Gamified learning for resuscitation education: A systematic review.

Aim: To systematically review published literature to evaluate the impact of gamified learning on educational and clinical outcomes during life support education. Methods: This systematic review was conducted as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR). A search of PubMed, Embase, and Cochrane was conducted from inception until February 12, 2024. Studies examining incorporation of gamified learning were eligible for inclusion. Reviewers independently extracted data on study design and outcomes; appropriate risk of bias assessment tools were used across all outcomes. Results: 2261 articles were identified and screened, yielding sixteen articles (seven randomized trials, nine observational studies) which comprised the final review. No meta-analyses were conducted due to significant heterogeneity of intervention, population, and outcome. Only one study was found to have a low risk of bias; the remaining studies were found to have moderate to high risk. Fourteen studies were in healthcare providers and two were in laypersons. Most studies (11 of 16) examined the impact of a digital platform (computer or smartphone). Most (15 of 16) studies found a positive effect on at least one educational domain; one study found no effect. No included study found a negative effect on any educational domain. Conclusion: This systematic review found a very heterogeneous group of studies with low certainty evidence, all but one of which demonstrated a positive effect on one or more educational domains. Future studies should examine the underlying causes of improved learning with gamification and assess the resource requirements with implementation and dissemination of gamified learning.

Blood lactate after pre-hospital blood transfusion for major trauma by helicopter emergency medical services.

BACKGROUND AND OBJECTIVES: The appropriate use of blood components is essential for ethical use of a precious, donated product. The aim of this study was to report in-hospital red blood cell (RBC) transfusion after pre-hospital transfusion by helicopter emergency medical service paramedics. A secondary aim was to assess the potential for venous blood lactate to predict ongoing transfusion. MATERIALS AND METHODS: All patients who received RBC in air ambulance were transported to a single adult major trauma centre, had venous blood lactate measured on arrival and did not die before ability to transfuse RBC were included. The association of venous blood lactate with ongoing RBC transfusion was assessed using multi-variable logistic regression analysis and reported using adjusted odds ratios (aOR). The discriminative ability of venous blood lactate was assessed using area under receiver operating characteristics curve (AUROC). RESULTS: From 1 January 2016 to 15 May 2019, there were 165 eligible patients, and 128 patients were included. In-hospital transfusion occurred in 97 (75.8%) of patients. Blood lactate was associated with ongoing RBC transfusion (aOR: 2.00; 95% confidence interval [CI]: 1.36-2.94). Blood lactate provided acceptable discriminative ability for ongoing transfusion (AUROC: 0.78; 95% CI: 0.70-0.86). CONCLUSIONS: After excluding patients with early deaths, a quarter of those who had prehospital RBC transfusion had no further transfusion in hospital. Venous blood lactate appears to provide value in identifying such patients. Lactate levels after pre-hospital transfusion could be used as a biomarker for transfusion requirement after trauma.

Diagnostic Accuracy of Posterior Circulation Stroke by Paramedics: A Systematic Review.

OBJECTIVE: This systematic review aims to identify the diagnostic accuracy of posterior circulation stroke (PCS) by paramedics and the causes and duration of delay in its recognition. METHODS: A systematic search using CINAHL Plus, MEDLINE, Scopus, and PubMed was performed. All databases were searched up to May 25, 2022. Studies were included where patients were adults, assessed by paramedics, and PCS was the primary diagnosis. Bias was assessed using the Newcastle-Ottawa Scale and the Effective Practice and Organization of Care tool. Results have been described by proportions, and both sensitivity calculations and subgroup analysis were performed utilizing MedCalc. RESULTS: A total of 797 titles/abstracts and a subsequent 87 full texts were screened, of which 15 were included. There were 5395 patients who were assessed by paramedics and had a confirmed diagnosis of PCS. Among five studies containing both true positive and false negative data, there were 98 (45.8%) true positives. PCS patients lost an average of 27 min (p < 0.001) compared to anterior stroke patients in the prehospital setting. One study revealed that educational intervention, including implementing the finger-to-nose test, increased the sensitivity for diagnosis from 45.8 to 74.1% (p = 0.039) and decreased the time from door to computed tomography from 62 to 41 min (p = 0.037). CONCLUSION: There is a substantial lack of evidence regarding the diagnosis of PCS by paramedics. Despite the low quality of evidence available, overall, the sensitivity for paramedic PCS diagnosis appears to be poor. Further investigation is required into paramedics' diagnosis of PCS and the use of educational interventions.Prospective Register of Systematic Reviews Registration Number: CRD42022324675.

