The early chain of care in bacteraemia patients: Early suspicion,treatment and survival in prehospital emergency care

Introduction

Bacteraemia is a first stage for patients risking conditions such as septic shock. The primary aim of this study is to describe factors in the early chain of care in bacteraemia, factors associated with increased chance of survival during the subsequent 28 days after admission to hospital. Furthermore, the long-term outcome was assessed.

National Characteristics of Emergency Medical Services in Frontier and Remote Areas

Although much is known about EMS care in urban, suburban, and rural settings, only limited national data describe EMS care in isolated and sparsely populated frontier regions. We sought to describe the national characteristics and outcomes of EMS care provided in frontier and remote (FAR) areas in the continental United States (US). We performed a cross-sectional analysis of the 2012 National Emergency Medical Services Information System (NEMSIS) data set, encompassing EMS response data from 40 States. We linked the NEMSIS dataset with Economic Research Service-identified FAR areas, defined as a ZIP Code >60 minutes driving time to an urban center with >50,000 persons. We excluded EMS responses resulting in intercepts, standbys, inter-facility transports, and medical transports. Using odds ratios, t-tests and the Wilcoxon rank-sum test, we compared patient demographics, response characteristics (location type, level of care), clinical impressions, and on-scene death between EMS responses in FAR and non-FAR areas. There were 15,005,588 EMS responses, including 983,286 (7.0%) in FAR and 14,025,302 (93.0%) in non-FAR areas. FAR and non-FAR EMS events exhibited similar median response 5 [IQR 3–10] vs. 5 [3–8] min), scene (14 [10–20] vs. 14 [10–20] min), and transport times (11 [5.,24] vs. 12 [7,19] min). Air medical (1.51% vs. 0.42%; OR 4.15 [95% CI: 4.03–4.27]) and Advanced Life Support care (62.4% vs. 57.9%; OR 1.25 [1.24–1.26]) were more common in FAR responses. FAR responses were more likely to be of American Indian or Alaska Native race (3.99% vs. 0.70%; OR 5.04, 95% CI: 4.97–5.11). Age, ethnicity, location type, and clinical impressions were similar between FAR and non-FAR responses. On-scene death was more likely in FAR than non-FAR responses (12.2 vs. 9.6 deaths/1,000 responses; OR 1.28, 95% CI: 1.25–1.30). Approximately 1 in 15 EMS responses in the continental US occur in FAR areas. FAR EMS responses are more likely to involve air medical or ALS care as well as on-scene death. These data highlight the unique characteristics of FAR EMS responses in the continental US.     

Epidemiology of Pediatric Transports andNon-Transports in an Urban Emergency Medical Services System

Objective. This study was done to describe an urban, Emergency Medical Service (EMS) system's experiences with pediatric patients andthe rate andcharacteristics of non-transports in this setting. Methods. A retrospective analysis of all pediatric patients responded to by the Detroit Fire Department Division of EMS between January 1, 2002 andAugust 30, 2002 was done. Results. There were 5,976 pediatric EMS cases. Children 10 years of age or older accounted for 49.4% of transports, 53.8% of all patients had medical illness, and38.8% of the patients belonged to the non-urgent category. A large percentage of patients were not transported (27.2%), most commonly secondary to parent/caregiver/patient refusals. The median number of minutes on-scene for refusals was longer than for transports (23.5 vs. 17.3, respectively)[difference = 6.2 minutes (95% CI: 5.6–6.9)]. The odds ratios (OR) for refusal was highest for assaults (2.09; 95% CI: 1.66–2.63), difficulty in breathing (1.38; 95% CI: 1.14–1.68), andmotor vehicle accidents (1.19; 95% CI: 1.04–1.37). Conclusions. In this system, the majority of pediatric patients are not severely ill, anda large number are not transported. Non-transports are more likely to be young adolescents, have been involved in assaults, andhave a longer on-scene time.     

