Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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Mobile integrated health-community paramedicine (MIH-CP) uses patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce unnecessary emergency department (ED) usage. The objective of this systematic review is to characterize the outcomes and methodologies used by MIH-CP programs around the world and assess the validity of the ways programs evaluate their effectiveness. ⋯ Most studies assessing MIH-CP programs reported success of their interventions. However, significant heterogeneity of outcome measures and varying quality of study methodologies exist among studies. Future studies designed with adequately matched controls and applying uniform core metrics for cost savings and health care usage are needed to better evaluate the effectiveness of MIH-CP programs.
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Objective: The number of out-of-hospital cardiac arrest (OHCA) patients who may benefit from prehospital extracorporeal cardiopulmonary resuscitation (ECPR) is yet to be elucidated. Patient eligibility is determined both by case characteristics and physical proximity to an ECPR service. We applied accessibility principles to historical cardiac arrest data, to identify the number of patients who would have been eligible for prehospital ECPR in Sydney, Australia, and the potential survival benefit had prehospital ECPR been available. ⋯ Using spatial and transport modeling, a prehospital team located at an optimal location could establish 437 (90%) patients onto ECMO within 60 min, with an estimated survival of 48% (IQR 38-57). Based on existing survival curves, compared to conventional CPR, an optimally located prehospital ECPR service has the potential to save one additional life for every 3.0 patients. Conclusions: A significant number of historical OHCA patients could have benefited from prehospital ECPR, with a potential survival benefit above conventional CPR.
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Randomized Controlled Trial
The effect of prehospital clinical trial-related procedures on scene interval, cognitive load, and error: a randomized simulation study.
Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. ⋯ In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.
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Practice Guideline
Evidence-Based Guideline for Prehospital Airway Management.
Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. ⋯ The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.
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To determine the effect of video and direct laryngoscopy on first-pass success rates for out-of-hospital orotracheal intubation. ⋯ We found substantial heterogeneity among out-of-hospital studies comparing video laryngoscopy to direct laryngoscopy on first-pass success, overall success, or intubation time. This heterogeneity was not explained with stratification by study design, clinician type, video laryngoscope blade geometry, or leave-one-out meta-analysis. A majority of studies showed that video laryngoscopy was associated with improved first pass success in all subgroups, but only for paramedics and not physicians when looking at overall success. This improvement was more common in studies that used Macintosh blades than those that used hyperangulated blades. Future research should explore the heterogeneity identified in our analysis with an emphasis on differences in training, clinical milieu, and specific video laryngoscope devices.