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Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review
Abstract and Figures
Background
Emergency physicians on‐scene provide highly specialized care to severely sick or injured patients. High quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p‐EMS research. This systematic review aims to describe the quality of pre‐hospital reporting of GCS and SBP data in studies where emergency physicians are present on‐scene.
Methods
A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed+ and Web of Science, in accordance with the PRISMA guidelines.Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables.
Results
We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases.Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26% to 45% of data were possible to extract from the included papers.
Conclusions
Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p‐EMS.
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... This was not available because of incomplete registration of prehospital data, a challenge for many registries and services. 43 The indication for performing or not performing time-critical interventions is not registered in the NTR. Instead, we used measures with a high likelihood of indication for interventions, such as injury stratification and GCS score less than 9 and assessed all AIS codes associated with potential need for CD. ...
Background:
Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients holds important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations.
Methods:
Retrospective analysis of the Norwegian Trauma Registry for 2015-2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score (NISS) ≥9 were included, dichotomized into age groups 16-64 years and ≥ 65 years. Prehospital and emergency department clinical management, advanced airway management (AAM), chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests.
Results:
9543 patients were included, of which 28% (n = 2711) were ≥ 65 years. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (OR 0.64, 95% CI 0.57-0.71), conveyed by air ambulance (OR 0.65, 95% CI 0.58-0.73), and transported directly to a trauma center (OR 0.86, 95% CI 0.79 - 0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with NISS≥25, showing lower rates for older adults (AAM: OR 0.60, 95% CI 0.47-0.76; Chest decompression: OR 0.46, 95% CI 0.25-0.85; X-ray chest: OR 0.54, 95% CI 0.39-0.75; X-ray pelvis: OR 0.69, 95% CI 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups.
Conclusions:
Older trauma patients were less likely to receive advanced prehospital care compared to younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities.
Level of evidence:
Epidemiological study, level III.
... In the records analyzed in this study, an overall high level of complete documentation was found, although there were several individual parameters that need more consistent documentation (49% availability for data on the respiration rate, temperature and blood glucose level). In past studies, the percent of cases with adequate RR documentation varied from 10-40%, and a recent systematic review on data quality in EMS reported that there were deficiencies in the completeness and accuracy of the reporting [35][36][37] . Therefore, the documentation of tele-EMS missions appears to be of relatively higher quality in terms of the completeness of the data. ...
Almost seven years ago, a telemedicine system was established as an additional component of the city of Aachen’s emergency medical service (EMS). It allows paramedics to engage in an immediate consultation with an EMS physician at any time. The system is not meant to replace the EMS physician on the scene during life-threatening emergencies. The aim of this study was to analyze teleconsultations during life-threatening missions and evaluate whether they improve patient care. Telemedical EMS (tele-EMS) physician consultations that occurred over the course of four years were evaluated. Missions were classified as involving potentially life-threatening conditions based on at least one of the following criteria: documented patient severity score, life-threatening vital signs, the judgement of the onsite EMS physician involved in the mission, or definite life-threatening diagnoses. The proportion of vital signs indicating that the patient was in a life-threatening condition was analyzed as the primary outcome at the start and end of the tele-EMS consultation. The secondary outcome parameters were the administered drug doses, tracer diagnoses made by the onsite EMS physicians during the missions, and quality of the documentation of the missions. From January 2015 to December 2018, a total of 10,362 tele-EMS consultations occurred; in 4,293 (41.4%) of the missions, the patient was initially in a potentially life-threatening condition. Out of those, a total of 3,441 (80.2%) missions were performed without an EMS physician at the scene. Records of 2,007 patients revealed 2,234 life-threatening vital signs of which 1,465 (65.6%) were remedied during the teleconsultation. Significant improvement was detected for oxygen saturation, hypotonia, tachy- and bradycardia, vigilance states, and hypoglycemia. Teleconsultation during missions involving patients with life-threatening conditions can significantly improve those patients' vital signs. Many potentially life-threatening cases could be handled by a tele-EMS physician as they did not require any invasive interventions that needed to be performed by an onsite EMS physician. Diagnoses of myocardial infarction, cardiac pulmonary edema, or malignant dysrhythmias necessitate the presence of onsite EMS physicians. Even during missions involving patients with life-threatening conditions, teleconsultation was feasible and often accessed by the paramedics.
Background
Lifeguards are integral to beach safety and collect data which is used for a variety of purposes, although guidelines and best practice have yet to be established. This study served to identify and characterise existing beach lifeguard service provider (BLSP) data collection procedures in order to identify the degree of uniformity and areas for improvement.
