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Preferences for emergency medical service transport after childhood injury: An emergency department-based multi-methods study.

ABSTRACT: BACKGROUND:Pre-hospital emergency medical services (EMS) transport can be associated with benefits following pediatric injury. However, many pediatric trauma patients do not use EMS. The objective of this study was to elucidate guardians' decision factors for pre-hospital transport for children after injury. METHODS:This is a multi-methods study of pediatric trauma patients (?14 years) and their guardians presenting to the ED of a Level I Pediatric Trauma Center via both EMS and non-EMS modalities. Demographic information and injury characteristics were collected. Semi-structured interviews were conducted, and qualitative codes were identified and assigned into themes. RESULTS:(Quantitative): Of the 29 child-guardian pairs, five participants initially presented by EMS, 18 were admitted, and the majority (66%) sustained mild injuries. Guardians' assessment of their child's injury severity did not correlate with Injury Severity Score (ISS). Neither EMS status (did or did not use EMS to transport to first hospital) nor rurality status of participants' place of residence were associated with disparate management in any of the three scenarios. (QUALITATIVE):Five themes emerged, which informed guardians' transport decisions: Factors Related to the Nature of the Patient's Injury, Guardian Attributes and Prior Experiences, Access and Availability of EMS, Perceived Risks and Benefits of EMS and Hospital, and Collaborative Decision-Making. Injury characteristics and contextual factors, like perceived EMS response times and advice from family or medical providers, were considered in choices about EMS utilization and hospital selection. Despite the view that EMS response times were important in determining what to do following injury, both EMS and non-EMS users were largely unfamiliar with the capabilities of EMS in their area. Finally, guardians described cost to be a theoretical risk of EMS use, and a few cited this as a factor contributing to their decision-making. CONCLUSIONS:Guardians used a variety of considerations to make transport decisions, including the five themes identified above. Future studies could explore modalities to disseminate information about pre-hospital decision-making for guardians and determine the relationship between EMS utilization and patient outcomes.

SUBMITTER: Thinnes R

PROVIDER: S-EPMC7508417 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Preferences for emergency medical service transport after childhood injury: An emergency department-based multi-methods study.

Thinnes Rob R Swanson Morgan B MB Wetjen Kristel K Harland Karisa K KK Mohr Nicholas M NM

Injury 20200513 9

<h4>Background</h4>Pre-hospital emergency medical services (EMS) transport can be associated with benefits following pediatric injury. However, many pediatric trauma patients do not use EMS. The objective of this study was to elucidate guardians' decision factors for pre-hospital transport for children after injury.<h4>Methods</h4>This is a multi-methods study of pediatric trauma patients (≤14 years) and their guardians presenting to the ED of a Level I Pediatric Trauma Center via both EMS and n ...[more]

