Could bystander first‐aid prevent trauma deaths at the scene of injury?

Objective: To identify potentially preventable prehospital deaths following traumatic cardiac arrest. Methods: Deaths following prehospital traumatic cardiac arrest during 2003 were reviewed in the state of Victoria, Australia. Possible survival with optimal bystander first‐aid and shorter ambulance response times were identified. Injury Severity Scores (ISS) were calculated. Victims with an ISS <50 and signs of life were reviewed for potentially preventable factors contributing to death including signs of airway obstruction, excessive bleeding and/or delayed ambulance response times. Results: We reviewed 112 cases that had full ambulance care records, hospital records and autopsy details in Victoria 2003. Most deaths involved road trauma and 55 victims had an ISS <50. Twelve patients received first‐aid from bystanders. Ambulance response times >10 min might have contributed to five deaths with an ISS <25. Conclusion: Five (4.5%) potentially preventable prehospital trauma deaths were identified. Three deaths potentially involved airway obstruction and two involved excessive bleeding. There is a case for increased awareness of the need for bystander first‐aid at scene following major trauma.     

Prehospital deaths in the Yorkshire Health Region.

OBJECTIVES: To estimate the proportion of prehospital deaths in a British population of trauma victims which may be preventable, and to investigate the effect of death at the scene and death in transit on potential survivorship. METHODS: Blinded review, by four specialists with an interest in trauma, of necropsy results and details of age, sex, and mechanism of injury for prehospital trauma deaths in the Yorkshire Health Region in a 12 month period. RESULTS: Complete records were traced on 305 of 337 trauma deaths, 190 being recorded as dead on arrival of emergency services and 115 dead on arrival at hospital. In the group declared dead at the scene, three of the four assessors considered 93% of deaths to have been inevitable and only 2% as potential survivors (25% of this group sustaining inevitably fatal injuries such as brain avulsion or decapitation). In the group dead on arrival 81% were felt to be inevitable deaths and 5% potential survivors. CONCLUSIONS: There seems to be less scope for salvage of victims of trauma death in a British population than has been recorded in America, possibly due to a higher proportion of blunt trauma deaths here. Those who die in transit consist of a less severely injured group with a higher potential for survival.     

Resuscitation for patients with out-of-hospital cardiac arrest: Singapore

AIM: To evaluate characteristics and outcome of out-of-hospital cardiac arrest (OHCA) patients presenting to the Emergency Department (ED), and to examine factors that could be used to determine to prolong or abort resuscitation for these patients. METHOD: All OHCA patients presenting to the ED were studied over a three-month period from November 2001 through January 2002. Patient with traumatic cardiac arrest were excluded. Data were collected from the ambulance case records, ED resuscitation charts, and the ED Very High Frequency (VHF) radio case-log sheet. Information collected included the patient's demographic characteristics, timings (time from call to ambulance arrival on scene, time from arrival at scene to departure from scene, time from scene to arrival in the ED) recorded in the pre-hospital setting, the outcome of the resuscitation, and the final outcome for patients who survived ED resuscitation. RESULTS: Ninety-three non-traumatic patients with an OHCA were studied during the three-month period. Of the 93 patients, 15 (16.1%) survived ED resuscitation, and one survived to hospital discharge. There were no statistically significant differences for age, race, or gender with regards to the outcome of the resuscitation. The initial cardiac rhythms were asystole (65), pulseless electrical activity (21), and ventricular fibrillation (7). Fourteen (15%) received bystander cardiopulmonary resuscitation (CPR). All seven patients with return of spontaneous circulation (ROSC) on arrival in the ED survived ED resuscitation. The ambulance took an average of 11.80 +/- 3.36 minutes for the survivors and 11.8 +/- 4.22 minutes for the non-survivors from the time of call to get to these patients. The average of the scene times was 12.5 +/- 4.61 minutes for the survivors and 12.0 +/- 4.02 minutes for the non-survivors. Transport time from the scene to the ED took an average of 39.1 +/- 8.32 minutes for the survivors and 37.2 +/- 9.00 minutes for the non-survivors. CONCLUSION: The survival rate for patients with OHCA after ED resuscitation is similar to the results from other studies. There is a need to increase the awareness and delivery of basic life support by public education. Automatic External Defibrillators (AED) should be available widely to ensure that the chance of early defibrillation is increased. Prolonged resuscitation efforts appear to be futile for OHCA patients if the time from cardiac arrest until arrival in the ED is > or = 30 minutes coupled with no ROSC, and if continuous asystole has been documented for > 10 minutes.     