Intubation Rates following Prehospital Administration of Ketamine for Acute Agitation: A Systematic Review and Meta-Analysis.

BACKGROUND: Ketamine is a fast-acting, dissociative anesthetic with a favorable adverse effect profile that is effective for managing acute agitation as a chemical restraint in the prehospital and emergency department (ED) settings. However, some previously published individual studies have reported high intubation rates when ketamine was administered prehospitally. OBJECTIVE: This systematic review aims to determine the rate and settings in which intubation following prehospital administration of ketamine for agitation is occurring, as well as associated indications and adverse events. METHODS: We searched PubMed, Scopus, Ovid MEDLINE, Embase, CINAHL Plus, PsycINFO, the Cochrane Library, ClinicalTrials.gov, OpenGrey, Open Access Theses and Dissertation, and Google Scholar from the earliest possible date until 13/February/2022. Inclusion criteria required studies to describe agitated patients who received ketamine in the prehospital setting as a first-line drug to control acute agitation. Reference lists of appraised studies were screened for additional relevant articles. Study quality was assessed using the Newcastle-Ottawa quality assessment scale. Synthesis of results was completed via meta-analysis, and the GRADE tool was used for certainty assessment. RESULTS: The search yielded 1466 unique records and abstracts, of which 50 full texts were reviewed, resulting in 18 being included in the analysis. All studies were observational in nature and 15 were from USA. There were 3476 patients in total, and the overall rate of intubation was 16% (95% confidence interval [CI] = 8%-26%). Most intubations occurred in the ED. Within the studies, the prehospital intubation rate ranged from 0% to 7.9% and the ED intubation rate ranged from 0 to 60%. The overall pooled prehospital intubation rate was 1% (95% CI = 0%-2%). The overall pooled ED intubation rate was 19% (95% CI = 11%-30%). The most common indications for intubation were for airway protection and respiratory depression/failure. CONCLUSIONS: There is wide variation in intubation rates between and within studies. The majority of intubations performed following prehospital administration of ketamine for agitation took place in the ED.

Pre-hospital guidelines for CPR-Induced Consciousness (CPRIC): A scoping review.

Background: CPR-Induced Consciousness is an emerging phenomenon with a paucity of consensus guidelines from peak resuscitative bodies. Local prehospital services have had to implement their own CPR-Induced Consciousness guidelines. This scoping review aims to identify prehospital CPR-Induced Consciousness guidelines and compare or contrast their management options. Objective: The purpose of this scoping review is to identify and compare as many prehospital CPR-Induced Consciousness guidelines as feasible, highlight common management trends, and discuss the factors that might impact CPR-Induced Consciousness guidelines and the management trends identified. Design: To search for prehospital CPR-Induced Consciousness guidelines, a bibliographical search of five databases was undertaken (MEDLINE, EMBASE, Cochrane, Scopus, and CINAHL plus). Also included was a grey literature search arm, comprised of four search strategies: 1. Customised Google search, 2. Hand searching of targeted websites, 3. Grey literature databases, 4. Consultation with subject experts. Results: Our search extracted 23 prehospital CPR-Induced Consciousness guidelines and one good practise statement from the International Liaison Committee on Resuscitation. Of the 23 prehospital guidelines available, we identified 20 different ways of treating CPR-Induced Consciousness. Midazolam was the most frequently used drug to treat CPR-Induced Consciousness (14/23, 61%), followed by Ketamine (11/23, 48%) and Fentanyl (9/23, 39%). Conclusion: Prehospital CPR-Induced Consciousness guidelines are both exceptionally uncommon and vary substantially from each other. This has a flow-on effect towards data collection and only serves to continue CPR-Induced Consciousness's relatively unknown status surrounding both knowledge of, and the effect CPR-Induced Consciousness treatment has on cardiac arrest outcomes.

Misleading medical literature: An observational study.

