure incident protocol.
This was a retrospective observational study of 15 patients exposed to chlorine gas after an accidental chlorine gas leak in a metal melting factory in Oman.
Six (40%) patients were admitted and nine (60%) patients were discharged from the emergency department (ED) after initial management. The important post-chlorine gas exposure clinical symptoms were eye irritation (66.6%), cough (73.3%), shortness of breath (40.0%), chest discomfort (66.6%), rhinorrhea (66.6%), dizziness (40.0%), vomiting (46.6%), sore throat (13.3%), and stridor (53.3%). Important signs included tachycardia (40.0%), tachypnea (40.0%), wheeze (20.0%), and use of accessory muscles for breathing (20.0%). Signs and symptoms of eye irritation, rhinorrhea, tachycardia, tachypnea, wheeze, and use of accessory muscles for breathing have shown significant correlation with outcome (admission) having P value of <.05.
In the presented acute chlorine gas exposure incidence, 15 exposed persons were brought to the ED, out of which six were admitted and nine were discharged after symptomatic treatment. Signs and symptoms of eye irritation, rhinorrhea, tachycardia, tachypnea, wheeze, and use of accessory muscles of breathing show significant relation with the outcome of admission.
Older persons with parkinsonism (PWP) are at high risk for hospitalization and adverse outcomes. Few effective strategies exist to prevent Emergency Department (ED) visits and hospitalization. The interdisciplinary Geriatrics Clinic for Parkinson’s (“our clinic”) was founded to address the complexity of parkinsonism in older patients, supported by a pharmacist-led telephone intervention (TI) service. Our primary objective was to study whether TI could avert ED visits in older PWP.
Using a prospective, observational cohort, we collected data from all calls in 2016, including who initiated and reasons for the calls, patient demographics, number of comorbidities and medications, diagnoses, duration of disease, and intervention provided. Calls with intention to visit ED were classified as “crisis calls”. Outcome of whether patients visited ED was collected within 1 week, and user satisfaction by anonymous survey within 3 weeks.
We received 337 calls concerning 114 patients, of which 82 (24%) were “crisis calls”. Eighty-one percent of calls were initiated by caregivers. Ninety-three percent of “crisis calls” resolved without ED visit after TI. The main reasons for “crisis calls” were non-motor symptoms (NMS) (39%), adverse drug effects (ADE) (29%), and motor symptoms (18%). Ninety-seven percent of callers were satisfied with the TI.
Pharmacist-led TI in a Geriatrics Clinic for Parkinson’s was effective in preventing ED visits in a population of older PWP, with high user satisfaction. Most calls were initiated by caregivers. Main reasons for crisis calls were NMS and ADE. These factors should be considered in care planning for older PWP.
Emergency departments (EDs) worldwide struggled to prepare for coronavirus disease 2019 (COVID-19) patient surge and to simultaneously preserve sufficient capacity for “regular” emergency care. While many hospitals used costly shelter facilities, it was decided to merge the acute medical unit (AMU) and the ED. The conjoined AMU-ED was segregated into a high-risk and a low-risk area to maintain continuity of emergency care. This strategy allowed for a feasible, swift, and dynamic expansion of ED capacity without the need for external tent facilities. This report details on the technical execution and discusses the pearls and potential pitfalls of this expansion strategy. Although ED preparedness for pandemics may be determined by local factors, such as hospital size, ED census, and primary health-care efficacy, the conjoined AMU-ED strategy may be a potential model for other EDs.
Several aspects led to the poor control of the coronavirus disease 2019 (COVID-19) outbreak in the US from a rural emergency department (ED) perspective. These include US residents’ attitude towards political involvement in health and civil rights; lack of enough testing kits and rapid test results, or not available at all; and personal protective equipment (PPE) shortages. These obstacles related to medical supplies and resources, and lack of coordinated approach to the pandemic in the US, are important information for retrospective disaster research to understand study limitations, extrapolate accurate and valid data, and for other countries to understand how and why the US had higher numbers of COVID-19 cases and deaths compared to other countries.
Police units often reach the trauma scene before Emergency Medical Services (EMS). Initiatives aiming at delivering early basic trauma care by non-medical providers including police personnel are on the rise. This study describes characteristics of trauma patients transported by police to US hospitals and identifies factors associated with survival in this patient population.
Using the 2015 National Trauma Data Bank (NTDB), an observational study was conducted of adult trauma patients who were transported by police. After describing the study population, the factors associated with survival to hospital discharge were evaluated using a multivariate analysis.
A total of 2,394 patients were included in the study. Patients had a median age of 34.0 years (interquartile range [IQR]: 25-48) and most were males (84.5%). Blunt trauma mechanism (59.4%) was more common than penetrating trauma (29.4%). Factors associated with improved survival included: comorbidity (odds ratio [OR] = 2.92; 95% CI, 1.33-6.40); use of drugs (OR = 2.91; 95% CI, 1.07-7.92); cut/pierce (OR = 11.07; 95% CI, 2.10-58.43); motor vehicle traffic (MVT) mechanism (OR = 6.56; 95% CI, 1.60-26.98); trauma resulting in fractures (OR = 3.03; 95% CI, 1.38-6.64); and private/commercial insurance (OR = 3.41; 95% CI, 1.10-10.55).