Methods
The ‘International Beach Lifeguard Data Collection and Reporting’ online survey was distributed via the International Drowning Researchers’ Alliance to BLSP supervisors and managers. The survey included questions on beach conditions and lifeguard activity data collection practices, and respondent’s opinions on their own BLSP’s methods.
Results
Variability in data collection practices was evident in surveys obtained from 55 lifeguard leaders in 12 countries. Discrepancies exist in definitions for ‘rescue’ among BLSPs, a significant amount of information related to beach conditions are recorded and beach visitation is primarily obtained by visual estimate. Respondents expressed challenges with getting frontline staff to collect information in the field and ensuring reporting consistency between recorders. They identified rescue victim demographic factors as key data they would like to collect in the future.
Conclusions
Inconsistencies in lifeguard data collection present challenges to operations, safety education and prevention efforts, research and policy relying on these data. Variation in definitions, methods and collected variables generally restricts analysis to a single BLSP with limited generalisability to other beach settings. Some gaps in lifeguard data collection may soon be addressed by technology, but developing uniform, internationally acceptable standards and definitions should be prioritised.
Objective:
The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate.
Methods:
We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality.
Results:
A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901).
Conclusion:
In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.
Background
Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template.
Methods
The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher’s Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties.
Results
All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method.
Conclusions
We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.
Electronic supplementary material
The online version of this article (10.1186/s12913-019-3976-6) contains supplementary material, which is available to authorized users.
Background
Endotracheal intubation (ETI) is the gold standard for the out-of-hospital emergency airway management in severely injured patients. Due to time-critical circumstances, poor patient presentation and hostile environments, it may be prone for mechanical complications and failure.
Methods
In a retrospective study (January 2011 to December 2013), all patients who underwent out-of-hospital ETI before admittance to a level 1 trauma center were analyzed consecutively. Patients with supraglottic airways, being under cardiopulmonary resuscitation and interfacility transports were excluded. The main study endpoint was the incidence of unrecognized tube malposition; secondary endpoints were Glasgow Outcome Scale (GOS) and in-hospital mortality adjusted to on-scene Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Abbreviated Injury Scale head (AIS head), and on-scene time.
Results
Out of 1176 patients, 151 underwent out-of-hospital ETI. At hospital admission, tube malpositions were recognized in nine patients (5.9%). Accidental and unrecognized esophageal intubation was detected in five patients (3.3%) and bronchial intubation in four patients (2.7%). Although ISS (p=0.053), AIS head (p=0.469), on-scene GCS (p=0.151), on-scene time (p=0.530), GOS (p=0.748) and in-hospital mortality (p=0.431) were similar compared with correctly positioned ETI tubes, three esophageal intubation patients died due to hypoxemic complications.
Discussion
In our study sample, out-of-hospital emergency ETI in severely injured patients was associated with a considerable tube misplacement rate. For safety, increased compliance to consequently use available technologies (eg, capnography, video laryngoscopy) for emergency ETI should be warranted.
Level of evidence
Level of Evidence IIA.
Background
Although pain treatment is an important objective in prehospital emergency medicine the incidence of oligoanalgesia is still high in prehospital patients. Given that prehospital emergency medicine in Germany is open for physicians of any speciality, the prehospital pain treatment may differ depending on the primary medical education. Aim of this study was to explore the difference in pain treatment between surgeons and anaesthesiologists in a physician staffed emergency medical service.
Methods
Retrospective single centre cohort analysis in a physician staffed ground based emergency medical service from January 2014 until December 2016. A total of 8882 consecutive emergency missions were screened. Primary outcome measure was the difference in application frequency of prehospital analgesics by anaesthesiologist or surgeon. Univariate and multivariate logistic regression analysis was used for statistical analysis including subgroup analysis for trauma and acute coronary syndrome.
Results
A total of 8238 patients were included in the analysis. There was a significant difference in the application frequency of analgesics between surgeons and anaesthesiologists especially for opioids (p < 0.001, OR 0.68 [0.56–0.82]). Fentanyl was the most common administered analgesic in the trauma subgroup, but significantly less common used by surgeons (p = 0.005, OR 0.63 [0.46–0.87]). In acute coronary syndrome cases there was no significant difference in morphine administration between anaesthesiologists and surgeons (p = 0.49, OR 0.88 [0.61–1.27]).
Conclusions
Increased training for prehospital pain treatment should be implemented, since opioids were administered notably less frequent by surgeons than by anaesthesiologists.