Evaluation of the prehospital management of road traffic fatalities in Victoria, Australia

INTRODUCTION: This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes. METHODS: The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion. RESULTS: One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable. CONCLUSION: The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.     

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19

IntroductionLonger prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients.MethodsThis retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes.ResultsThere were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01].ConclusionThe median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.     

Potential time savings by prehospital administration of activated charcoal

Objective. Activated charcoal (AC) has been proven useful in many toxic ingestions. Theoretically, administration of AC in the prehospital environment could save valuable time in the treatment of patients who have sustained potentially toxic oral ingestions. The purpose of this study was to determine the frequency of prehospital AC administration and to identify time savings that could potentially result from field AC administration.

Methods. Adult patients with a chief complaint of toxic ingestion who had complete emergency medical services (EMS) and emergency department (ED) records and no medical treatment (gastric emptying, AC administration) prior to EMS arrival were eligible for inclusion. Data obtained from EMS and ED records included time of EMS departure from the scene, time of EMS arrival at the ED, and time of administration of AC in the ED. Since most EMS agencies in this system do not insert gastric tubes, patients requiring gastric tube placement for administration of AC were excluded.

Results. Twenty-nine of 117 (24.8%) adult patients received oral AC with no other intervention. None of the 117 patients received AC in the prehospital setting. The EMS transport time for these patients ranged from 5 to 43 minutes (mean 16.2 ± 9.7 minutes). The delay from ED arrival to AC administration ranged from 5 to 94 minutes (mean 48.8 ± 24.1 minutes), and was more than 60 minutes for 14 (48.2%) of the patients. The total time interval from scene departure to ED AC administration ranged from 17 to 111 minutes (mean 65.0 ± 25.9 minutes). Conclusions. In a selected subset of patients who tolerate oral AC, prehospital administration of AC could result in earlier and potentially more efficacious AC therapy. Prospective study of the benefits and feasibility of prehospital AC administration is indicated.     

山东省某三甲医院2004-2014年急诊患者病死率研究

目的：研究一家大型综合性三甲医院急诊科2004—2014年患者病死率变化,并分析其可能的影响因素。方法统计2004年、2009年和2014年该院急诊科就诊人次及死亡患者人数,计算病死率,并收集上述3年全部死亡患者临床资料,采用方差分析和χ2检验对数据进行分析。结果2004—2014年,该院急诊患者数量显著增加（2014年较2004年增加了38.0％,抢救和留观人数增加71.6％）,病死率总体呈上升趋势（2004年 0.3％,2009年 0.8％,2014年 0.7％,P ＜0.01）,纳入上述3年共1091例死亡患者进行分析。基线临床特征：男：女比例为1.36∶1,该比例2004—2014年间无显著变化;平均寿命61.9岁,过去10年亦无显著变化。救治条件：该院急诊科医护人员数量和硬件设施配备均有明显提升。流行病学特点：心、脑血管疾病和猝死是急诊死亡三大主要原因,三者所占总比例以及外伤、肿瘤等各自所占比例2004—2014年均无显著变化。急救意识：发病至急诊就诊时间2004—2014年无显著变化,救护车应用比例未发生改变;患者家属配合抢救的比例显著下降（2004年 61.1％,2009年 60.2％,2014年 42.8％,P ＜0.01）。时间分布：急诊死亡患者就诊的节假日分布、昼夜班次分布均无显著变化,平均急诊滞留时间明显上升（2004年 22.4 h,2014年 39.3 h,P ＝0.02）。结论2004—2014年间,尽管急诊科硬件设施和人员配备得到显著改善,急诊患者病死率仍呈上升趋势,这一状况可能与就诊患者数量（尤其是危重患者数量）大幅度增加、病患自我急救意识无改善、对急诊救治的配合程度显著下降、急诊滞留时间显著增加等相关。     