急诊护士对院前急救护理的心理体验

目的了解急诊护士对院前急救护理的真实心理体验。方法 采用质性研究中现象学方法对12名急诊护士进行深入访谈,了解其对院前急救护理的体验,运用类属分析法归纳主题。结果急诊护士对院前急救护理的身心感受提炼出4个主题:①压力、困惑、担忧;②不适、疲惫、无奈;③对传染病的恐惧;④茫然、质疑、兴奋。结论医院管理者应重视和改善120急救环境的建设,关注急诊护士的心理问题,提高护士工作的积极性,从而提高院前急救护理质量。     

急救医疗系统对脑出血患者预后的影响

目的 探讨急救医疗系统(EMS)对脑出血患者预后的影响.方法 将107例首发脑出血患者按入院方式不同分为观察组46例(通过EMS入院),对照组61例(自行入院),回顾性分析两组患者院前延迟时间、30d的治疗效果、48h内病死率.结果 观察组中位院前延迟时间1h,对照组中位院前延迟时间2h,两组比较差异有统计学意义(P＜0.01).30d治疗效果:观察组效果良好24例(52.2％),预后不良22例(47.8％)；对照组效果良好26例(42.6％),预后不良35例(57.4％),两组治疗效果比较,差异无统计学意义(P＞0.05).观察组48h内病死率6.5％,对照组48h内病死率21.3％,两组比较,差异有统计学意义(P＜0.05).结论 EMS服务能够明显缩短院前延迟时间,降低脑出血早期病死率,并有可能改善预后.     

Utilization of Emergency Medical Services by Patients with Acute Coronary Syndromes in the Arab Gulf States

Background

Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.

Objective

To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE). Methods: Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).

Results

Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03–1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48–2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34–1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02–1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09–1.51), and current smoking (OR 1.30; 95% CI 1.13–1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED.

Conclusion

Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.     

Emergency care staff can improve survival rates from sepsis

Patients die from sepsis. Reports of mortality as high as 50% are associated with patients who have severe sepsis. Often the signs and symptoms are unmanaged within the emergency care environment. This paper discusses the Surviving Sepsis Campaign and outlines a number of management steps that practitioners caring for patients within emergency care can use to reduce mortality. The sepsis resuscitation bundle is discussed in depth as its goals can be achieved within the emergency department. A number of relevant web sites are provided that guide interested readers to other information on the Surviving Sepsis Campaign.     

Medical consequences of violence: a two-year prospective study from a primary care accident and emergency department in Norway

Objective - To assess the medical consequences of violence from the perspective of a primary care accident and emergency department. Design - Prospective observational study. Setting - Bergen Legevakt (AED). Subjects - All assault victims treated at the AED 1994-96. Main outcome measures - Diagnoses, treatments, number of consultations at the AED, sickness certificates, rates of admittances to hospitals, referrals to specialists and injury severity ratings using Abbreviated Injury Scale (AIS) and Shepherd's injury severity scale. Results - 1803 assault victims were registered, 433 (24%) females and 1370 (76%) males. Most injuries were of slight severity, corresponding to AIS 0 to 1 (82%) or Shepherd's scale 0 to 1 (74%). Bruises/contusions and cuts/lacerations dominated. The majority of patients did not receive any specific treatment at the AED and they were not given sickness certificates, but 11% were admitted to hospitals and 30% were referred to specialists. Males were more likely to be seriously injured than females. Conclusion - Most physical injuries caused by violence and treated at a primary care accident and emergency department are minor.     

Emergency department sepsis screening tool decreases time to antibiotics in patients with sepsis

Recent literature has highlighted the importance of early identification and treatment of sepsis; however, limited data exists to help recognize sepsis in the emergency department (ED) through use of a screening tool. The purpose of this study was to evaluate the impact of a sepsis screening tool implemented in an academic medical center ED on compliance with the 3-hour sepsis bundle.This was a retrospective cohort study that included a total of 115 patients, of which 58 were in the pre-tool group and 57 were in the post-tool group. There was no difference in 3-hour bundle compliance between groups (36.2% vs. 47.4%, P?=?0.26). There was no difference in the following bundle components: lactate (79.3% vs. 80.7%, P?=?0.85), blood cultures (86.2% vs. 96.5%, P?=?0.09), blood cultures before administering antibiotics (91.4% vs. 100%, P?=?0.57) and adequate fluids administration (44.7% vs. 41.9%, P?=?0.820). A significantly higher number of patients received antibiotics within 3?h in the post-tool group (58.6% vs. 89.5%, P?<?0.001). Statistically significant secondary outcomes included average time to antibiotics (P?=?0.04), administering antibiotics within an hour (P?>?0.001), and ICU length of stay (P?=?0.03). There was no difference in 30-day mortality, however mortality was numerically lower in the post-tool group (36.2% vs. 26.3%, P?=?0.25).Although implementation of an ED sepsis screening tool did not increase 3-hour bundle compliance, it did increase the proportion of patients receiving timely antimicrobial therapy and demonstrated a trend towards decreased mortality.     

