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Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence
Background
The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known.
Methods
This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages.
Results
Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood.
Conclusions
This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.
Journal Article
Living and dying in Brick City : stories from the front lines of an inner-city E.R.
Dr. Davis looks at the healthcare crisis in the inner city from the perspective of a doctor who works on the front line of emergency medical care in the community where he grew up, and as a member of that community who has faced the same challenges as the people he treats every day.
Book
Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis
Background
Circulatory failure is classified into four types of shock (obstructive, cardiogenic, distributive, and hypovolemic) that must be distinguished as each requires a different treatment. Point-of-care ultrasound (POCUS) is widely used in clinical practice for acute conditions, and several diagnostic protocols using POCUS for shock have been developed. This study aimed to evaluate the diagnostic accuracy of POCUS in identifying the etiology of shock.
Methods
We conducted a systematic literature search of MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Clinicaltrial.gov, European Union Clinical Trials Register, WHO International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) until June 15, 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was conducted to pool the diagnostic accuracy of POCUS for each type of shock. The study protocol was prospectively registered in UMIN-CTR (UMIN 000048025).
Results
Of the 1553 studies identified, 36 studies were full-text reviewed, and 12 studies with 1132 patients were included in the meta-analysis. Pooled sensitivity and specificity were 0.82 [95% confidence interval (CI) 0.68–0.91] and 0.98 [95% CI 0.92–0.99] for obstructive shock, 0.78 [95% CI 0.56–0.91] and 0.96 [95% CI 0.92–0.98] for cardiogenic shock, 0.90 [95% CI 0.84–0.94] and 0.92 [95% CI 0.88–0.95] for hypovolemic shock, and 0.79 [95% CI 0.71–0.85] and 0.96 [95% CI 0.91–0.98] for distributive shock, respectively. The area under the receiver operating characteristic curve for each type of shock was approximately 0.95. The positive likelihood ratios for each type of shock were all greater than 10, especially 40 [95% CI 11–105] for obstructive shock. The negative likelihood ratio for each type of shock was approximately 0.2.
Conclusions
The identification of the etiology for each type of shock using POCUS was characterized by high sensitivity and positive likelihood ratios, especially for obstructive shock.
Journal Article
Little Elephant's blocked trunk
\"An elephant has being playing with his toys and putting all of them away in the wrong place. Soon his mother notices that something is not quite right with her little one's trunk\"-- Provided by publisher.
Book
Cardiopulmonary resuscitation duration and favorable neurological outcome after out-of-hospital cardiac arrest: a nationwide multicenter observational study in Japan (the JAAM-OHCA registry)
Objective
We aimed to assess the association between cardiopulmonary resuscitation (CPR duration) and outcomes after OHCA.
Methods
This secondary analysis of a prospective, multicenter, observational study included adult non-traumatic OHCA patients aged ≥ 18 years between June 2014 and December 2017. CPR duration was defined as the time from professional CPR initiation to the time of return of spontaneous circulation or termination of resuscitation. The primary outcome was 1-month survival, with favorable neurological outcomes defined by cerebral performance category 1 or 2. We performed multivariable logistic regression analysis to investigate the association between CPR duration and favorable neurological outcomes. We also investigated the association between CPR duration and favorable neurological outcomes stratified by case features, including the first documented cardiac rhythm, witnessed status, and presence of bystander CPR.
Results
A total of 23,803 patients were included in this analysis. Multivariable logistic regression analysis demonstrated that the probability of favorable neurological outcomes decreased with CPR duration (i.e., 20.8% [226/1084] in the ≤ 20 min group versus 0.0% [0/708] in the 91–120 min group,
P
for trend < 0.001). Furthermore, the impact of CPR duration differed depending on the presence of case features; those with shockable, witnessed arrest, and bystander CPR were more likely to achieve favorable neurological outcomes after prolonged CPR duration > 30 min.
Conclusion
The probability of favorable neurological outcome rapidly decreased within a few minutes of CPR duration. But, the impact of CPR duration may be influenced by each patient’s clinical feature.
Journal Article
Legacy : a black physician reckons with racism in medicine
\"The rousing, captivating story of a Black physician, her career in medicine, and the deep inequities that still exist in the U.S. healthcare system Growing up in Brooklyn, New York, it never occurred to Uché Blackstock and her twin sister, Oni, that they would be anything but physicians. In the 1980s, their mother headed an organization of Black women physicians, and for years the girls watched these fiercely intelligent women in white coats tend to their patients and neighbors, host community health fairs, cure ills, and save lives. What Dr. Uché Blackstock did not understand as a child-or learn about at Harvard Medical School, where she and her sister had followed in their mother's footsteps, making them the first Black mother-daughter legacies from the school-were the profound and long-standing systemic inequities that mean just 2 percent of all U.S. physicians today are Black women; the racist practices and policies that ensure Black Americans have far worse health outcomes than any other group in the country; and the flawed system that endangers the well-being of communities like theirs. As an ER physician, and later as a professor in academic medicine, Dr. Blackstock became profoundly aware of the systemic barriers that Black patients and physicians continue to face. Legacy is a journey through the critical intersection of racism and healthcare. At once a searing indictment of our healthcare system, a generational family memoir, and a call to action, Legacy is Dr. Blackstock's odyssey from child to medical student to practicing physician-to finally seizing her own power as a health equity advocate against the backdrop of the pandemic and the Black Lives Matter movement\"-- Provided by publisher.