Prehospital use of activated charcoal: A pilot study

Activated charcoal (AC) is most effective when administered soon after the ingestion of certain substances. Delays are recognized to occur at times in the administration of AC after arrival of poisoned patients in the emergency department (ED). In addition, it has been recognized that these delays may be avoided if AC administration is begun in selected patients by paramedics while en route to the ED. We present a pilot study evaluating the administration of AC to poisoned patients in the ambulance prior to arrival in the ED. We performed a retrospective review of Emergency Medical System (EMS) run sheets and ED records of poisoned patients during a 6-month period from two area hospitals. Cases were identified that met criteria for the prehospital administration of AC. Cases were divided into two groups: those who received prehospital AC, and those who did not. Groups were compared for ambulance transport time, time from first paramedic contact to AC administration, and whether AC was tolerated by the patient. A total of 14 patients received prehospital AC (group 1). This group was compared to 22 cases that would have qualified under County protocol to receive prehospital AC, but for whatever reason did not (group 2). Group 2 patients all received AC after arriving in the ED. Average ambulance transport times did not statistically differ among groups. The average time from first encounter with paramedics to administration of AC was 5.0 minutes when AC administration was given in the ambulance as compared to 51.4 minutes when delayed until arrival in the ED. Tolerance was similar among the groups. The time to initiate AC administration may be significantly shortened when begun by prehospital personnel. All EMS should consider including AC in protocols addressing the prehospital management of certain poisoned patients.     

The pattern of ambulance arrivals in the emergency department of an acute care hospital in Singapore

Methods—All (13 697) ambulance arrivals in 1996 to the ED of Tan Tock Seng Hospital were studied and where relevant compared with the walk in and total arrivals of the same year. The following data were obtained from computer records: (a) patients'' demographic data; (b) number of ambulance arrivals by hour; (c) the classification of the ambulance arrivals by emergency or non-emergency, trauma or non-trauma; (d) cause of injury for trauma cases; (e) discharge status. Results—The ambulance arrivals in 1996 constituted 12.4% of the patient load for this department. There was no difference in modes of patient arrival to the ED by sex and ethnic group. However, there was significant evidence to show that more patients age > 60 came by ambulance than those age < 12 (p << 0.01). Some 98.5% of the ambulance arrivals were emergencies; 40.7% of the ambulance arrivals were attributable to trauma versus 27.3% of the walk in arrivals. The majority of the trauma cases brought in by ambulance were because of road traffic accidents (15.3%) or home accidents (7.4%). The peak in ambulance arrivals was between 2100–2300 hours compared with 1000–1200 for the walk in arrivals. More than half of the ambulance arrivals were admitted. Conclusion—In planning resource allocation and in the development of contingency plans, the resource use of ambulance patients and the pattern of their arrivals should be taken into account.     

Effect of Emergency Medical Services Use on Hospital Outcomes of Acute Hemorrhagic Stroke

Background: It is unclear whether the use of emergency medical services (EMS) is associated with enhanced survival and decreased disability after hemorrhagic stroke and whether the effect size of EMS use differs according to the length of stay (LOS) in emergency department (ED). Methods: Adult patients (19 years and older) with acute hemorrhagic stroke who survived to admission at 29 hospitals between 2008 and 2011 were analyzed, excluding those who had symptom-to-ED arrival time of 3 h or greater, received thrombolysis or craniotomy before inter-hospital transfer, or had experienced cardiac arrest, had unknown information about ambulance use and outcomes. Exposure variable was EMS use. Endpoints were survival at discharge and worsened modified Rankin Scale (W-MRS) defined as 3 or greater points difference between pre- and post-event MRS. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) for the outcomes were calculated, including potential confounders (demographic, socioeconomic status, clinical parameter, comorbidity, behavior, and time of event) in the final model and stratifying patients by inter-hospital transfer and by time interval from symptom to ED arrival (S2D). ED LOS, classified into short (<120 min) and long (≥120 min), was added to the final model for testing of the interaction model. Results: A total of 2,095 hemorrhagic strokes were analyzed in which 75.6% were transported by EMS. For outcome measures, 17.4% and 41.4% were dead and had worsened MRS, respectively. AORs (95% CIs) of EMS were 0.67 (0.51–0.89) for death and 0.74 (0.59–0.92) for W-MRS in all patients. The effect size of EMS, however, was different according to LOS in ED. AORs (95% CIs) for death were 0.74 (0.54–1.01) in short LOS and 0.60 (0.44–0.83) in long LOS group. AORs (95% CIs) for W-MRS were 0.76 (0.60–0.97) in short LOS and 0.68 (0.52–0.88) in long LOS group. Conclusions: EMS transport was associated with lower hospital mortality and disability after acute hemorrhagic stroke. Effect size of EMS use for mortality was significant in patients with long ED LOS.     

