Background
Fatal trauma is one of the leading causes of death in Western industrialized countries. The aim of the present study was to determine the preventability of traumatic deaths, analyze the ...medical measures related to preventable deaths, detect management failures, and reveal specific injury patterns in order to avoid traumatic deaths in Berlin.
Materials and methods
In this prospective observational study all autopsied, direct trauma fatalities in Berlin in 2010 were included with systematic data acquisition, including police files, medical records, death certificates, and autopsy records. An interdisciplinary expert board judged the preventability of traumatic death according to the classification of non-preventable (NP), potentially preventable (PP), and definitively preventable (DP) fatalities.
Results
Of the fatalities recorded, 84.9 % (
n
= 224) were classified as NP, 9.8 % (
n
= 26) as PP, and 5.3 % (
n
= 14) as DP. The incidence of severe traumatic brain injury (sTBI) was significantly lower in PP/DP than in NP, and the incidence of fatal exsanguinations was significantly higher. Most PP and NP deaths occurred in the prehospital setting. Notably, no PP or DP was recorded for fatalities treated by a HEMS crew. Causes of DP deaths consisted of tension pneumothorax, unrecognized trauma, exsanguinations, asphyxia, and occult bleeding with a false negative computed tomography scan.
Conclusions
The trauma mortality in Berlin, compared to worldwide published data, is low. Nevertheless, 15.2 % (
n
= 40) of traumatic deaths were classified as preventable. Compulsory training in trauma management might further reduce trauma-related mortality. The main focus should remain on prevention programs, as the majority of the fatalities occurred as a result of non-survivable injuries.
Helicopter emergency medical services (HEMS) is commonly elected transport for acute ischemic stroke (AIS) known as a time-critical illness.
To conduct a systematic review in order to explore the ...HEMS impact on healthcare status, process and outcome measures for AIS patients.
A systematic search was conducted of PubMed, Medline, CINAHL, Cochrane Library and Google Scholar. The gray literature and reference lists of included articles were also searched. Thirty studies met inclusion criteria.
Using Donabedian's framework, two studies focused on the impact on healthcare structure, twenty-three explored the impact on process measures, and five focused on clinical outcomes. HEMS structure implications could not be assessed due to insufficient studies. HEMS showed no significant outcome benefit compared to ground emergency medical services (EMS) and the impact on process measures was ambiguous.
HEMS necessity varied considerably between studies. More robust studies are needed for detection of the most suitable use of HEMS in AIS.
Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) attempts to improve the management of out-of-hospital cardiac arrest by laypersons who are unable to recognize cardiac arrest and are ...unfamiliar with CPR. Therefore, we investigated the sensitivity and specificity of our new DA-CPR protocol for achieving implementation of bystander CPR in out-of-hospital cardiac arrest victims not already receiving bystander CPR.
Since 2007, we have applied a new DA-CPR protocol that uses supplementary key words. Fire departments prospectively collected baseline data on DA-CPR from January 2009 to December 2011. DA-CPR was attempted in 2747 patients; of these, 417 (15.2%) did not experience cardiac arrest. The sensitivity and specificity of the 2007 protocol versus estimated values of the previous standard protocol were 72.9% versus 50.3% and 99.6% versus 99.8%, respectively. We identified key words that may be useful for detecting out-of-hospital cardiac arrest. Multiple logistic regression analysis revealed that the occurrence of cardiac arrest after an emergency call (odds ratio, 16.85) and placing an emergency call away from the scene of the arrest (odds ratio, 11.04) were potentially associated with failure to provide DA-CPR. Furthermore, at-home cardiac arrest (odds ratio, 1.61) and family members as bystanders (odds ratio, 1.55) were associated with bystander noncompliance with DA-CPR. No complications were reported in the 417 patients who received DA-CPR but did not have cardiac arrest.
Our 2007 protocol is safe and highly specific and may be more sensitive than the standard protocol. Understanding the factors associated with failure of bystanders to provide DA-CPR and implementing public education are necessary to increase the benefit of DA-CPR.
