Prehospital Care (prehospital + care)

Distribution by Scientific Domains

Selected Abstracts

Knowledge Translation in the Emergency Medical Services: A Research Agenda for Advancing Prehospital Care

David C. Cone MD
Little is known about knowledge translation in the practice of out-of-hospital medicine. It is generally accepted that much work is needed regarding "getting the evidence straight" in emergency medical services, given the substantial number of interventions that are performed regularly in the field but lack meaningful scientific support. Additional attention also needs to be given to "getting the evidence used," because there is some evidence that evidence-based practices are being incompletely or incorrectly applied in the field. In an effort to help advance a research agenda for knowledge translation in emergency medical services, nine recommendations are put forth to help address the problems identified. [source]

Options in Prehospital analgesia

Meredith L Borland
Abstract Background: Prehospital analgesia options for paramedics have been limited due to the difficulty in achieving safe and effective pain relief without compromising transportation to hospital. The present paper identifies the analgesia methods currently available in the prehospital setting so as to evaluate the various options and highlight areas for future research. Methods: A literature review of Medline and Embase databases from 1966 until the present was undertaken. Further hand searching of all the references identified in these papers was also performed. All current literature was analysed and categorized according to one of four levels of evidence using National Health and Medical Research Council of Australia guidelines (1999). Results: There is a paucity of randomized control trials relating to prehospital analgesia. All published literature was level III or IV prospective or retrospective studies. Drug options used included nitrous oxide/oxygen mixtures, intravenous/intramuscular nalbuphine, intravenous tramadol and intravenous pure opiate agonists. Conclusions: The evidence supporting analgesic options in the prehospital setting is limited. There are few published data in this area despite the inadequacy of pain relief being recognized as a weakness in prehospital care. Prehospital analgesia is an area worthy of innovative methods for the administration of safe and effective analgesics without significant impact on transport times. Such methods should be prospectively evaluated in well-constructed trials. [source]

Factors associated with discussion of care plans and code status at the time of hospital admission: Results from the Multicenter Hospitalist Study,

Andrew D. Auerbach MD
Abstract BACKGROUND: Hospital admission is a time when patients are sickest and also often encountering an entirely new set of caregivers. As a result, understanding and documenting a patient's care preferences at hospital admission is critically important. OBJECTIVE: To understand factors associated with documentation of care planning discussions in patients admitted to general medical services at 6 academic medical centers. DESIGN: Observational cohort study using data collected during the Multicenter Hospitalist Study, conducted between July 1, 2002 and June 30, 2004. SETTING: Prospective trial enrolling patients admitted to general medicine services at 6 university-based teaching hospitals. PATIENTS: Patients were eligible for this study if they were 18 years of age or older, admitted to a hospitalist or nonhospitalist physician, and able to give informed consent. MEASUREMENTS: Presence of chart documentation that the admitting team had discussed care plans with the patient within the first 24 hours of hospitalization. Notations such as "full code" were not counted as a discussion, whereas notations such as "discussed care wishes and plan with patient" were counted. RESULTS: A total of 17,097 patients over the age of 18 gave informed consent and completed an interview and chart abstraction; of these, 1776 (10.3%) had a code status discussion (CD) documented in the first 24 hours of their admission. Patients with a CD were older (69 years vs. 56 years, P < 0.0001), more often white (52.8% vs. 43.3%, P < 0.0001), and more likely to have cancer (19.8% vs. 11.4%, P < 0.0001), or depression (35.1% vs. 30.9%, P < 0.0001). There was marked variability in CD documentation across sites of enrollment (2.8%-24.9%, P < 0.0001). Despite strong associations seen in unadjusted comparisons, in multivariable models many socioeconomic factors, functional status, comorbid illness, and documentation of a surrogate decision maker were only moderately associated with a CD (adjusted odds ratios all less than 2.0). However, patients' site of enrollment (odds ratios 1.74-5.14) and informal notations describing prehospital care wishes (eg, orders for "do not resuscitate"/"do not intubate;" odds ratios 3.22-11.32 compared with no preexisting documentation) were powerfully associated with CD documentation. Site remained a powerful influence even in patients with no documented prehospital wishes. LIMITATIONS: Our results are derived from a relatively small number of academic sites, and we cannot connect documentation differences to differences in patient outcomes. CONCLUSIONS: Documentation of a CD at admission was more strongly associated with informal documentation of prehospital care wishes and where the patient was hospitalized than legal care planning documents (such as durable power of attorney), or comorbid illnesses. Efforts to improve communication between hospitalists and their patients might target local documentation practices and culture. Journal of Hospital Medicine 2008;3(6):437,445. 2008 Society of Hospital Medicine. [source]