Addressing inadequacies in Victoria's trauma system: Responses of the Consultative Committee on Road Traffic Fatalities and Victorian trauma services

Objectives: Victoria's new trauma care system has been followed by reductions in preventable and potentially preventable deaths and in deficiencies contributing to death. This improvement has followed triaging more patients to expanded major trauma services where mortality was already lower rather than to improved results within the major trauma services, metropolitan or rural trauma services or ambulance services, Victoria. The objective of the present study was to identify continuing inadequacies within the individual trauma services and in association with representatives of these services to develop appropriate countermeasures. Methods: Initially, presentations were made to each trauma service of their fatalities evaluated after introduction of the new trauma system. At separate working party meetings with each service consensus recommendations were finalized and these disseminated to stakeholders. Results: Recommendations related to the need for Trauma Director/Coordinator appointments at all designated hospitals receiving major trauma, improved facilities and equipment, the trauma team, referral, communications, protocols, a prompting system, education, audit and feedback, infrastructure, staffing, documentation and inter‐hospital patient transfer. Conclusion: Interaction between the Consultative Committee on Road Traffic Fatalities and Victorian trauma services identified continuing deficiencies in the new trauma care system and developed consensus recommendations to target these problems. These require implementation through the State Trauma Committee.     

急诊死亡患者临床特征的研究

目的：探讨大型综合性医院急诊抢救死亡患者的临床特征。方法：对1880例急诊临床死亡患者的临床特征进行回顾性分析,主要内容包括年龄、性别、既往病史、首发症状、来诊方式、来诊时间和死因诊断等。结果：①本组前五位死亡原因为原因不明死亡（42.23%）,创伤（17.61%）、脑血管疾病（15.32%）、心血管疾病（7.34%）和恶性肿瘤晚期（4.30%）;②创伤死亡患者的男性明显高于女性（男/女：261/70）,也显著高于其他各组（均P〈0.01）;③原因不明死亡、心血管系统疾病、脑血管疾病和恶性肿瘤晚期的急诊死亡年龄特征呈增龄变化,而创伤急诊死亡高峰年龄段在15～30岁（38.37%,127/331）;④发病至就诊时间〈1h为59.04%（1110/1880）,全部死亡患者中由120送诊的只有29.08%（528/1880）。⑤发病至死亡时间〈1h的为39.89%（750/1880）,不明原因患者在发病1h内急诊死亡占66.25%（526/794）,高于创伤（41.69%,138/331）,且差异有统计学意义（χ2=58.239,P〈0.01）。结论：急诊抢救死亡多为发病后〈1h就诊,发病至死亡〈1h,和死亡原因不明的,和非120送诊的患者,这提示加强急诊患者最初的诊治尤为重要。     

Physicians at the roadside: Pre-hospital emergency care in the United Kingdom

In some parts of the United Kingdom (UK), family doctors (or "general practitioners" as they are called in the UK) are routinely called upon by the emergency medical services (EMS) system to attend road accidents. The doctors are volunteers and travel to the scene of the accident in their own cars. Members of one such general practitioner accident service operating in Mid-Anglia complete an accident report form after attending each incident. In 1983, the Mid-Anglia General Practitioner Accident Service (MAGPAS) received 1,715 calls for medical assistance, and in 95% of these a doctor was sent immediately. Of these calls, 57% were passed to the doctor within one minute of the receipt of the call in the MAGPAS control room, and 78% were relayed within two minutes. This rapid call-out, combined with the close proximity of the local doctor to the accident site, resulted in the doctors arriving ahead of the ambulance in 42% of the calls. A total of 54 patients with airway obstruction were treated by the doctors prior to the arrival of the ambulance. Ninety-nine patients required immediate intravenous fluid replacement in the pre-hospital phase of their medical care. This report suggests that general practitioners in rural areas can play a vital role in the early management of trauma patients, especially in the absence of ambulance personnel trained in advanced life support skills.     

