Dataset Information

Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System.

ABSTRACT: Importance:The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain. Objective:To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality. Design, Setting, and Participants:This cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018. Main Outcomes and Measures:The association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality. Results:A total of 10?216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 (14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score ?3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]). Conclusions and Relevance:In this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

SUBMITTER: Gauss T

PROVIDER: S-EPMC6764001 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System.

Gauss Tobias T Ageron François-Xavier FX Devaud Marie-Laure ML Debaty Guillaume G Travers Stéphane S Garrigue Delphine D Raux Mathieu M Harrois Anatole A Bouzat Pierre P

JAMA surgery 20191201 12

<h4>Importance</h4>The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain.<h4>Objective</h4>To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality.<h4>Design, setting, and participants</h4>This cohort study was conducted from January 2009 to December 2016. Data for th ...[more]

PMID: 31553431

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Project description:BackgroundIn Germany, emergency medical teams are staffed with physicians but evidence regarding their prehospital diagnostic accuracy remains poor.ObjectiveTo evaluate the out-of-hospital diagnostic accuracy of physician-staffed emergency medical teams (PEMTs).MethodsA retrospective observational cohort study involving the Emergency Medical Service Bonn, Germany, from January to December 2004 and 2014 respectively. A total of 8346 patients underwent medical treatment by PEMTs, of which 1960 adult patients (inclusion criteria: ≥18 years of age, hospital diagnosis available) were included for further analysis. Reasons for non-inclusion: death on scene, outpatient, interhospital transfer, mental illness, false alarm, no hospital medical history available. The overall diagnostic accuracy (correct or false) of PEMTs was measured after matching the prehospital diagnosis with the corresponding diagnosis of the hospital. Secondary outcome measures were incidence of common PEMT diagnoses (acute coronary syndrome (ACS), dyspnea, stroke/intracerebral bleeding), recognition rate of a given disease by PEMTs, and prehospital diagnostic accuracy in elderly patients.ResultsPEMT calls increased 2-fold over a decade (2004: n = 3151 vs. 2014: n = 5195). Overall diagnostic accuracy of PEMTs increased from 87.5% in 2004 to 92.6% in the year 2014. The incidence of common PEMT diagnoses such as ACS, dyspnea or stroke/intracerebral bleeding increased 2-fold from 2004 to 2014. The recognition rate of a given disease by the PEMT varied between 2004 and 2014: an increase was observed when a stroke/intracerebral bleeding was diagnosed (2004: 67% vs. 2014: 83%; p = 0.054), a decreased rate of recognition occurred when a syncope/collapse was diagnosed (2004: 81% vs. 2014: 56%; p = 0.007) and a sepsis appears to be a rare event for EMS personnel (2004: 0% vs. 2014: 23%). Linear regression analysis revealed that the prehospital diagnostic accuracy decreases in the elderly patient.ConclusionsThe overall prehospital diagnostic accuracy of PEMTs improved between the year 2004 and 2014 respectively. Our findings suggest that the incidence of common diseases (ACS, dyspnea stroke/intracerebral bleeding, sepsis) increased over a 10-year period. Diagnostic accuracy of different diseases varied but generally decreased in the elderly patient. Regular training of EMS personnel and public campaigns should be implemented to improve the diagnostic accuracy in the future.

Project description:BackgroundSelection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement.MethodsPre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times.ResultsAmong 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74-80% and the range of undertriage was 20-32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was "Police/fire brigade request immediate response" recorded in 4321 (22.7%) of the incidents. Criteria from the groups "Accidents" and "Road traffic accidents" were recorded in 10,875 (57.2%) incidents, and criteria from the groups "Transport reservations" and "Unidentified problem" in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records.ConclusionsBoth P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.

Project description:Severe paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC.Paediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS)?>?15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available.Ninety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p?=?0.011), and shorter times to PTC (67 vs 261mins, p?=?0.015) and length of intensive care unit stays (2 vs 0?days, p?=?0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P?<?0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P?<?0.01).Physician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival.

Project description:ImportanceTime to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes.ObjectiveTo evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems.Design, setting, and participantsRetrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle.Main outcome and measureIn-hospital mortality.ResultsOf the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR, 0.45; 95% CI, 0.36-0.56) and stab wound (OR, 0.32; 95% CI, 0.20-0.52) subgroups.Conclusions and relevancePrivate vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

Dataset Information

Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System.

Publications

Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System.

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