Is ECG-guidance a helpful method to correctly position a central venous catheter during prehospital emergency care?

J. S. David
Background:, Insertion of a central venous catheter (CVC) in an emergency situation is challenging and may be potentially associated with more complications. Because CVC positioning by ECG-guidance may help to decrease the frequency of a malpositioned catheter, we decided to prospectively evaluate the usefulness of positioning a CVC by ECG-guidance during prehospital emergency care. Methods:, Prospective observational study during which all patients requiring CVC placement during prehospital care were included. We compared two periods of 1 year during which CVCs were inserted without and then with the help of ECG-guidance. Results:, Eighty successive patients were included. We observed a significant reduction of incorrectly positioned CVCs with ECG-guidance (13% vs. 38%, P < 0.05) and a decreased number of chest X-rays needed to verify the position of the CVC (40 vs. 54, P < 0.05). Conclusion:, ECG-guidance is a safe and feasible technique which significantly improved the rate of CVCs correctly positioned during prehospital emergency care. [source]

Prehospital management of diabetic emergencies , a population-based intervention study

A. Holstein
Background: Diabetes-related emergencies are frequent and potentially life-threatening. A study was performed to obtain reliable data about the prevalence of diabetic emergencies and to improve the quality of prehospital care of patients with diabetes-related emergencies. Methods: A prospective population-based study in a German emergency medical service district in the period from 1997 to 2000 was conducted. After initial diabetes training for the entire emergency team, a standardized protocol was introduced for prehospital emergency therapy of severe hypoglycaemia (SH) and severe hyperglycaemic disorders. A rapid blood glucose test was performed on all emergency patients with the exception of resuscitations and deaths. Indicators of treatment quality before and after these interventions were compared. Results: A rapid blood glucose test was performed in 6631 (85%) of the 7804 emergencies that occurred during the period investigated. The prevalence of acute diabetic complications was 3.1%, and 213 cases of SH and 29 severe hyperglycaemic disorders were recorded. Education of the emergency team led to a significant improvement in the quality of treatment. Larger volumes of iv 40% glucose solution (50 20 ml (1997,2000) vs. 25 17 ml (1993,96); P < 0.0001) were administered to patients with SH. Insulin-treated patients who were well educated about their diabetes were more often treated only at the emergency scene, after SH (25% vs. 8%; P = 0.007), and without complications. In 50 patients who experienced sulfonylurea-induced SH, the mandatory additional glucose infusions and hospitalization for further observation reduced mortality from 4.9% to 0% (P = 0.2). Conclusion: Training of the emergency team is an effective and efficient intervention to improve quality of treatment and prognosis outcome for patients with diabetic emergencies. Treatment of SH at the emergency scene only was demonstrated to be safe in type 1 diabetic patients who had previously received structured patient education. [source]

Unique Characteristics of Emergency Care Research: Scope, Populations, and Infrastructure