Study of early warning of accident and emergency departments by ambulance services.

OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.     

Is it Appropriate for Patients to be Discharged at the Scene by Paramedics?

Background: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. Objective: We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. Methods: We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. Results: There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4; 95% confidence interval [CI] 3.0–3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3; 95% CI 2.8–3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2; 95% CI 3.4–5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8; 95% CI 0.99–3.2) within 24 hours of discharge compared to those discharged from ED. Conclusion: Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.     

Statewide Method of Measuring Ambulance Patient Offload Times

Objective: Ambulance patient offload time (APOT) also known colloquially as “Wall time” has been described in various jurisdictions but seems to be highly variable. Any attempt to improve APOT requires the use of common definitions and standard methodology to measure the extent of the problem. Methods: An Ambulance Offload Delay Task Force in California developed a set of standard definitions and methodology to measure APOT for transported 9-1-1 patients. It is defined as the time “interval between the arrival of an ambulance at an emergency department and the time that the patient is transferred to an ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for care of the patient.” Local EMS agencies voluntarily reported data according to the standard methodology to the California EMS Authority (State agency). Results: Data were reported for 9-1-1 transports during 2017 from 9 of 33 local EMS Agencies in California that comprise 37 percent of the state population. These represent 830,637 ambulance transports to 126 hospitals. APOT shows significant variation by EMS agency with half of the agencies demonstrating significant delays. Offload times vary markedly by hospital as well as by region. Three-fourths of hospitals detained EMS crews more than one hour, 40% more than two hours, and one-third delayed EMS return to service by more than three hours. Conclusion: This first step to address offload delays in California consists of standardized definitions for data collection to address the significant variability inherent in obtaining data from 33 local agencies, hundreds of EMS provider agencies, and 320 acute care hospital Emergency Departments that receive 9-1-1 ambulance transports. The first year of standardized data collection of ambulance patient offload times revealed significant ambulance patient offload time delays that are not distributed uniformly, resulting in a substantial financial burden for some EMS providers in California.     

EMS blood collection from patients with acute chest pain reduces emergency department length of stay

BackgroundExpediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States.MethodsA prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016–4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin.ResultsThe use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6–100). NPV improved to 100% (95% CI: 92.9–100) when using the EMS and 3-h ED troponin measures.ConclusionsEMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.     

Study of early warning of accident and emergency departments by ambulance services.

OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.     

Paramedic Judgment of the Need for Trauma Team Activation for Pediatric Patients

Abstract. Objective:To determine the value of paramedic judgment in determining the need for trauma team activation (TTA) for pediatric blunt trauma patients. Methods:A prospective, observational study was conducted at the ED of Children's Hospital Medical Center of Akron between July 12, 1996, and February 28, 1997, in cooperation with Akron Fire Department emergency medical technician-paramedics (EMT-Ps). The ED provides on-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released at the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgment, a patient needed TTA. Patients 0–14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of <10 feet were included in the study. TTA was defined as necessary if the patient was admitted to the intensive care unit (ICU) or operating room (OR) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hospital records were reviewed. Coroners' records as well as medical records of all trauma admissions during the study period were reviewed to ensure that the patients released at the scene were not mistriaged. Results: One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to need TTA were admitted to the ICU/OR, and neither of the patients identified by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have TTA deteriorated after arrival to the ED. Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for TTA for pediatric blunt trauma patients were 50% (95% CI 9.2–90.8) and 87.7% (95% CI 78.0–93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9–49.1) and 97.3% (95% CI 89.6–99.5). None of the patients released at the scene was mistriaged based on the review of the coroners' and trauma admission records. Conclusion:Results of this investigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for pediatric blunt trauma patients is not sufficiently sensitive to be of clinical use. The low sensitivity is explained by the deterioration in the clinical condition of 2 initially stable patients. The paramedic disposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjured pediatric trauma patients. Injured pediatric trauma patients who appear to be stable may deteriorate shortly after injury. However, if a pediatric patient appears injured, transport from the scene and examination by a trauma specialist are needed. Finally, the role of paramedic judgment must be further defined by larger studies with urban, rural, and suburban EMS systems before it can be used as a sole predictor of TTA.