A consensus-based template for documenting and reporting in physician-staffed pre-hospital services

Background: Physician-staffed pre-hospital units are employed in many Western emergency medical services (EMS) systems. Although these services usually integrate well within their EMS, little is known about the quality of care delivered, the precision of dispatch, and whether the services deliver a higher quality of care to pre-hospital patients. There is no common data set collected to document the activity of physician pre-hospital activity which makes shared research efforts difficult. The aim of this study was to develop a core data set for routine documentation and reporting in physician-staffed pre-hospital services in Europe. Methods: Using predefined criteria, we recruited sixteen European experts in the field of pre-hospital care. These experts were guided through a four-step modified nominal group technique. The process was carried out using both e-mail-based communication and a plenary meeting in Stavanger, Norway. Results: The core data set was divided into 5 sections: “fixed system variables”, “event operational descriptors”, “ patient descriptors”, “process mapping”, and “outcome measures and quality indicators”. After the initial round, a total of 361 variables were proposed by the experts. Subsequent rounds reduced the number of core variables to 45. These constituted the final core data set. Emphasis was placed on the standardisation of reporting time variables, chief complaints and diagnostic and therapeutic procedures. Conclusions: Using a modified nominal group technique, we have established a core data set for documenting and reporting in physician-staffed pre-hospital services. We believe that this template could facilitate future studies within the field and facilitate standardised reporting and future shared research efforts in advanced prehospital care.publishedVersio

Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest

Aim: We compared the prognostic abilities of neurofilament light (NfL) and neuron-specific enolase (NSE) in patients resuscitated from out-ofhospital cardiac arrest (OHCA) of various aetiologies. Methods: We analysed frozen blood samples obtained at 24 and 48 hours from OHCA patients treated in 21 Finnish intensive care units in 2010 and 2011. We defined unfavourable outcome as Cerebral Performance Category (CPC) 3-5 at 12 months after OHCA. We evaluated the prognostic ability of the biomarkers by calculating the area under the receiver operating characteristic curves (AUROCs [95% confidence intervals]) and compared these with a bootstrap method. Results: Out of 248 adult patients, 12-month outcome was unfavourable in 120 (48.4%). The median (interquartile range) NfL concentrations for patients with unfavourable and those with favourable outcome, respectively, were 689 (146-1804) pg/mL vs. 31 (17-61) pg/mL at 24 h and 1162 (147-4360) pg/mL vs. 36 (21-87) pg/mL at 48 h, p < 0.001 for both. The corresponding NSE concentrations were 13.3 (7.2-27.3) mg/L vs. 8.5 (5.8- 13.2) mg/L at 24 h and 20.4 (8.1-56.6) mg/L vs. 8.2 (5.9-12.1) mg/L at 48 h, p < 0.001 for both. The AUROCs to predict an unfavourable outcome were 0.90 (0.86-0.94) for NfL vs. 0.65 (0.58-0.72) for NSE at 24 h, p < 0.001 and 0.88 (0.83-0.93) for NfL and 0.73 (0.66-0.81) for NSE at 48 h, p < 0.001. Conclusion: Compared to NSE, NfL demonstrated superior accuracy in predicting long-term unfavourable outcome after OHCA.Peer reviewe

All rights reserved r 2008 The Authors Journal compilation r

This article is intended as a generic guide to evidencebased airway management for all categories of pre-hospital personnel. It is based on a review of relevant literature but the majority of the studies have not been performed under realistic, pre-hospital conditions and the recommendations are therefore based on a low level of evidence (D). The advice given depends on the qualifications of the personnel available in a given emergency medical service (EMS). Anaesthetic training and routine in anaesthesia and neuromuscular blockade is necessary for the use of most techniques in the treatment of patients with airway reflexes. For anaesthesiologists, the Task Force commissioned by the Scandinavian Society of Anaesthesia and Intensive Care Medicine recommends endotracheal intubation (ETI) following rapid sequence induction when securing the pre-hospital airway, although repeated unsuccessful intubation attempts should be avoided independent of formal qualifications. Other physicians, as well as paramedics and other EMS personnel, are recommended the lateral trauma recovery position as a basic intervention combined with assisted mask-ventilation in trauma patients. When performing advanced cardiopulmonary resuscitation, we recommend that non-anaesthesiologists primarily use a supraglottic airway device. A supraglottic device such as the laryngeal tube or the intubation laryngeal mask should also be available as a backup device for anaesthesiologists in failed ETI. Accepted for publication 25 February 2008 Key words: Pre-hospital; airway management; endotracheal intubation; laryngeal mask airway; laryngeal tube airway; combitube; emergency medical systems. Purpose T HIS article is intended as a guide to evidencebased pre-hospital airway management. The available litterature on pre-hospital airway management reflects vast differences in pre-hospital emergency medicine service (EMS) organisation, qualification levels, training programmes and even terminology. These differences make comparisons between systems and treatment protocols difficult at best. The conduct of clinical trials in pre-hospital airway management is hampered by the 2001/20/ EC directive of the European Parliament concerning informed consent. This paper describes selected equipment and techniques available for pre-hospital airway management. Advice given differs, depending on which category of personnel is available in a given EMS. Our baseline assumption is that a certain level of education and training is necessary for the safe use of a specific technique. Distinction must be made between personnel trained and experienced in providing and monitoring anaesthesia and other groups of personnel with limited or no anaesthetic skills. This distinction dictates which drugs and equipment that should be available in the prehospital setting. Differences between regions and systems Paramedic-based systems are the rule in the United States, whereas physician-based pre-hospital systems are common in Europe. Ideally, the best person to manage the pre-hospital airway should 89