D. Mark Courtney MD
Abstract The National Institutes of Health (NIH) Clinical and Translational Science Awards (CTSA) program and the 2006 Institute of Medicine (IOM) Report on the future of emergency care highlight the need for coordinated emergency care research (ECR) to improve the outcomes of acutely ill or injured patients. In response, the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP) sponsored the Emergency Care Research Network (ECRN) Conference in Washington, DC, on May 28, 2008. The conference objectives were to identify the unique nature of ECR and the infrastructure needed to support ECR networks and to understand the optimal role of emergency medicine (EM) and other acute care specialties in research networks. Prior to the conference, participants responded to questions addressing the relevant issues that would form the basis of breakout session discussions; two of these breakout questions are summarized in this report: 1) what makes EM research unique? and 2) what are the critical components needed to establish and maintain networked ECR? Emergency care research was defined as "the systematic examination of patient care that is expected to be continuously available to diverse populations presenting with undifferentiated symptoms of acute illness, or acutely decompensated chronic illness, and whose outcomes depend on timely diagnosis and treatment." The chain of ECR may extend beyond the physical emergency department (ED) in both place and time and integrate prehospital care, as well as short- and long-term outcome determination. ECR may extend beyond individual patients and have as the focus of investigation the actual system of emergency care delivery itself and its effects on the community with respect to access to care, use of resources, and cost. Infrastructure determinants of research network success identified by conference participants included multidisciplinary collaboration, accurate long-term outcome determination, novel information technology, intellectual infrastructure, and wider network relationships that extend beyond the ED. [source]

Climate Change and Emergency Medicine: Impacts and Opportunities

Jeremy J. Hess MD
Abstract There is scientific consensus that the climate is changing, that human activity plays a major role, and that the changes will continue through this century. Expert consensus holds that significant health effects are very likely. Public health and health care systems must understand these impacts to properly pursue preparedness and prevention activities. All of medicine will very likely be affected, and certain medical specialties are likely to be more significantly burdened based on their clinical activity, ease of public access, public health roles, and energy use profiles. These specialties have been called on to consider the likely impacts on their patients and practice and to prepare their practitioners. Emergency medicine (EM), with its focus on urgent and emergent ambulatory care, role as a safety-net provider, urban concentration, and broad-based clinical mission, will very likely experience a significant rise in demand for its services over and above current annual increases. Clinically, EM will see amplification of weather-related disease patterns and shifts in disease distribution. In EM's prehospital care and disaster response activities, both emergency medical services (EMS) activity and disaster medical assistance team (DMAT) deployment activities will likely increase. EM's public health roles, including disaster preparedness, emergency department (ED)-based surveillance, and safety-net care, are likely to face increasing demands, along with pressures to improve fuel efficiency and reduce greenhouse gas emissions. Finally, EM's roles in ED and hospital management, particularly related to building and purchasing, are likely to be impacted by efforts to reduce greenhouse gas emissions and enhance energy efficiency. Climate change thus presents multiple clinical and public health challenges to EM, but also creates numerous opportunities for research, education, and leadership on an emerging health issue of global scope. [source]

19 A Novel Approach to Residency Education in EMS: The MD-PM Ambulance

Angela Fiege
Challenge:, Indiana University EM residents have actively provided prehospital care as crew members on a hospital-based air ambulance service. This service functions as a secondary responder for high acuity patients who have already had first tier evaluation and care. First response, ground EMS experiences have been observational only as residents have ridden along with a two-paramedic team on an urban ambulance service for 24 hours during their residency careers. Resident understanding of first response care and challenges faced by initial EMS providers has been limited to that gleaned during their observational period. Solution:, Most EM residencies do not provide opportunities for residents to function as first response providers. Therefore, we developed a Physician-Paramedic team to provide first response care within a busy metropolitan area. This two-member team operates within a "geozone" that includes a diverse patient population with both medical and trauma complaints. Unlike other residency ground EMS programs, the MD-PM truck responds primarily to all ambulance requests within their designated geozone and assists outside their designated geozone for multi-patient casualties in which a physician response would benefit patient care (fires, motor vehicle accidents, multiple gunshot victims). Residents on the MD-PM truck not only provide care equivalent to that expected of a nationally certified paramedic (IVs, drug administration, splinting, packaging), but also perform advanced skills such as RSI which is outside the scope of a traditional two-paramedic team. Immersion into the first response ground EMS system will provide valuable insight into the challenges of providing care outside of the hospital. [source]