OBJECTIVE: Language that implies a conclusion not supported by the evidence is common in the medical literature. The hypothesis of the present study was that medical journal publications are more likely to use misleading language for the interpretation of a demonstrated null (i.e. chance or not statistically significant) effect than a demonstrated real (i.e. statistically significant) effect. METHODS: This was an observational study of the medical literature with a systematic sampling method. Articles published in The Journal of the American Medical Association, The Lancet and The New England Journal of Medicine over the last two decades were eligible. The language used around the P-value was assessed for misleadingness (i.e. either suggesting an effect existed when a real effect did not exist or vice versa). RESULTS: There were 228 unique manuscripts examined, containing 400 statements interpreting a P-value proximate to 0.05. The P-value was between 0.036 and 0.050 for 303 (75.8%) statements and between 0.050 and 0.064 for 97 (24.3%) statements. Forty-four (11%) of the statements were misleading. There were 40 (41.2%) false-positive sentences, implying statistical significance when the P-value was >0.05, and four (1.3%) false-negative sentences, implying no statistical significance when the P-value <0.05 (relative risk 31.2; 95% confidence interval 11.5-85.1; P < 0.0001). The proportion of included manuscripts containing at least one misleading sentence was 16.2% (95% confidence interval 12.0-21.6). CONCLUSIONS: Among a random selection of sentences in prestigious journals describing P-values close to 0.05, 1 in 10 are misleading (n = 44, 11%) and this is more prevalent when the P-values are above 0.05 compared to below 0.05. Caution is advised for researchers, clinicians and editors to align with the context and purpose of P-values.

A bibliometric analysis of paramedicine publications using the Scopus database: 2010-2019.

BACKGROUND: Paramedicine is an evolving profession undergoing increases in scholarly activity and peer-reviewed publications. This study aims to complete the first extensive bibliometric examination of the worldwide paramedicine literature. METHOD: Scopus was utilised to search for paramedicine-based articles published in peer-reviewed journals between 2010 and 2019 inclusive. The included articles were examined for citation count, journal, journal quartile, country of origin, university affiliation, collaboration, and topic. RESULTS: Paramedicine-based publications have steadily increased and are predominantly published in prehospital or emergency healthcare journals. The majority of highly cited authors were located in Australia; however, only one of these authors was identified as a paramedic. Monash University (Australia) was the most productive institution (11.7% of total articles) and collaboration was mostly within national boundaries (53.2%). CONCLUSION: This study demonstrates the progressive increase in paramedic scholarly activity over the past decade. Although a large number of articles originate from two countries (Australia and the USA) and one university, numerous nations and institutions are contributing to this body of knowledge. The growing literature base is indicative of the evolution of paramedicine; however, the high level of non-paramedic authors suggests the opportunity for further scholarly development within the paramedic discipline.

Prehospital paramedic pleural decompression: A systematic review.

BACKGROUND: Tension pneumothorax (TPT) is a frequent life-threat following thoracic injury. Time-critical decompression of the pleural cavity improves survival. However, whilst paramedics utilise needle thoracostomy (NT) and/or finger thoracostomy (FT) in the prehospital setting, the superiority of one technique over the other remains unknown. AIM: To determine and compare procedural success, complications and mortality between NT and FT for treatment of a suspected TPT when performed by paramedics. METHODS: We searched four databases (Ovid Medline, PubMed, CINAHL and Embase) from their commencement until 25th August 2020. Studies were included if they analysed patients suffering from a suspected TPT who were treated in the prehospital setting with a NT or FT by paramedics (or local equivalent nonphysicians). RESULTS: The search yielded 293 articles after duplicates were removed of which 19 were included for final analysis. Seventeen studies were retrospective (8 cohort; 7 case series; 2 case control) and two were prospective cohort studies. Only one study was comparative, and none were randomised controlled trials. Most studies were conducted in the USA (n=13) and the remaining in Australia (n=4), Switzerland (n=1) and Canada (n=1). Mortality ranged from 12.5% to 79% for NT and 64.7% to 92.9% for FT patients. A higher proportion of complications were reported among patients managed with NT (13.7%) compared to FT (4.8%). We extracted three common themes from the papers of what constituted as a successful pleural decompression; vital signs improvement, successful pleural cavity access and absence of TPT at hospital arrival. CONCLUSION: Evidence surrounding prehospital pleural decompression of a TPT by paramedics is limited. Available literature suggests that both FT and NT are safe for pleural decompression, however both procedures have associated complications. Additional high-quality evidence and comparative studies investigating the outcomes of interest is necessary to determine if and which procedure is superior in the prehospital setting.