-正方观点-全身性感染新定义：有助于ICU外的医护人员快速筛选出脓毒症患者

1992年共识会,定义脓毒症为当患者符合两个全身性发炎反应综合征（systemic inflammatory response syndrome,SIRS）且怀疑这些症状是因为感染所造成。2016年第三次国际脓毒症既脓毒症休克共识会,定义脓毒症为宿主对感染的失调反应导致危及生命的器官功能障碍,诊断脓毒症的临床条件为当患者在怀疑或确定感染的前提下,器官衰竭评估分数（sequential organ failure assessment,SOFA）急速增加超过2分。定义脓毒性休克为一部分脓毒症的患者,出现严重的循环障碍及细胞代谢异常,导致病死率显著增加,诊断标准为脓毒症患者,在充分补充血容量后,仍需要升压药物以维持平均动脉压≥65 mmHg（1 mmHg=0.133 kPa）且血清乳酸水平＞2 mmol/L。并提出快速器官衰竭评估（quick SOFA,qSOFA）即神志改变,收缩压≤100 mmHg,或呼吸频率≥ 22次/min,患者符合两个qSOFA条件时,即应怀疑脓毒症进入重症病房观察。作为一个医院管理者及脓毒症流行学者,新版定义为在ICU外的医护人员提供一个简洁的方法,快速筛选出脓毒症患者,进行积极治疗,增进照顾质量,新版定义除了专家意见外,运用流行病学的方法,以患者是否死亡或需要＞ 3 d ICU治疗作为结果指标,测试新定义的效度,新定义在预测死亡能力比SIRS高。在进行临床试验及流行病调查时,使用新版的脓毒症定义与我们最关心的终点——病死率有较好的相关,同时避免脓毒症与严重脓毒症定义不同所造成的混淆。     

徐州市医务人员公共卫生事件应急能力的现状调查

目的通过徐州市各级医疗机构医务人员应对突发性公共卫生事件能力的调查分析,力求为健全应对体系、提高对突发性公共卫生事件应对能力提供参考数据.方法随机分层整群抽取徐州市三所一、二、三级医院及疾病预防控制部门的医务人员,通过问卷调查和统计分析,了解其对突发性公共卫生事件的应对能力和工作态度.结果徐州市医务人员对突发性公共卫生事件的相关概念、应急处理措施、工作职责的自测成绩分别为73.3、67.9和64.2分;对〈突发性公共卫生事件应急条例〉所赋予工作职责,态度积极和较积极的占82.5%;对可引起公共卫生问题的传染病测试得分高于80分的有SARS、艾滋病、禽流感,而对结核病及血吸虫病的测试得分仅为46.3和35.0分;对新发传染病防治知识、技能的自测成绩大于80分的疾病有SARS、艾滋病、O139霍乱、禽流感和丙型肝炎;对莱姆病、汉坦病毒、巴尔通体感染等引起的疾病自测成绩平均低于50分.结论徐州市医务人员,对突发性公共卫生事件的基本概念较明确,应对态度积极.对可引起公共卫生问题的常见病具有较好知识储备,对新发传染病及结核病相关知识与技能还应进一步加强.     

院校合作共建共享急救护理教学资源平台的研究与实践

目的 探索高职高专护理专业院校合作共建共享急救护理资源平台的效果,拓展学生网络学习方式,以提高学生的急救护理能力,为社会、医护人员自主移动学习和远程学习急救护理知识提供有利条件.方法 院校合作共同搭建资源平台,采用自制急救护理课程教学平台用户评价指标体系,对急救护理资源平台进行测评.同时采用随机抽样方法,抽取2012级护理3班100名学生为实验组,2012级护理1班98名学生为对照组.实验组学生进行教学改革,主要利用急救护理教学资源平台进行教学,教师利用平台为学生答疑;对照组采用传统教学法.课程结束后,对两组学生的理论、操作技能及急救护理综合测评3种成绩进行统计学分析.结果 急救护理课程教学资源平台建设效果较好,各维度中得分从高到低排序为内容性、效应性、技术性及发展性.实验组学生理论、操作技能、综合测评成绩得分均高于对照组,差异有统计学意义(P＜0.05).结论 院校合作共建共享急救护理资源平台有利于提高学生自主学习能力,提升教学效果.     