Changing Role of EMS -Analyses of Non-Conveyed and Conveyed Patients in Finland

Abstract Background: Emergency Medical Services (EMS) and Emergency Departments (ED) have seen increasing attendance rates in the last decades. Currently, EMS are increasingly assessing and treating patients without the need to convey patients to health care facility. The aim of this study was to describe and compare the patient casemix between conveyed and non-conveyed patients and to analyze factors related to non-conveyance decision making. Methods: This was a prospective study design of EMS patients in Finland, and data was collected between 1st June and 30th November 2018. Adjusted ICPC2-classification was used as the reason for care. NEWS2-points were collected and analyzed both statistically and with a semi-supervised information extraction method. EMS patients’ geographic location and distance to health care facilities were analyzed by urban–rural classification. Results: Of the EMS patients (40,263), 59.8% were over 65 years of age and 46.0% of the patients had zero NEWS2 points. The most common ICPC2 code was weakness/tiredness, general (A04), as seen in 13.5% of all patients. When comparing patients between the non-conveyance and conveyance group, a total of 35,454 EMS patients met the inclusion criteria and 14,874 patients (42.0%) were not conveyed to health care facilities. According the multivariable logistic regression model, the non-conveyance decision was more likely made by ALS units, when the EMS arrival time was in the evening or night and when the distance to the health care facility was 21-40 km. Furthermore, younger patients, female gender, whether the patient had used alcohol and a rural area were also related to the non-conveyance decision. If the patient’s NEWS2 score increased by one or two points, the likelihood of conveyance increased. When there was less than 1 h to complete a shift, this did not associate with either nonconveyance or conveyance decisions. Conclusions: The role of EMS might be changing. This warrants to redesign the chain-of-survival in EMS to include not only high-risk patient groups but also non-critical and general acute patients with non-specific reasons for care. Assessment and on-scene treatment without conveyance can be called the “stretched arm of the emergency department”, but should be planned carefully to ensure patient safety. Keywords: Emergency medical services [MeSH], Non-conveyance, Conveyance</p

A pilot study of the King LT supralaryngeal airway use in a rural Iowa EMS system

Introduction In 2003, the King Laryngeal Tube (LT) received FDA approval for US sales. Prehospital systems in urban setting have begun evaluating and adopting the LT for clinical airway management. However, it is not routinely approved by State EMS Boards for use by all prehospita

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions.Peer reviewe

Microbial Diversity and Bioactive Substances in Disease Suppressive Composts from India

© 2016 Taylor and Francis Group, LLC. The present study aimed to investigate microbial communities in seven Indian composts and their potential for biocontrol of Fusarium oxysporum f. sp. lycopersici. In addition, identification of bioactive substances in disease suppressive composts was also attempted. Composts were chosen based on disease suppressiveness and subjected to molecular microbial analyses. Total genomic DNA from the composts was extracted and amplified with polymerase chain reaction using primers targeting the 18S rRNA and 16S rRNA genes of fungi and bacteria, respectively. Denaturing gradient gel electrophoresis (DGGE) fingerprinting and DNA sequencing were used to identify the fungal and bacterial targets. Phylogenetic analysis of the fungal 18S rRNA ITS gene sequences showed that phylum Ascomycota was dominant in all composts, while in the bacterial 16S rRNA gene sequences, the phylum Proteobacteria was dominant. Some fungi in disease suppressive composts grouped phylogenetically close to F. oxysporum. Bacterial sequences with close similarity (>95% identity) with Actinobacterium showed a strong presence only in disease suppressive composts. Disease suppressive composts formed a separate group in the cluster analysis of 18S rRNA ITS and 16S rRNA gene sequences. Gas chromatography-time of flight-mass spectrometry was performed with compost extracts to determine if bioactive substances were present in disease suppressive composts. The analysis of compost organic matter showed a negative association of disease suppressiveness with phloroglucinol, sitosterol, and monoenoic fatty acid, while cholesterol and certain organic acids were positively associated with suppressiveness

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of out of hospital cardiac arrest: A feasibility study

© 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. Background: The best initial approach to advanced airway management during out of hospital cardiac arrest (OHCA) is unknown. The traditional role of tracheal intubation has been challenged by the introduction of supraglottic airway devices (SGAs), but there is contradictory evidence from observational studies. We assessed the feasibility of a cluster-randomized trial to compare the i-gel SGA vs the laryngeal mask airway supreme (LMAS) vs current practice during OHCA. Methods: We conducted a cluster-randomized trial in a single ambulance service in England, with individual paramedics as the unit of randomization. Consenting paramedics were randomized to use either the i-gel or the LMAS or usual practice for all patients with non-traumatic adult OHCA, that they attended over a 12-month period. The primary outcome was study feasibility, including paramedic and patient recruitment and protocol adherence. Secondary outcomes included survival to hospital discharge and 90 days. Results: Of the 535 paramedics approached, 184 consented and 171 attended study training. Each paramedic attended between 0 and 11 patients (median 3; interquartile range 2-5). We recruited 615 patients at a constant rate, although the LMAS arm was suspended in the final two months following three adverse incidents. The study protocol was adhered to in 80% of patients. Patient characteristics were similar in the three study arms, and there were no differences in secondary outcomes. Conclusions: We have shown that a prospective trial of alternative airway management strategies in OHCA, cluster randomized by paramedic, is feasible