Unintended consequences: The impact of airway management modifications introduced in response to COVID-19 on intubations in a tertiary centre emergency department.

OBJECTIVE: In response to COVID-19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first-attempt success (FAS) associated with ED intubation. METHODS: An analysis of prospectively collected registry data of all ED intubations over a 3-year period at an Australian Major Trauma Centre. During the first 6 months of the COVID-19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with 'sign-off' for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre-drawn medications. RESULTS: There were 783 patients, 136 in the COVID-19 era and 647 in the pre-COVID-19 comparator group. The rate of hypoxia was higher during the COVID-19 era compared to pre-COVID-19 (18.4% vs 9.6%, P < 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID-19 vs 22.6% pre-COVID-19, P < 0.001). Other adverse events were similar before and during COVID-19 (hypotension 12.5% vs 7.9%, P = 0.082; bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID-19 (95.6% vs 82.5%, P < 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P < 0.001) and rocuronium (86.8% vs 52.1%, P < 0.001). CONCLUSIONS: This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.

Review article: Paramedic pain management of femur fractures in the prehospital setting: A systematic review.

Femur shaft and neck of femur (NOF) fractures are often undertreated in the prehospital setting. These injuries can present unique clinical and logistical concerns in the prehospital setting. This systematic review aimed to investigate paramedic prehospital pain management of patients who had suffered NOF or femur fractures, and to investigate which interventions are effective. A systematic review was conducted in line with Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines. Four databases were searched from inception date 23 March 2020. Articles were independently reviewed by two authors and conflicts resolved by a third author, followed by a hand search of the included reference lists. References were included if they addressed paramedic interventions for NOF or femur shaft fractures. Outcomes of interest were the effectiveness and complications of different modalities administered by paramedics. The search yielded 6868 articles, of which 19 met the final inclusion criteria. Studies investigated a variety of interventions including traction splints, intravenous (IV) analgesia and alternative analgesic options. Traction splinting and IV analgesia were consistently reported as underutilised. Alternative analgesics such as auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and fascia iliaca compartment block were found to be effective techniques that could be safely and competently employed by paramedics, reducing pain for patients with limited adverse events. NOF and femur shaft fractures are an undertreated injury in the prehospital setting. Traction splinting and IV analgesia remain the traditional methodologies of treatment for these injuries; however, there are alternatives such as TENS, auricular acupressure and fascia iliaca compartment block that appear to be emerging as safe and effective options for the prehospital setting.

Top 100 cited paramedicine papers: A bibliometric study.

OBJECTIVE: Understanding the impact different journal articles have in any academic field is important - particularly in emerging professions. A bibliometric analysis like this does not yet exist for paramedicine, despite the rapid increase in its primary literature. The objective of the present study was to identify and analyse the 100 top-cited articles about paramedicine. METHODS: We searched the Scopus database in August 2020 for studies relating to paramedicine. After screening titles and abstracts, we extracted the citation count, journal name, publication year, and country of origin. We manually assessed whether the study was clinical or not, noted the sex of the authors, the profession of first and last authors and the study design used. RESULTS: The median citation count for the top 100 papers in paramedicine was 58 (interquartile range 46-84 citations). The articles were published across 48 different journals, with Resuscitation and Prehospital Emergency Care being the two most frequent. The top-cited paramedic papers originated from 16 different countries and were written predominantly by medical doctors. Three quarters (73%) of the studies had a clinical focus, and a quarter (26%) were randomised controlled trials. CONCLUSIONS: The evolution of paramedicine towards professionalism is backed up by the growth of its own body of knowledge. This analysis of the 100 most cited studies in paramedicine is the first of its kind and highlights that paramedicine articles have a high citation count and are published across numerous journals, but with a relative lack of contribution from paramedic practitioners and female researchers.

The Definition of Paramedicine: An International Delphi Study.