Electronic supplementary material
The online version of this article (10.1186/s12871-019-0683-0) contains supplementary material, which is available to authorized users.
Background
Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients.
Methods
Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of ≤8) from 2005 to 2010 and 2012–2015 in two study locations were determined. Isolated TBI patients transported directly from the accident scene to the university hospital were included. A modified six-month Glasgow Outcome Score (GOS) was defined as death, unfavourable outcome (GOS 2–3) and favourable outcome (GOS 4–5) and used to assess the neurological outcomes. Binary logistic regression analysis was used to predict mortality and good neurological outcome. The following prognostic variables for TBI were available in the prehospital setting: age, on-scene GCS, hypoxia and hypotension. As per the hypothesis that treatment provided by an on-scene anaesthetist would be beneficial to TBI outcomes, physician was added as a potential predictive factor with regard to the prognosis.
Results
The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05–1.07), lower on-scene GCS (OR 0.85 CI 0.79–0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20–2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08–14.23). In the secondary analysis lower age (OR 0.95 CI 0.94–0.96), a higher on-scene GCS (OR 1.21 CI 1.20–1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09–2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04–0.82) was associated with poor outcome.
Conclusion
Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.
Background:
Hypoxia and hypotension may be associated with secondary brain injury and negative outcomes in patients with traumatic and non-traumatic intracranial pathology. Guidelines exist only for the prehospital management of patients with severe traumatic brain injury (TBI). In patients with non-traumatic intracranial pathology, TBI guideline recommendations may be applied to assess whether hypoxia and hypotension should be avoided during prehospital treatment. The main study objective was to assess the extent to which Danish Helicopter Emergency Medical Service (HEMS) critical care teams adhere to the prehospital TBI guideline recommendations for the management of patients with a clinical diagnosis of non-traumatic intracranial pathology or isolated TBI. Furthermore, in the same two groups of patients, we evaluated the adherence of the Danish HEMS critical care teams to recommendations aiming to maintain systolic blood pressure (SBP) > 110 mmHg and > 120 mmHg.
Methods:
In total, 211 prehospital patient records were studied. All patients were treated for non-traumatic intracranial pathology or isolated TBI by the Danish HEMS critical care teams from October 1, 2014, to January 1, 2017. Adherence to the prehospital TBI guideline recommendations and the SBP recommendations above was assessed in non-TBI and TBI populations.
Results:
The adherence rates to TBI guideline recommendations among Danish HEMS critical care teams were 69% (n = 106 [95% CI: 61-77%]) in the non-TBI population and 74% (n = 43 [95% CI: 61-85%]) in the TBI population. SBP > 110 mmHg was observed in 74% (n = 113 [95% CI: 66-81%]) and 69% (n = 40 [95% CI: 56-81%]) of cases in the non-TBI and TBI population, respectively. SBP > 120 mmHg was observed in 55% (n = 84, [95% CI: 47-63%]) of patients in the non-TBI population and 55% (n = 32 [95% CI: 42-68%]) of the patients in the TBI population.
Conclusions:
Due to a lack of comparative data, it is difficult to determine the performance quality of the Danish HEMS critical care teams. Our findings may suggest that adherence to TBI guidelines and SBP recommendations needs to be a continuous focal point for the Danish HEMS to avoid secondary brain damage.
BACKGROUND: Oligoanalgesia, as well as adverse events related to the initiated pain therapy, are prevalent in out-of-hospital emergency medicine, even when a physician is present. We sought to identify factors involved in insufficient pain therapy of patients presenting with an initial Glasgow Coma Scale (GCS) ≥ 8 in the out-of-hospital phase, when therapy is provided by a physician-staffed helicopter emergency medical service (p-HEMS).
METHODS: This was a multicenter, secondary data analysis of conscious patients treated in primary p-HEMS missions between January 1, 2005, and December 31, 2017. Patients with a numeric rating scale (NRS) pain score >= 4, GCS >= 8 on the scene, without cardiopulmonary resuscitation, and a < VI were included. Multivariable logistic binary regression analyses were used to identify characteristics of oligoanalgesia (NRS >= 4 at handover or pain reduction < 3). Linear regression analysis was used to identify changes in pain treatment within the study period.