急诊分诊安全管理模式对急诊护理质量的影响

[目的]研究急诊分诊安全管理模式应用于急诊分诊工作中的护理效果.[方法]依据笔者的急诊科风险管理相关经验,对比分析本院急诊分诊在实施安全管理模式前后的护理满意度.实施前的时间为2013年3月1日至2013年4月30日,实施后的时间为2014年3月至2014年4月30日.在前后各两个月中依据方便抽样的方法抽取400名患者或其家属进行调查询问.[结果]急诊分诊安全管理模式实施后护理满意度为98.25％,比实施前显著上升（P＜0.05）.[结论]将急诊分诊安全管理模式运用于临床急诊分诊中可以显著提升护理质量,提高护理工作满意度,值得推广与应用.     

Measuring sustainable practice change of the sepsis guideline in one emergency department: A retrospective health care record audit

Aims and objectivesTo explore the longitudinal impact of the New South Wales Sepsis guideline on time to antibiotics, triage assessment and emergency management before and four years after guideline implementation.BackgroundGlobally, sepsis continues to be a significant cause of mortality and morbidity within hospitals. To reduce avoidable adverse patient outcomes the corner stone has been to improve the early recognition and management of sepsis. The New South Wales government in Australia introduced sepsis guidelines into Emergency Departments. However, the longitudinal impact of the sepsis guideline, has never been conducted.MethodsA 12-month retrospective randomised health care record audit of adult patients with a sepsis diagnosis was conducted 12-months before and four years after implementation of the sepsis guideline.ResultsThis study demonstrated sustained improvement in allocation of urgent triage categories in the follow-up group (n = 43; 53.1%) and a reduction in the median time to antibiotics from 189 min to 102 min (p ≤ 0.001) after the implementation of the sepsis guideline.ConclusionThe study has demonstrated the sepsis guideline has improved a sustained change in early assessment, recognition and management of patients presenting with sepsis in one tertiary referral Emergency Department.     

EZ-IO® intraosseous device implementation in German Helicopter Emergency Medical Service

BackgroundIntraosseous access (IO) is a rapid and safe alternative when peripheral venous access is difficult. Our aim was to summarize the first three years experience with the use of a semi-automatic IO device (EZ-IO^®) in German Helicopter Emergency Medical Service (HEMS).MethodsIncluded were all patients during study period (January 2009–December 2011) requiring an IO access performed by HEMS team. Outcome variables were IO rate, IO insertion success rates, site of IO access, type of EZ-IO^® needle set used, strategy of vascular access, procedure related problems and operator's satisfaction.ResultsIO rate was 0.3% (348/120.923). Overall success rate was 99.6% with a first attempt success rate of 85.9%; there was only one failure (0.4%). There were three insertion sites: proximal tibia (87.2%), distal tibia (7.5%) and proximal humerus (5.3%). Within total study group IO was predominantly the second-line strategy (39% vs. 61%, p < 0.001), but in children < 7 years, in trauma cases and in cardiac arrest IO was more often first-line strategy (64% vs. 28%, p < 0.001; 48% vs. 34%, p < 0.032; 50% vs. 29%, p < 0.002 respectively). Patients with IO access were significantly younger (41.7 ± 28.7 vs. 56.5 ± 24.4 years; p < 0.001), more often male (63.2% vs. 57.7%; p = 0.037), included more trauma cases (37.3% vs. 30.0%; p = 0.003) and more often patients with a NACA-Score ≥ 5 rating (77.0% vs. 18.6%; p < 0.001). Patients who required IO access generally presented with more severely compromised vital signs associated with the need for more invasive resuscitation actions such as intubation, chest drains, CPR and defibrillation. In 93% EZ-IO^® needle set handling was rated “good”. Problems were reported in 1.6% (needle dislocation 0.8%, needle bending 0.4% and parafusion 0.4%).ConclusionsThe IO route was generally used in the most critically ill of patients. Our relatively low rate of usage would indicate that this would be compatible with the recommendations of established guidelines. The EZ-IO^® intraosseous device proved feasible with a high success rate in adult and pediatric emergency patients in HEMS.