INTRODUCTION: Although paramedicine is an integral element of healthcare systems, there is a lack of universal consensus on its definition. This study aimed to derive a global consensus definition of paramedicine. METHODS: Key attributes pertaining to paramedicine were identified from existing definitions within the literature. Utilising text analysis, common attribute themes were identified and six initial domains were developed. These domains formed the basis for a four-round Delphi study with a panel of 58 global experts within paramedicine to develop an international consensus definition. RESULTS: Response rates across the study varied from 96.6% (round 1) to 63.8% (round 4). Participant feedback on appropriate attributes to include in the definition reflected the high level of specialized clinical care inherent within paramedicine, and its status as an essential element of healthcare systems. In addition, the results highlighted the extensive range of paramedicine capabilities and roles, and the diverse environments within which paramedics work. CONCLUSION: Delphi methodology was utilized to develop a global consensus definition of paramedicine. This definition is as follows: paramedicine is a domain of practice and health profession that specialises across a range of settings including, but not limited to, emergency and primary care. Paramedics work in a variety of clinical settings such as emergency medical services, ambulance services, hospitals and clinics as well as non-clinical roles, such as education, leadership, public health and research. Paramedics possess complex knowledge and skills, a broad scope of practice and are an essential part of the healthcare system. Depending on location, paramedics may practice under medical direction or independently, often in unscheduled, unpredictable or dynamic settings. We believe that the generation and provision of this consensus definition is essential to enable the further development and maturation of the discipline of paramedicine.

Paramedic streaming upon arrival in emergency department: A prospective study.

OBJECTIVE: The role of paramedics in hospital triage or streaming models has not been adequately explored and is potentially a missed opportunity for enhanced patient flow. The aim of the present study was to assess the concordance between a streaming decision by paramedics with the decision by nurses after arrival to the ED. METHODS: A prospective observational study was conducted. Paramedics were met at the entrance to the hospital and asked which destination they thought was appropriate (the index test). The ED nurse streaming decision was the reference standard. Cases of discordance were reviewed and assessed for clinical risk by an independent expert panel that was blinded. RESULTS: We collected data from 500 cases that were transported by ambulance consisting of 55% males with a median age of 57 years (interquartile range 38-75). The overall concordance between paramedics' and streaming decision was 86.4% (95% confidence interval 83.1-89.1). The concordance was highest among patients streamed to resuscitation and general cubicles. Among discordant cases (n = 68), 39 were streamed to a more acute destination than the paramedic suggested. Of the 68 discordant cases, 56 were deemed to be of no clinical risk. CONCLUSIONS: Despite limited knowledge of patient load within the ED, paramedics can allocate a streaming destination with high accuracy and this appears to be associated with low clinical risks. Early pre-hospital notification of streaming destination with proactive allocation of ED destination presents a real opportunity to minimise off-load times and improve patient flow.

Lunacy in a tertiary emergency department: A 3-year cohort study of the association between moon cycles and occupational violence and aggression.

OBJECTIVE: Occupational violence and aggression (OVA) in the ED is an issue of global concern and increasing incidence. The empirical evidence for the relationship between the lunar cycle and 'lunatics' remains equivocal. The present study aims to examine the association between OVA in ED and the full moon (FM). METHODS: Data on all presentations were extracted from The Alfred Hospital ED records for consecutive patients over a 3-year period (January 2013-December 2015). The primary outcome of the present study is OVA among patients in the ED. Univariable and multivariable logistic regression were used to determine the association between aspects of the lunar cycle and OVA. RESULTS: There were 184 059 ED presentations during the 3 years, 6234 (3.4%) of which occurred on a FM. There were 1853 episodes of OVA, 57 (3.1%) of which occurred on a FM. OVA among patients presenting to ED was not associated with the FM (adjusted odds ratio [OR] 0.92 [95% confidence interval 0.70-1.20]; P = 0.53). However, the first quarter (FQ) (adjusted OR 1.38 [1.11-1.72]; P < 0.01) and third quarter (TQ) (adjusted OR 1.29 [95% confidence interval 1.03-1.62]; P = 0.03) moons of the lunar cycle were independently associated with OVA. CONCLUSIONS: Contrary to traditional beliefs, the FQ and TQ of the lunar cycle but not the FM were associated with OVA. This highlights a relatively unexplored relationship that has previously been overshadowed by the FM in the literature. Prediction models of violence in the ED could consider incorporating the FQ and TQ of the lunar cycle in their models.

Review article: Pre-hospital provider clinical judgement upon arrival to the emergency department: A systematic review and meta-analysis.

