The discrimination of quick Paediatric Early Warning Scores in the pre-hospital setting.

In our previous study, a Paediatric Early Warning Score could be calculated for only one-fifth of 102,993 children transported by ambulance to hospital, as components other than supplemental oxygen were not reliably measured: respiratory rate 90,358 (88%); Glasgow Coma Score 83,648 (81%); heart rate 83,330 (81%); time to capillary reperfusion 81,685 (79%); oxygen saturation 71,372 (69%); temperature 60,402 (59%); systolic blood pressure 37,088 (36%). We tested 12 abbreviated scores with 3-5 components. The discrimination of these 12 scores for the primary outcome (30-day mortality or admission to paediatric intensive care), as measured by the area under the receiving operator characteristic curve, ranged from 0.69 to 0.80. Scores could be calculated for at most 74,508 (72%) children when heart rate, conscious level and respiratory rate were measured, with or without supplemental oxygen: the discrimination of these two versions was 0.75 and 0.77, respectively. Optimal threshold scores of 3 and 2 for these two abbreviated versions discriminated an outcome rate of 2-3% in about one third of children from the other children who had < 1% rate of outcome.

Paediatric early warning scores are predictors of adverse outcome in the pre-hospital setting: A national cohort study.

INTRODUCTION: Physiological deterioration often precedes clinical deterioration as patients develop critical illness. Use of a specific Paediatric Early Warning Score (PEWS), based on basic physiological measurements, may help identify children prior to their clinical deterioration. NHS Scotland has adopted a single national PEWS - PEWS (Scotland). We aim to look at the utility of PEWS (Scotland) in unselected paediatric ambulance patients. METHODS: We performed a retrospective cohort of all ambulance patients aged under 16 years conveyed to hospital in Scotland between 2011 and 2015. Patients were matched to their 30 day mortality and ICU admission using data linkage. RESULTS: Full results were available for 21,202 children and young people (CYP). On multivariate logistic regression, PEWS (Scotland) was an independent predictor of the primary outcome (ICU admission within 48 h or death within 30 days) with an odds ratio of 1.403 (95%CI 1.349-1.460, p < 0.001). Area Under Receiving Operator Curve (AUROC) for aggregated PEWS was 0.797 (95% CI 0.759 to 0.836, p < 0.001). The optimal PEWS using Youlden's Index was 5. DISCUSSION: These data show PEWS (Scotland) to be a useful tool in a pre-hospital setting. A single set of physiological observations undertaken prior to arrival at hospital can identify a group of children at higher risk of an adverse in-hospital outcome. Paediatric care is becoming more specialised and focussed on a smaller number of centres. In this context, use of PEWS (Scotland) in the pre-hospital phase may allow changes to paediatric pre-hospital pathways to improve both admission to ICU and child mortality rates.

Comparison of non-invasive and invasive blood pressure in aeromedical care.

Blood pressure measurement is an essential physiological measurement for all critically ill patients. Previous work has shown that non-invasive blood pressure is not an accurate reflection of invasive blood pressure measurement. In a transport environment, the effects of motion and vibration may make non-invasive blood pressure less accurate. Consecutive critically ill patients transported by a dedicated aeromedical retrieval and critical care transfer service with simultaneous invasive and non-invasive blood pressure measurements were analysed. Two sets of measurements were recorded, first in a hospital environment before departure (pre-flight) and a second during aeromedical transport (in-flight). A total of 56 complete sets of data were analysed. Bland-Altman plots showed limits of agreement (precision) for pre-flight systolic blood pressure were -37.3 mmHg to 30.0 mmHg, and for pre-flight mean arterial pressure -20.5 mmHg to 25.0 mmHg. The limits of agreement for in-flight systolic blood pressure were -40.6 mmHg to 33.1 mmHg, while those for in-flight mean blood pressure in-flight were -23.6 mmHg to 24.6 mmHg. The bias for the four conditions ranged from 0.5 to -3.8 mmHg. There were no significant differences in values between pre-flight and in-flight blood pressure measurements for all categories of blood pressure measurement. Thus, our data show that non-invasive blood pressure is not a precise reflection of invasive intra-arterial blood pressure. Mean blood pressure measured non-invasively may be a better marker of invasive blood pressure than systolic blood pressure. Our data show no evidence of non-invasive blood pressures being less accurate in an aeromedical transport environment.