In this study population, a relatively high survival rate was noted (93.5%). Police transport of patients with blunt trauma was unexpectedly more common. Factors associated with survival to hospital discharge were identified. These factors can be used to implement more standardized and protocol-driven risk stratification tools of trauma patients on scene to improve police involvement in trauma patient transport.
Emergency department (ED) throughput efficiency is largely dependent on staffing and process, and many operational interventions to increase throughput have been described.
We systematically searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials to find studies describing the impact of throughput strategies on ED length of stay and left without being seen rates. Two independent reviewers screened studies, evaluated quality and risk of bias, and stratified eligible studies by intervention type. We assessed statistical heterogeneity using the chi-squared statistic and the I-squared (I2) statistic, and pooled results where appropriate. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.
Ninety-four (94) studies met inclusion criteria (Cohen's k = 0.7). Most were observational, five were determined to be low quality (Cohen's k = 0.6), and almost all reported modest reductions in length of stay and left without being seen rates, although there was substantial variability within and between intervention types. Fast track and patient streaming interventions showed the most consistent reduction in length of stay and left without being seenrates. Shifting high-level providers to triage appears effective and generally cost neutral. Evidence for enhanced testing strategies and alternative staffing models was less compelling.
Introducing a fast track and optimizing processes for important case-mix groups will likely enhance throughput efficiency. Expediting diagnostic and treatment decisions by shifting physician-patient contact to the earliest possible process point (e.g., triage) is an effective cost-neutral strategy to increase flow. Focusing ED staff on operational improvement is likely to improve performance, regardless of the intervention type.
Deaths are frequently under-estimated during emergencies, times when accurate mortality estimates are crucial for emergency response. This study estimates excess all-cause, pneumonia and influenza mortality during the coronavirus disease 2019 (COVID-19) pandemic using the 11 September 2020 release of weekly mortality data from the United States (U.S.) Mortality Surveillance System (MSS) from 27 September 2015 to 9 May 2020, using semiparametric and conventional time-series models in 13 states with high reported COVID-19 deaths and apparently complete mortality data: California, Colorado, Connecticut, Florida, Illinois, Indiana, Louisiana, Massachusetts, Michigan, New Jersey, New York, Pennsylvania and Washington. We estimated greater excess mortality than official COVID-19 mortality in the U.S. (excess mortality 95% confidence interval (CI) 100 013–127 501 vs. 78 834 COVID-19 deaths) and 9 states: California (excess mortality 95% CI 3338–6344) vs. 2849 COVID-19 deaths); Connecticut (excess mortality 95% CI 3095–3952) vs. 2932 COVID-19 deaths); Illinois (95% CI 4646–6111) vs. 3525 COVID-19 deaths); Louisiana (excess mortality 95% CI 2341–3183 vs. 2267 COVID-19 deaths); Massachusetts (95% CI 5562–7201 vs. 5050 COVID-19 deaths); New Jersey (95% CI 13 170–16 058 vs. 10 465 COVID-19 deaths); New York (95% CI 32 538–39 960 vs. 26 584 COVID-19 deaths); and Pennsylvania (95% CI 5125–6560 vs. 3793 COVID-19 deaths). Conventional model results were consistent with semiparametric results but less precise. Significant excess pneumonia deaths were also found for all locations and we estimated hundreds of excess influenza deaths in New York. We find that official COVID-19 mortality substantially understates actual mortality, excess deaths cannot be explained entirely by official COVID-19 death counts. Mortality reporting lags appeared to worsen during the pandemic, when timeliness in surveillance systems was most crucial for improving pandemic response.
Existing peer-reviewed literature describing emergency medical technician (EMT) acquisition and transmission of 12-lead electrocardiograms (12L-ECGs), in the absence of a paramedic, is largely limited to feasibility studies.
The objective of this retrospective observational study was to describe the impact of EMT-acquired 12L-ECGs in Suffolk County, New York (USA), both in terms of the diagnostic quality of the transmitted 12L-ECGs and the number of prehospital percutaneous coronary intervention (PCI)-center notifications made as a result of transmitted 12L-ECGs demonstrating a ST-elevation myocardial infarction (STEMI).
A pre-existing database was queried for Emergency Medical Services (EMS) calls on which an EMT acquired a 12L-ECG from program initiation (January 2017) through December 31, 2019. Scanned copies of the 12L-ECGs were requested in order to be reviewed by a blinded emergency physician.
Of the 665 calls, 99 had no 12L-ECG available within the database. For 543 (96%) of the available 12L-ECGs, the quality was sufficient to diagnose the presence or absence of a STEMI. Eighteen notifications were made to PCI-centers about a concern for STEMI. The median time spent on scene and transporting to the hospital were 18 and 11 minutes, respectively. The median time from PCI-center notification to EMS arrival at the emergency department (ED) was seven minutes (IQR 5-14).
In the event a cardiac monitor is available, after a limited educational intervention, EMTs are capable of acquiring a diagnostically useful 12L-ECG and transmitting it to a remote medical control physician for interpretation. This allows for prehospital PCI-center activation for a concern of a 12L-ECG with a STEMI, in the event that a paramedic is not available to care for the patient.