Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement.

Exsanguination remains the leading cause of preventable death among victims of trauma. For adult and pediatric trauma patients in the prehospital phase of care, methods to control hemorrhage and hemostatic resuscitation are described in this joint consensus opinion by the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians.

Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery.

➤: The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs). ➤: Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal. ➤: There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery. ➤: There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered. ➤: The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered. ➤: The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.

Perceptions of legal legitimacy in veterans treatment courts: A test of a modified version of procedural justice theory.

OBJECTIVE: Perceptions of the legitimacy of a society's legal system help explain individual responses to courts and legal actors. Normative considerations such as fair and respectful treatment as well as social identification have demonstrated the ability to enhance perceived legal legitimacy and future cooperation. Veterans treatment courts (VTCs) are a rapidly disseminating and understudied intervention. Their targeting of a socially esteemed group presents an interesting venue to explore normative theories of justice. The present study tested a modified version of Tyler's theory of procedural justice in this setting. HYPOTHESES: We hypothesized that procedural justice, social bonds, and receipt of gratitude for military service would be positively associated with veteran identity and legal legitimacy. We further hypothesized that participants' identification as veterans would mediate the relationships between the three independent variables and legitimacy. METHOD: A cross-sectional survey design was used with a convenience sample (N = 191) of participants in two VTCs. Analyses controlled for race, ethnicity, recidivism risk, and combat exposure. RESULTS: Perceptions of procedural justice, social bonds, and receipt of gratitude were positively associated with veteran identity and perceptions of legal legitimacy. Further, veteran identity was found to be a significant mediator between the first three constructs and legal legitimacy. CONCLUSIONS: The results support the importance of procedural justice in explaining perceptions of legal legitimacy in a novel context that is rapidly proliferating and understudied and has unique social identity considerations. The addition of gratitude and veteran identity to Tyler's model raises implications for VTC practice and further inquiry. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

COVID-19 Pandemic: The Role of EMS Physicians in a Community Response Effort.

The COVID-19 pandemic is a worldwide historical event that will continue to affect nearly every aspect of ordinary life, including affecting our economic, political, and healthcare eco-systems. An effective pandemic response demands a coordinated and integrated response across community healthcare stakeholders, including Public Health and Emergency Management Officials. EMS systems are in a unique position and perform an essential role on the frontlines of COVID-19, including facilitating coordination of response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. EMS physicians serve their communities at a unique intersection as clinical leaders, population health experts, and advocates. This paper examines and recommends crucial roles for EMS physician leaders as communities work together in pandemic response.

Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement.

The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the National Association of EMTs (NAEMT) have previously offered varied guidance on the use of ketamine in trauma patients. The following consensus statement represents the collective positions of the ACS-COT, ACEP, NASEMSO, NAEMSP and NAEMT. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, nurses and pharmacists in their treatment of the trauma patient in both the prehospital and hospital setting.

Pharmacoeconomic impact of an alternative workflow process for stroke.

OBJECTIVE: The objective of this study was to evaluate a new multidisciplinary process in which intravenous alteplase (tPA) waste, used for acute ischemic stroke (AIS), was salvaged in an attempt to maximize cost effectiveness without impacting door-to-needle (DTN) administration times. DESIGN: This was a retrospective cohort between May 2017 and February 2018. The primary endpoint evaluated for this study was the total tPA salvaged and total cost savings in U.S. dollars. Secondary endpoints evaluated included overall DTN time in minutes. SETTING: Emergency department of a primary stroke center. PATIENTS: A convenience sample of sequential adult (>18 years) patients who received tPA in the ED for AIS were included for analysis. INTERVENTIONS: New stroke process which involved bedside mixing of tPA and salvaging of excess waste in the main central pharmacy. MEASUREMENTS AND MAIN RESULTS: A total of 50 patients were included in the final analysis. There were 25 patients included in the new process and old process groups respectively. A total of 605 mg of alteplase was salvaged from 25 patients in the new process group which was associated with an estimated cost savings of over $120,000 annually. Patients in the new process group had statistically faster average (52 min vs. 60 min; p = 0.01) and median (50 min vs. 58 min; p = 0.03) DTN administration times. CONCLUSION: Preliminary data, in this pilot study, utilizing a multidisciplinary model for tPA administration led to significant cost savings of tPA and decreases in overall DTN administration times.