A rural emergency medical retrieval service: the first year.

INTRODUCTION: We describe the first year of operation of a rural emergency medical retrieval service (EMRS), staffed by emergency medicine and anaesthetic consultants and providing air based retrieval of critically ill and injured patients from general practitioner led community hospitals in rural west Scotland. METHODS: Data were collected on all patients referred to the service, both those subsequently transported and those where transport by the service was not indicated, for a period of 1 year from 1 October 2004 to 30 September 2005. Data collected included information on demographics, physiology, and medical interventions. Detailed data were collected regarding advanced airway care and any complications relating to transfer. RESULTS: Forty patients were attended and advice was given on a further 21 patients. Twenty one of the 40 patients (53%) required rapid sequence intubation prior to transfer. The median Injury Severity Score (ISS) for trauma patients was 26 (range 2-59). The median Acute Physiology and Chronic Health Evaluation (APACHE) II score for all patients was 11 (range 2-37). CONCLUSION: Our data show a high level of acuity among this patient group and a need for advanced medical intervention to ensure safe transfer.

Establishing a rural Emergency Medical Retrieval Service.

In 2004 the Argyll and Clyde health board established the Emergency Medical Retrieval Service to support its rural community hospitals. This article describes both why the service was established and its aims. This service covers a geographically extensive area, with approximately 85,000 people living in remote locations. Rural general practitioners in six community hospitals provide initial patient assessment and resuscitation. Providing emergency care and safe transfer of seriously ill and injured patients presenting to these community hospitals is a significant challenge. All parties involved felt that there was a need to provide a service to transport critically ill and injured patients from these remote locations to definitive care. The idea of the team is to bring the resuscitation room to the patient in the rural setting. With this aim and in order to implement the Intensive Care Society guidelines for the transport of critically ill patients, it was decided that consultants in Emergency Medicine and Anaesthetics with an interest in critical care would staff the service medically. This service is unique within the UK and the authors aim to report our findings from ongoing research and audit in future papers.

Emergency department thrombolysis improves door to needle times.

OBJECTIVE: To identify the effect on door to needle (DTN) time of moving the site of thrombolysis delivery from the coronary care unit (CCU) to the emergency department (ED). To ascertain if moving the site of thrombolysis enables appropriate use of thrombolysis. DESIGN: Prospective cohort study. SETTING: CCU and ED of a 450 bed Scottish district general hospital without on-site primary angioplasty. PARTICIPANTS: Primary site for thrombolysis of patients presenting to the hospital with ST elevation MI (STEMI) moved from CCU to ED on 1 April 2000. Study patients who had a confirmed STEMI and/or received thrombolytic therapy before this date were defined as the pre-change group; those who were diagnosed as STEMI and/or received thrombolytic therapy after this date were defined as the post-change group. STATISTICAL ANALYSIS: Mann-Whitney test was used to compare medians and chi(2) test for categorical data. RESULTS: 1349 patients were discharged from CCU with a diagnosis of STEMI or received thrombolysis in the ED or CCU between April 1998 and April 2002. There were 632 patients in the pre-change group and 654 patients in the post-change group. Sixty three patients were excluded. Median DTN time for the pre-change group (321 thrombolysed patients) was 64 minutes and median DTN time for the post-change group (324 thrombolysed patients) was 35 minutes, a median difference of 25 minutes (95% CI for difference 20 to 29 minutes, p<0.0001, Mann-Whitney U test). A total of 37 patients were thrombolysed but did not have a final diagnosis of STEMI. CONCLUSION: A significant reduction in DTN times accompanied this change in practice in this hospital.