PMID: 32507453

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Project description:ImportanceEvidence from national studies indicates systematic differences in hospitals in which racial/ethnic minorities receive care, with most care obtained in a small proportion of hospitals. Little is known about the source of these differences.ObjectivesTo examine the patterns of emergency department (ED) destination of emergency medical services (EMS) transport according to patient race/ethnicity, and to compare the patterns between those transported by EMS and those who did not use EMS.Design, setting, and participantsThis cohort study of US EMS and EDs used Medicare claims data from January 1, 2006, to December 31, 2012. Enrollees aged 66 years or older with continuous fee-for-service Medicare coverage (N = 864 750) were selected for the sample. Zip codes with a sizable count (>10) of Hispanic, non-Hispanic black, and non-Hispanic white enrollees were used for comparison of EMS use across racial/ethnic subgroups. Data on all ED visits, with and without EMS use, were obtained. Data analysis was performed from December 18, 2018, to July 7, 2019.Main outcomes and measuresThe main outcome measure was whether an EMS transport destination was the most frequent ED destination among white patients (reference ED). The secondary outcomes were (1) whether the ED destination was a safety-net hospital and (2) the distance of EMS transport from the ED destination.ResultsThe study cohort comprised 864 750 Medicare enrollees from 4175 selected zip codes who had 458 701 ED visits using EMS transport. Of these EMS-transported enrollees, 26.1% (127 555) were younger than 75 years, and most were women (302 430 [66.8%]). Overall, the proportion of white patients transported to the reference ED was 61.3% (95% CI, 61.0% to 61.7%); this rate was lower among black enrollees (difference of -5.3%; 95% CI, -6.0% to -4.6%) and Hispanic enrollees (difference of -2.5%; 95% CI, -3.2% to -1.7%). A similar pattern was found among patients with high-risk acute conditions; the proportion transported to the reference ED was 61.5% (95% CI, 60.7% to 62.2%) among white enrollees, whereas this proportion was lower among black enrollees (difference of -6.7%; 95% CI, -8.3% to -5.0%) and Hispanic enrollees (difference of -2.6%; 95% CI, -4.5% to -0.7%). In major US cities, a larger black-white discordance in ED destination was observed (-9.3%; 95% CI, -10.9% to -7.7%). Black and Hispanic patients were more likely to be transported to a safety-net ED compared with their white counterparts; the proportion transported to a safety-net ED among white enrollees (18.5%; 95% CI, 18.1% to 18.7%) was lower compared with that among black enrollees (difference of 2.7%; 95% CI, 2.2% to 3.2%) and Hispanic enrollees (difference of 1.9%; 95% CI, 1.3% to 2.4%). Concordance rates of non-EMS-transported ED visits were statistically significantly lower than for EMS-transported ED visits; the concordance rate among white enrollees of 52.9% (95% CI, 52.1% to 53.6%) was higher compared with that among black enrollees (difference of -4.8%; 95% CI, -6.4% to -3.3%) and Hispanic enrollees (difference of -3.0%; 95% CI, -4.7% to -1.3%).Conclusions and relevanceThis study found race/ethnicity variation in ED destination for patients using EMS transport, with black and Hispanic patients more likely to be transported to a safety-net hospital ED compared with white patients living in the same zip code.

Project description:BackgroundMechanical ventilation in helicopter emergency medical service (HEMS) environments is a procedure which carries a significant risk of complications. Limited data on the quality and performance of mechanical ventilation in HEMS are available in the literature.MethodWe conducted an international survey to evaluate mechanical ventilation infrastructure in HEMS and collect data of transported ventilated patients. From June 20-22, 2019, the participating HEMS bases were asked to provide data via a web-based platform. Vital parameters and ventilation settings of the patients at first patient contact and at handover were compared using non-parametric statistical tests.ResultsOut of 215 invited HEMS bases, 53 responded. Respondents were from Germany, Denmark, United Kingdom, Luxembourg, Austria and Switzerland. Of the HEMS bases, all teams were physician staffed, mainly anesthesiologists (79%), the majority were board certified (92.5%) and trained in intensive care medicine (89%) and had a median (range) experience in HEMS of 9 (0-25) years. HEMS may provide a high level of expertise in mechanical ventilation whereas the majority of ventilators are able to provide pressure controlled ventilation and continuous positive airway pressure modes (77%). Data of 30 ventilated patients with a median (range) age of 54 (21-100) years and 53% male gender were analyzed. Of these, 24 were primary missions and 6 interfacility transports. At handover, oxygen saturation (p?<?0.01) and positive end-expiratory pressure (p?=?0.04) of the patients were significantly higher compared to first patient contact.ConclusionIn this survey, the management of ventilated HEMS-patients was not associated with ventilation related serious adverse events. Patient conditions, training of medical crew and different technical and environmental resources are likely to influence management. Further studies are necessary to assess safety and process quality of mechanical ventilation in HEMS.Trial registrationThe survey was prospectively registered at Research Registry ( researchregistry2925 ).