Postoperative Hyperglycemia Can Be Safely and Effectively Controlled in Both Diabetic and Nondiabetic Patients with Use of a Subcutaneous Insulin Protocol.

BACKGROUND: Postoperative hyperglycemia related to stress has been shown to be an independent risk factor for periprosthetic joint infection. In a non-intensive care, general-surgery setting, a standardized postoperative insulin protocol has been shown to decrease the rate of wound infections. We hypothesized that the use of a similar protocol is both safe and effective for controlling hyperglycemia in patients who have undergone total joint replacement. METHODS: We performed a retrospective cohort study of 489 consecutive patients who underwent primary or revision total hip or knee arthroplasty between January 2008 and April 2013. All patients were tested with point-of-care (finger-stick) glucose determinations postoperatively and were started on a subcutaneous insulin protocol if they had postoperative stress hyperglycemia of >140 mg/dL when fasting or >180 mg/dL after meals. Insulin was discontinued when blood glucose decreased to <100 mg/dL. RESULTS: Of the 489 patients, 301 (62%) qualified for the insulin protocol. Thirty-seven (17%) of the 220 patients for whom the hemoglobin A1c level was available were diabetic, and 21 (11%) of the 187 patients for whom body mass index data were available were morbidly obese (body mass index, ≥40 kg/m2). Diabetes (p < 0.001), revision surgery (p < 0.001), male sex (p = 0.0110), and obesity (including morbid obesity) (p = 0.0051) were independent factors resulting in significant glycemic elevation. A trend toward hyperglycemia occurred in younger patients but did not reach significance (p = 0.063). The glucose levels of patients in all of these groups responded well to insulin. None of the patients who were managed with the insulin experienced a periprosthetic joint infection. There were no injuries related to hypoglycemia. CONCLUSIONS: The findings of the present study suggest that hyperglycemia is a common link between seemingly disparate factors related to the increased prevalence of periprosthetic joint infection. The standardized subcutaneous insulin protocol was both safe and effective for the treatment of hyperglycemia for nondiabetic as well as diabetic patients. Patients who have undergone total joint replacement, especially those with revision procedures, male sex, morbid obesity, and diabetes, should be evaluated for hyperglycemia starting in the post-anesthesia care unit and should be managed with the insulin protocol when that risk is identified. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Experience with an anonymous web-based state EMS safety incident reporting system.

BACKGROUND: Patient and provider safety is paramount in all aspects of emergency medical services (EMS) systems. The leaders, administrators, and policymakers of these systems must have an understanding of situations that present potential for harm to patients or providers. OBJECTIVE: This study analyzed reports to a statewide EMS safety event reporting system with the purpose of categorizing the types of incidents reported and identifying opportunities to prevent future safety events. METHODS: This statewide EMS safety incident reporting system is a Web-based system to which any individual can anonymously report any event or situation perceived to impact safety. We reviewed all reports between the system's inception in 2003 through August 2010. A stipulation of the system is that any entry containing information that identifies an EMS provider, agency, or patient will be deleted and thus not included in the analysis. Each event report included the description of the event, the relationship of the reporter, and the year in which the event occurred. Each entry was placed into a category that best represents the situation described. RESULTS: A total of 415 reports were received during the study period, and 186 reports were excluded-163 (39%) excluded by the state because of identifiable information and 23 (6%) excluded by the authors because of nonsensical description. Within the remaining 229 reports, there were 237 distinct safety events. These events were classified as actions/behavior (32%), vehicle/transportation (16%), staffing or ambulance availability (13%), communications (8%), medical equipment (9%), multiple patients/agencies/units and level-of-care issues (7%), medical procedure (6%), medication (5%), accident scene management/scene safety (3%), and protocol issues (1%). EMS providers directly involved in the event represented the largest reporting group (33%). We also provide examples of statewide system and policy changes that were made in direct response to these reports. CONCLUSION: This EMS safety incident reporting system identified situations that occurred in many categories of EMS care. These potential dangers represent opportunity to assess, and ultimately change, policy and procedures to reduce potential safety events and medical errors and improve overall safety. A substantial number of cases were excluded to maintain the promise of anonymity within the system.