Abstract Background The goal of this study is to better understand the trend in epidemiological features and the outcomes of emergency medical service (EMS)-assessed out-of-hospital cardiac arrest ...(OHCA) according to the community urbanization level: metropolitan, urban, and rural. Methods This study was performed within a nationwide EMS system with a single-tiered basic-to-intermediate service level and approximately 900 destination hospitals for eligible OHCA cases in South Korea (with 48 million people). A nationwide OHCA database, which included information regarding demographics, Utstein criteria, EMS, and hospital factors and outcomes, was constructed using the EMS run sheets of eligible cases who were transported by 119 EMS ambulances and followed by a medical record review from 2006 to 2010. Cases with an unknown outcome were excluded. The community urbanization level was categorized according to population size, with metropolitan areas (more than 500,000 residents), urban areas (100,000–500,000 residents), and rural areas (<100,000 residents). The primary end point was the survival to discharge rate. Age- and sex-adjusted survival rates (ASRs) and standardized survival ratios (SSRs) with 95% confidence intervals (CIs) were calculated compared to a standard population. The adjusted odds ratios (AORs) and 95% CIs for survival were calculated and adjusted for potential risk factors using stratified multivariable logistic regression analysis. Results There were 97,291 EMS-assessed OHCAs with 73,826 (75.9%) EMS-treated cases analyzed, after excluding the patients with unknown outcome ( N = 4172). The standardized incidence rate increased from 37.5 in 2006 to 46.8 in 2010 per 100,000 person-years for EMS-assessed OHCAs, and the survival rate was 3.0% for EMS-assessed OHCAs (3.3% for cardiac etiology and 2.3% for non-cardiac etiology) and 3.6% for EMS-treated OHCAs. Significantly different trends were found by urbanization level for bystander CPR, EMS performance, and the level of the destination hospital. The ASRs for survival were significantly improved by year in the metropolitan areas (3.6% in 2006 to 5.3% in 2010) but remained low in the urban areas (1.4% in 2006 to 2.3% in 2010) and very low in the rural areas (0.5 in 2006 and 0.8 in 2010). The SSRs (95% CIs) in the metropolitan areas were 1.19 (1.06–1.34) in 2006 and 1.77 (1.64–1.92) in 2010, whereas the SSRs were observed to be less than 1.00 during the five-year period in both urban and rural areas. The AORs (95% CIs) for survival significantly increased to 1.42 (1.22–1.66) in the metropolitan areas and to 1.58 (1.18–2.11) in the urban areas while not increasing in the rural areas, compared to the level of each group of areas in 2006. Conclusions In this nationwide cohort study from 2006 to 2010, the standardized incidence rate and survival to discharge rate of EMS-assessed OHCAs increased annually in metropolitan and urban communities but did not increase in rural communities. Further investigations should be undertaken to improve the performance and outcomes in rural communities.
Evidence suggests that EMS-physician-guided cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OOHCA) may be associated with improved outcomes, yet randomized controlled trials ...are not available. The goal of this meta-analysis was to determine the association between EMS-physician- versus paramedic-guided CPR and survival after OOHCA.
Studies that compared EMS-physician- versus paramedic-guided CPR in OOHCA published until June 2014 were systematically searched in MEDLINE, EMBASE and Cochrane databases. All studies were required to contain survival data. Data on study characteristics, methods, and as well as survival outcomes were extracted. A random-effects model was used for the meta-analysis due to a high degree of heterogeneity among the studies (I(2) = 44%). Return of spontaneous circulation ROSC, survival to hospital admission, and survival to hospital discharge were the outcome measures. Out of 3,385 potentially eligible studies, 14 met the inclusion criteria. In the pooled analysis (n = 126,829), EMS-physician-guided CPR was associated with significantly improved outcomes compared to paramedic-guided CPR: ROSC 36.2% (95% confidence interval CI 31.0 - 41.7%) vs. 23.4% (95% CI 18.5 - 29.2%) (pooled odds ratio OR 1.89, 95% CI 1.36 - 2.63, p < 0.001); survival to hospital admission 30.1 % (95% CI 24.2 - 36.7%) vs. 19.2% (95% CI 12.7 - 28.1%) (pooled OR 1.78, 95% CI 0.97 - 3.28, p = 0.06); and survival to discharge 15.1% (95% CI 14.6 - 15.7%) vs. 8.4% (95% CI 8.2 - 8.5%) (pooled OR 2.03, 95% CI 1.48 - 2.79, p < 0.001).
This systematic review suggests that EMS-physician-guided CPR in out-of-hospital cardiac arrest is associated with improved survival outcomes.
Summary
Trauma and injury place a significant burden on healthcare systems. In most high‐income countries, well‐developed acute pre‐hospital and trauma care systems have been established. In Europe, ...mobile physician‐staffed medical teams are available for the most severely injured patients and apply a wide variety of lifesaving interventions at the same time as ensuring patient comfort. In trauma systems providing pre‐hospital care, medical interventions are performed earlier in the patient journey and do not affect time to definite care. The mode of transport from the accident scene depends on the organisation of the healthcare system and the level of hospital care to which the patient is transported. This varies from ‘scoop and run’ to a basic community care setting, to advanced helicopter emergency medical service transport to a level 4 trauma centre. Secondary transport of trauma patients to a higher level of care should be avoided and may lead to a delay in definitive care. Critically injured patients must be accompanied by at least two healthcare professionals, one of whom must be skilled in cardiopulmonary resuscitation and advanced airway management techniques. Ideally, the standard of care provided during transport, including the level of monitoring, should mirror hospital care. Pre‐hospital care focuses on the critical care patient, but the majority of injured patients need only close observation and pain management during transport. Providing comfort and preventing additional injury is the responsibility of the whole transport team.