Book
A Secure Cloud-Assisted Wireless Body Area Network in Mobile Emergency Medical Care System
Recent advances in medical treatment and emergency applications, the need of integrating wireless body area network (WBAN) with cloud computing can be motivated by providing useful and real time information about patients’ health state to the doctors and emergency staffs. WBAN is a set of body sensors carried by the patient to collect and transmit numerous health items to medical clouds via wireless and public communication channels. Therefore, a cloud-assisted WBAN facilitates response in case of emergency which can save patients’ lives. Since the patient’s data is sensitive and private, it is important to provide strong security and protection on the patient’s medical data over public and insecure communication channels. In this paper, we address the challenge of participant authentication in mobile emergency medical care systems for patients supervision and propose a secure cloud-assisted architecture for accessing and monitoring health items collected by WBAN. For ensuring a high level of security and providing a mutual authentication property, chaotic maps based authentication and key agreement mechanisms are designed according to the concept of Diffie-Hellman key exchange, which depends on the CMBDLP and CMBDHP problems. Security and performance analyses show how the proposed system guaranteed the patient privacy and the system confidentiality of sensitive medical data while preserving the low computation property in medical treatment and remote medical monitoring.
Journal Article
Outcome assessment for out-of-hospital cardiac arrest patients in Singapore and Japan with initial shockable rhythm
Background
Singapore and Osaka in Japan have comparable population sizes and prehospital management; however, the frequency of ECPR differs greatly for out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm. Given this disparity, we hypothesized that the outcomes among the OHCA patients with initial shockable rhythm in Singapore were different from those in Osaka. The aim of this study was to evaluate the outcomes of OHCA patients with initial shockable rhythm in Singapore compared to the expected outcomes derived from Osaka data using machine learning-based prediction models.
Methods
This was a secondary analysis of two OHCA databases: the Singapore PAROS database (SG-PAROS) and the Osaka-CRITICAL database from Osaka, Japan. This study included adult (18–74 years) OHCA patients with initial shockable rhythm. A machine learning-based prediction model was derived and validated using data from the Osaka-CRITICAL database (derivation data 2012–2017, validation data 2018–2019), and applied to the SG-PAROS database (2010–2016 data), to predict the risk-adjusted probability of favorable neurological outcomes. The observed and expected outcomes were compared using the observed–expected ratio (OE ratio) with 95% confidence intervals (CI).
Results
From the SG-PAROS database, 1,789 patients were included in the analysis. For OHCA patients who achieved return of spontaneous circulation (ROSC) on hospital arrival, the observed favorable neurological outcome was at the same level as expected (OE ratio: 0.905 [95%CI: 0.784–1.036]). On the other hand, for those who had continued cardiac arrest on hospital arrival, the outcomes were lower than expected (shockable rhythm on hospital arrival, OE ratio: 0.369 [95%CI: 0.258–0.499], and nonshockable rhythm, OE ratio: 0.137 [95%CI: 0.065–0.235]).
Conclusion
This observational study found that the outcomes for patients with initial shockable rhythm but who did not obtain ROSC on hospital arrival in Singapore were lower than expected from Osaka. We hypothesize this is mainly due to differences in the use of ECPR.
Journal Article
The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study
Background
Vasopressin is a second-line vasoactive agent for refractory septic shock. Vasopressin loading is not generally performed because of the lack of evidence for its effects and safety. However, based on our previous findings, we hypothesized it can predict the responsibility to vasopressin infusion with safety, and prospectively examined it in the present study.
Methods
Vasopressin loading was performed via the intravenous administration of a bolus of 1 U, followed by its continuous infusion at 1U/h in patients with septic shock treated with ≥ 0.2 μg/kg/min noradrenaline. An arterial pressure wave analysis was conducted, and endocrinological tests were performed immediately prior to vasopressin loading. We classified patients into responders/non-responders based on mean arterial pressure (MAP) changes after vasopressin loading. Based on our previous findings, the lower tertile of MAP changes was selected as the cut-off. The change in the catecholamine index (CAI) after 6 h was assigned as the primary outcome. Digital ischemia, mesenteric ischemia, and myocardial ischemia during the admission period were prospectively and systematically recorded as adverse events.
Results
Ninety-two patients were registered during the study period and examined. Sixty-two patients with a MAP change > 22 mmHg were assigned as responders and the others as non-responders. Blood adrenocorticotropic hormone levels were significantly higher in non-responders. Stroke volume variations were higher in responders before loading, while stroke volume and dP/dt
max
were higher in responders after loading. Median CAI changes were − 10 in responders and 0 in non-responders, which was significantly lower in the former (p < 0.0001). AUROC of MAP change with vasopressin loading to predict CAI change < 0 after continuous infusion was 0.843 with sensitivity of 0.92 and specificity of 0.77. Ischemia events were observed in 5 cases (5.4%).
Conclusions
Vasopressin loading may be safely introduced for septic shock. Vasopressin loading may be used to predict responses to its continuous infusion and select appropriate strategies to increase blood pressure.
Journal Article