RESULTS: We analyzed data from 106,730 patients (3.6% missing data at variable level). Of these patients, 82.9% received some type of analgesic therapy on scene; 79.1% of all patients received analgesic drugs, and 38.6% received non-pharmacological interventions, while 37.4% received both types of intervention. Oligoanalgesia was identified in 18.4% (95% confidence interval [CI], 18.1%–18.6%) of patients. Factors associated with oligoanalgesia were a low National Advisory Committee for Aeronautics (NACA) score and a low NRS score, as well as central nervous system or gynecological/obstetric complaints. The use of weak opioids (odds ratio 1.05, 95% CI 0.68–1.57) had no clinically relevant association with oligoanalgesia, in contrast to the use of strong or moderate opioids, non-opioid analgesics, or ketamine. We observed changes in the analgesic drugs used over the 12-year study period, particularly in the use of strong opioids (fentanyl or sufentanil), from 30.3% to 42.3% (p value < 0.001). Of all patients, 17.1% (95% CI, 16.9%–17.3%) did not receive any type of pain therapy.
CONCLUSIONS: In the studied p-HEMS cohort, oligoanalgesia was present in 18.4% of all cases. Special presenting complaints, low NACA scores, and low pain scores were associated with the occurrence of oligoanalgesia. However, 17.1% of patients received no type of pain therapy, which suggests scope for further improvement in prehospital pain therapy. Pharmacological and non-pharmaceutical pain relief should be initiated whenever indicated.
Objective:
Physician-based helicopter emergency medical services (HEMS) provide specialist medical care to the accident scene in order to improve the survival of severely injured patients. Studies that focus on the role of physician-based HEMS in pediatric trauma are scarce. The aim of this retrospective, observational study was to determine the effect of physician-based HEMS assistance on the survival of severely injured pediatric patients.
Methods:
All consecutive severely injured pediatric patients (age < 18 years and Injury Severity Score > 15) treated between October 1, 2000, and February 28, 2013, were included. The survival of patients who received medical care of physician-based HEMS was compared with the survival of patients treated by an ambulance paramedic crew (ie, emergency medical services group) only. A regression model was developed for calculating the survival benefit in the physician-based HEMS group.
Results:
A total of 308 patients were included; 112 (36%) were primarily treated by emergency medical services, and 196 (64%) patients received additional physician-based HEMS assistance on scene. The model with the best diagnostic properties and fit contained physician-based HEMS assistance, 3 components of the Glasgow Coma Scale (eye, motor, and verbal) scored prehospitally (before intubation), ordinal values for the Injury Severity Scale, systolic blood pressure, and respiratory rate. This model predicted that 5 additional patients survived because of physician-based HEMS assistance. This corresponds with 2.5 additional lives saved per 100 physician-based HEMS dispatches for severely injured pediatric patients.
Conclusion:
The data suggest that an additional 2.5 lives might be saved per 100 physician-based HEMS dispatches for severely injured pediatric patients.
Aim:
To report the initial experience and outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an adjunct to pre-hospital resuscitation of patients with exsanguinating pelvic haemorrhage.
Methods:
Descriptive case series of consecutive adult patients, treated with pre-hospital Zone III REBOA by a physician-led pre-hospital trauma service, between January 2014 and July 2018.
Results:
REBOA was attempted in 19 trauma patients (13 successful, six failed attempts) and two non-trauma patients (both successful) with exsanguinating pelvic haemorrhage. Trauma patients were severely injured (median ISS 34, IQR: 27-43) and profoundly hypotensive (median systolic blood pressure [SBP] 57, IQR: 40-68 mmHg). REBOA significantly improved blood pressure (Pre-REBOA median SBP 57, IQR: 35-67 mmHg versus Post- REBOA SBP 114, IQR: 86-132 mmHg; Median of differences 66, 95% CI: 25-74 mmHg; P < 0.001). REBOA was associated with significantly lower risk of pre-hospital cardiac arrest (REBOA 0/13 [0%] versus no REBOA 3/6 [50%], P = 0.021) and death from exsanguination (REBOA 0/13 [0%] versus no REBOA 4/6 [67%], P = 0.004), when compared to patients with a failed attempt. Successful REBOA was associated with improved survival (REBOA 8/13 [62%] versus no REBOA 2/6 [33%]; P = 0.350). Distal arterial thrombus requiring thrombectomy was common in the REBOA group (10/13, 77%).
Conclusion:
REBOA is a feasible pre-hospital resuscitation strategy for patients with exsanguinating pelvic haemorrhage. REBOA significantly improves blood pressure and may reduce the risk of pre-hospital hypovolaemic cardiac arrest and early death due to exsanguination. Distal arterial thrombus formation is common, and should be actively managed.