Project description:ObjectiveRising emergency medical services (EMS) utilisation increases transport to hospital emergency departments (ED). However, some patients receive outpatient treatment (discharged) while others are hospitalised (admitted). The aims of this analysis were to compare admitted and discharged cases, to assess whether cases that were discharged from the ED could be identified using dispatch data and to compare dispatch keyword categories and hospital diagnoses.DesignRetrospective observational study using linked secondary data.Setting and participants78 303 cases brought to 1 of 14 ED in the city of Munich, Germany, by EMS between 1 July 2013 and 30 June 2014.Main outcome measuresCharacteristics of admitted and discharged cases were assessed. Logistic regression was used to estimate the association between discharge and age, sex, time of day, ambulance type and dispatch keyword category. Keyword categories were compared to hospital diagnoses.Results39.4% of cases were discharged. They were especially likely to be young (OR 10.53 (CI 9.31 to 11.92), comparing <15-year-olds to >70-year-olds) and to fall under the categories 'accidents/trauma' (OR 2.87 (CI 2.74 to 3.01)) or 'other emergencies (unspecified)' (OR 1.23 (CI 1.12 to 1.34) (compared with 'cardiovascular'). Most frequent diagnoses came from chapter 'injury and poisoning' (30.1%) of the 10th revision of the international statistical classification of disease and related health problems (ICD-10), yet these diagnoses were more frequent at discharge (42.7 vs 22.0%) whereas circulatory system disease was less frequent (2.6 vs 21.8%). Except for accidents/trauma and intoxication/poisoning many underlying diagnoses were observed for the same dispatch keyword.ConclusionYoung age and dispatch for accidents or trauma were the strongest predictors of discharge. Even within the same dispatch keyword category the distribution of diagnoses differed between admitted and discharged cases. Discharge from the ED does not indicate that urgent response was unnecessary. However, these cases could be suitable for allocation to hospitals with low inpatient bed capacities and are of particular interest for future studies regarding the urgency of their condition.

Project description:BackgroundDespite evidence of benefit after injury, helicopter emergency medical services (HEMS) overtriage remains high. Scene and transfer overtriage are distinct processes. Our objectives were to identify geographic variation in overtriage and patient-level predictors, and determine if overtriage impacts population-level outcomes.MethodsPatients 16 years or older undergoing scene or interfacility HEMS in the Pennsylvania Trauma Outcomes Study were included. Overtriage was defined as discharge within 24 hours of arrival. Patients were mapped to zip code, and rates of overtriage were calculated. Hot spot analysis identified regions of high and low overtriage. Mixed-effects logistic regression determined patient predictors of overtriage. High and low overtriage regions were compared for population-level injury fatality rates. Analyses were performed for scene and transfer patients separately.ResultsA total of 85,572 patients were included (37.4% transfers). Overtriage was 5.5% among scene and 11.8% among transfer HEMS (p < 0.01). Hot spot analysis demonstrated geographic variation in high and low overtriage for scene and transfer patients. For scene patients, overtriage was associated with distance (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06 per 10 miles; p = 0.04), neck injury (OR, 1.27; 95% CI, 1.01-1.60; p = 0.04), and single-system injury (OR, 1.37; 95% CI, 1.15-1.64; p < 0.01). For transfer patients, overtriage was associated with rurality (OR, 1.64; 95% CI, 1.22-2.21; p < 0.01), facial injury (OR, 1.22; 95% CI, 1.03-1.44; p = 0.02), and single-system injury (OR, 1.35; 95% CI, 1.18-2.19; p < 0.01). For scene patients, high overtriage was associated with higher injury fatality rate (coefficient, 1.72; 95% CI, 1.68-1.76; p < 0.01); low overtriage was associated with lower injury fatality rate (coefficient, -0.73; 95% CI, -0.78 to -0.68; p < 0.01). For transfer patients, high overtriage was not associated with injury fatality rate (p = 0.53); low overtriage was associated with lower injury fatality rate (coefficient, -2.87; 95% CI, -4.59 to -1.16; p < 0.01).ConclusionGeographic overtriage rates vary significantly for scene and transfer HEMS, and are associated with population-level outcomes. These findings can help guide targeted performance improvement initiatives to reduce HEMS overtriage.Level of evidenceTherapeutic, level IV.

Dataset Information

Preferences for emergency medical service transport after childhood injury: An emergency department-based multi-methods study.

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Preferences for emergency medical service transport after childhood injury: An emergency department-based multi-methods study.

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