Objectives: Although the factors driving emergency department demand have been extensively investigated, a comparatively minimal amount is known about the factors that are driving an increase in ...emergency ambulance demand. Methods: We conducted a retrospective observational study of consecutive cases attended by Ambulance Victoria in Melbourne, Australia from 2008 to 2015. Incidence rates were calculated, and adjusted time series regression analyses were performed to assess the driving factors of ambulance demand. Results: A total of 2,443,952 consecutive cases were included. Demand grew by 29.2% over the 8-year period. The age-specific incidence increased significantly over time for patients aged < 60 years, but not for patients aged ≥ 60 years. After adjustment for seasonality and population growth, demand increased by 1.4% per annum (incident rate ratio IRR = 1.014 1.011-1.017). The largest annual growth in demand was observed in patients with a history of mental health issues (IRR = 1.058 1.054-1.062), alcohol/drug abuse (IRR = 1.061 1.056-1.066), or a Charlson Comorbidity Index CCI score ≥ 4 (IRR = 1.045 1.039-1.051). Cases involving patients of relative socio-economic/educational disadvantage, younger age, or with no preexisting health conditions according to the CCI also grew faster than the overall patient population. Cases requiring transport to hospital increased by 1.2% annually (IRR = 1.012 1.009-1.016), although patients not requiring medical intervention from paramedics increased by 6.7% annually (IRR = 1.067 1.063-1.072). Conclusions: Increases in ambulance demand exceeded population growth. Emergency ambulances were increasingly utilized for transport of patients who did not require medical intervention from paramedics. Identifying the characteristics of patients driving ambulance demand will enable targeted demand management strategies.
In our metropolitan area, the Stroke Code (SC) system allows immediate transfer of patients with acute stroke to a stroke center. It may be activated by community hospitals (A), emergency medical ...services (EMS, B), or the emergency department of the stroke center (C). Our aim was to analyze whether the SC activation source influences the access to thrombolytic therapy and outcome of patients with ischemic stroke.
We prospectively registered patients with ischemic stroke admitted to the acute stroke unit who arrived through the SC system. The primary outcome variable was good outcome at discharge (Rankin Scale <or= 2). Secondary outcome was neurologic improvement >or=4 in National Institutes of Health Stroke Scale (NIHSS) score or NIHSS score 0 to 1 at 24 hours.
A total of 262 consecutive patients with hyperacute ischemic stroke were studied; the SC source was A in 112, B in 57, and C in 92. Median time from onset to admission was longer in Group A and stroke severity higher in Groups B and C. Percentage of tPA administration was higher in patients from Groups B and C (27%, 54%, and 46% of patients; p = 0.001). With respect to Group A, Group B was associated with good outcome with an odds of 2.9 (1.2-6.6; p = 0.01), and Group C with an odds of 2.4 (1.1-4.9; p = 0.01) after adjustment for age and stroke severity at baseline. Patients coming via levels B and C were more likely to improve at 24 hours.
Patients arriving directly to the stroke center via emergency medical services or on their own receive neurologic attention sooner, are more frequently treated with tPA, and have better clinical outcome than those patients who are first taken to a community hospital.
The aim of this study was to investigate regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand.
This was a ...population-based cohort study of OHCA using data from the Aus-ROC Australian and New Zealand OHCA Epistry over the period of 01 January 2015–31 December 2015. Seven ambulance services contributed data to the Epistry with a capture population of 19.8 million people. All OHCA attended by ambulance, regardless of aetiology or patient age, were included.
In 2015, there were 19,722 OHCA cases recorded in the Aus-ROC Epistry with an overall crude incidence of 102.5 cases per 100,000 population (range: 51.0–107.7 per 100,000 population). Of all OHCA cases attended by EMS (excluding EMS-witnessed cases), bystander CPR was performed in 41% of cases (range: 36%–50%). Resuscitation was attempted (by EMS) in 48% of cases (range: 40%–68%). The crude incidence for attempted resuscitation cases was 47.6 per 100,000 population (range: 34.7–54.1 per 100,000 population). Of cases with attempted resuscitation, 28% survived the event (range: 21%–36%) and 12% survived to hospital discharge or 30 days (range: 9%–17%; data provided by five ambulance services).
In the first results of the Aus-ROC Australian and New Zealand OHCA Epistry, significant regional variation in the incidence, characteristics and outcomes was observed. Understanding the system-level and public health drivers of this variation will assist in optimisation of the chain of survival provided to OHCA patients with the aim of improving outcomes.
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