Glasgow Coma Scale Motor Component (“Patient Does Not Follow Commands”) Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients

Study objective Trauma victims are frequently triaged to a trauma center according to the patient\u27s calculated Glasgow Coma Scale (GCS) score despite its known inconsistencies. The substitution of a simpler binary assessment of GCS-motor (GCS-m) score less than 6 (ie, “patient does not follow commands”) would simplify field triage. We compare total GCS score to this binary assessment for predicting trauma outcomes. Methods This retrospective analysis of a statewide trauma registry includes records from 393,877 patients from 1999 to 2013. Patients with initial GCS score less than or equal to 13 were compared with those with GCS-m score less than 6 for outcomes of Injury Severity Score (ISS) greater than 15, ISS greater than 24, death, ICU admission, need for surgery, or need for craniotomy. We judged a priori that differences less than 5% lack clinical importance. Results The relative differences between GCS and GCS-m scores less than 6 were less than 5% and thus clinically unimportant for all outcomes tested, even when statistically significant. For the 6 outcomes, the differences in areas under receiver operating characteristic curves ranged from 0.014 to 0.048. Total GCS score less than or equal to 13 was slightly more sensitive (difference 3.3%; 95% confidence interval 3.2% to 3.4%) and slightly less specific (difference –1.5%; 95% confidence interval –1.6% to –1.5%) than GCS-m score less than 6 for predicting ISS greater than 15, with similar overall accuracy (74.1% versus 74.2%). Conclusion Replacement of the total GCS score with a simple binary decision point of GCS-m score less than 6, or a patient who “does not follow commands,” predicts serious injury, as well as the total GCS score, and would simplify out-of-hospital trauma triage

Emergency medical services clinicians in the United States are increasingly exposed to death

Abstract Introduction Exposure to patient death places healthcare workers at increased risk for burnout and traumatic stress, yet limited data exist exploring exposure to death among emergency medical services (EMS) clinicians. Our objective was to describe changes in EMS encounters involving on‐scene death from 2018 to 2021. Methods We retrospectively analyzed deidentified EMS records for 9‐1‐1 responses from the ESO Data Collaborative from 2018 to 2021. We identified cases where patient dispositions of death on scene, with or without attempted resuscitation, and without EMS transport. A non‐parametric test of trend was used to assess for monotonic increase in agency‐level encounters involving on‐scene death and the proportion of EMS clinicians exposed to ≥1 on‐scene death. Results We analyzed records from 1109 EMS agencies. These agencies responded to 4,286,976 calls in 2018, 5,097,920 calls in 2019, 4,939,651 calls in 2020, and 5,347,340 calls in 2021.The total number of encounters with death on scene rose from 49,802 in 2018 to 60,542 in 2019 to 76,535 in 2020 and 80,388 in 2021. Agency‐level annual counts of encounters involving death on scene rose from a median of 14 (interquartile range [IQR], 4–40) in 2018 to 2023 (IQR, 6–63) in 2021 (P‐trend < 0.001). In 2018, 56% of EMS clinicians responded to a call with death on scene, and this number rose to 63% of EMS clinicians in 2021 (P‐trend < 0.001). Conclusion From 2018 to 2021, EMS clinicians were increasingly exposed to death. This trend may be driven by COVID‐19 and its effects on the healthcare system and reinforces the need for evidence‐based death notification training to support EMS clinicians

National Prehospital Evidence-Based Guidelines Strategy: A Summary for EMS Stakeholders

<p>Multiple national organizations have recommended and supported a national investment to increase the scientific evidence available to guide patient care delivered by Emergency Medical Services (EMS) and incorporate that evidence directly into EMS systems. Ongoing efforts seek to develop, implement, and evaluate prehospital evidence-based guidelines (EBGs) using the National Model Process created by a multidisciplinary panel of experts convened by the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC). Yet, these and other EBG efforts have occurred in relative isolation, with limited direct collaboration between national projects, and have experienced challenges in implementation of individual guidelines. There is a need to develop sustainable relationships among stakeholders that facilitate a common vision that facilitates EBG efforts. Herein, we summarize a National Strategy on EBGs developed by the National Association of EMS Physicians (NAEMSP) with involvement of 57 stakeholder organizations, and with the financial support of the National Highway Traffic Safety Administration (NHTSA) and the EMS for Children program. The Strategy proposes seven action items that support collaborative efforts in advancing prehospital EBGs. The first proposed action is creation of a Prehospital Guidelines Consortium (PGC) representing national medical and EMS organizations that have an interest in prehospital EBGs and their benefits to patient outcomes. Other action items include promoting research that supports creation and evaluates the impact of EBGs, promoting the development of new EBGs through improved stakeholder collaboration, and improving education on evidence-based medicine for all prehospital providers. The Strategy intends to facilitate implementation of EBGs by improving guideline dissemination and incorporation into protocols, and seeks to establish standardized evaluation methods for prehospital EBGs. Finally, the Strategy proposes that key stakeholder organizations financially support the Prehospital Guidelines Consortium as a means of implementing the Strategy, while together promoting additional funding for continued EBG efforts.</p

Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services

<p><b>Background</b>: Administrators of Emergency Medical Services (EMS) operations lack guidance on how to mitigate workplace fatigue, which affects greater than half of all EMS personnel. The primary objective of the Fatigue in EMS Project was to create an evidence-based guideline for fatigue risk management tailored to EMS operations. <b>Methods</b>: Systematic searches were conducted from 1980 to September 2016 and guided by seven research questions framed in the Population, Intervention, Comparison, Outcome (PICO) framework. Teams of investigators applied inclusion criteria, which included limiting the retained literature to EMS personnel or similar shift worker groups. The expert panel reviewed summaries of the evidence based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The panel evaluated the quality of evidence for each PICO question separately, considered the balance between benefits and harms, considered the values and preferences of the targeted population, and evaluated the resource requirements/needs. The GRADE Evidence-to-Decision (EtD) Framework was used to prepare draft recommendations based on the evidence, and the Content Validity Index (CVI) was used to quantify the panel's agreement on the relevance and clarity of each recommendation. CVI scores for relevance and clarity were measured separately on a 1–4 scale to indicate consensus/agreement among panel members and conclusion of recommendation development. <b>Results</b>: The EtD framework was applied to all 7 PICO questions, and the panel created 5 recommendations. PICO1: The panel recommends using fatigue/sleepiness survey instruments to measure and monitor fatigue in EMS personnel. PICO2: The panel recommends that EMS personnel work shifts shorter than 24 hours in duration. PICO3: The panel recommends that EMS personnel have access to caffeine as a fatigue countermeasure. PICO4: The panel recommends that, EMS personnel have the opportunity to nap while on duty to mitigate fatigue. PICO5: The panel recommends that EMS personnel receive education and training to mitigate fatigue and fatigue-related risks. The panel referenced insufficient evidence as the reason for making no recommendation linked to 2 PICO questions. <b>Conclusions</b>: Based on a review of the evidence, the panel developed a guideline with 5 recommendations for fatigue risk management in EMS operations.</p