Pre-hospital providers (PHPs) undertake initial patient assessment, often spending considerable time with patients prior to arrival at ED. However, continuity of this assessment with ongoing care of patients in the ED is limited, with repeated assessment in the ED, starting with the process of triage in hospital. A systematic review of the literature was conducted to assess the ability of PHPs to predict patient outcomes in the ED. Manuscripts were screened and were eligible for inclusion if they included patients transported by non-physician PHPs to the ED and assessed ability of PHPs to predict triage scores, clinical course, treatment requirements or disposition from ED. The initial search returned 10 753 unique articles. After screening and full text review, 10 studies were included in data analysis. Of these, six assessed prediction of disposition (admission versus discharge) from ED, two compared triage score application, one assessed prediction of clinical requirements and one assessed prediction of mortality prior to discharge. Prediction of admission across five studies had a pooled sensitivity of 0.73 (95% confidence interval 0.67-0.79) and specificity of 0.78 (95% confidence interval 0.69-0.85). Triage score application had weighted kappa variables of 0.409 and 0.452 indicating moderate agreement on assessment priority between PHPs and triage nurses. The ability of PHPs to assign triage scores, predict clinical course and predict disposition from the ED have mild concordance with clinical assessment by ED staff. This is an area of potential expansion in PHPs' role; however, training would be required prior to implementation.

Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis.

BACKGROUND: Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI. METHODS: This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period. RESULTS: There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)). CONCLUSIONS: This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.

Finger thoracostomy in patients with chest trauma performed by paramedics on a helicopter emergency medical service.

OBJECTIVE: To determine the frequency of finger thoracostomy performed by intensive care flight paramedics after the introduction of a training programme in this procedure and complications of the procedure that were diagnosed after hospital arrival. METHODS: This was a retrospective cohort study of adult and paediatric trauma patients undergoing finger thoracostomy performed by paramedics on a helicopter emergency medical service between June 2015 and May 2018. Hospital data were obtained through a manual search of the medical records at each of the three receiving major trauma services. Additional data were sourced from the Victorian State Trauma Registry. RESULTS: The final analysis included 103 cases, of which 73.8% underwent bilateral procedures with a total of 179 finger thoracostomies performed. The mean age of patients was 42.8 (standard deviation 21.4) years and 73.8% were male. Motor vehicle collision was the most common mechanism of injury accounting for 54.4% of cases. The median Injury Severity Score was 41 (interquartile range 29-54). There were 30 patients who died pre-hospital, with most (n = 25) having finger thoracostomy performed in the setting of a traumatic cardiac arrest. A supine chest X-ray was performed prior to intercostal catheter insertion in 38 of 73 patients arriving at hospital; of these, none demonstrated a tension pneumothorax. There were three cases of potential complications related to the finger thoracostomy. CONCLUSION: Finger thoracostomy was frequently performed by intensive care flight paramedics. It was associated with a low rate of major complications and given the deficiencies of needle thoracostomy, should be the preferred approach for chest decompression.

Proactive review by the emergency department before inter-hospital transfer (the PREVENT study).

OBJECTIVES: To determine the population of patients where patient transfer may be prevented by assessment of a senior ED registrar at the referring hospital. METHODS: Patients transferred from Caulfield Hospital, specialising in community services, rehabilitation, aged care and aged mental health to The Alfred Emergency and Trauma Centre, an adult major referral centre within the same clinical network were identified from 1 July 2016 to 31 December 2016. Medical records were reviewed independently by two clinicians to determine preventability of transfer and whether attendance by a senior ED registrar could have prevented the transfer. RESULTS: There were 221 patients included with a mean age of 73.6(15.1) years. The median time spent in the ED was 4 h (interquartile range 2-8) and 197 (89.1%) were admitted. There were 107 (48.6%) transfers deemed preventable or potentially preventable, with 104 preventable by attendance of a senior ED registrar. The most common indication for transfer was acute trauma (n = 55; 24.9%), and the odds of a case being preventable or potentially preventable if transferred for the primary indication of trauma was 3.9 (95% confidence interval 2.1-7.1; P < 0.001). Among the preventable cases, the total cost of transfer was AU$105 984 over 6 months, not accounting for the costs of duplication of care. CONCLUSIONS: This proof-of-concept study suggests that strategies to expand the provision of acute care to outreach within specialist networks and reduce patient transfers should be further explored. An outreach programme for improved acute assessment of patients at the referring hospital particularly after acute trauma may prevent transfers, improving care pathways.

What Is the Clinical Evidence Supporting Trauma Team Training (TTT): A Systematic Review and Meta-Analysis.

Background and Objectives: Major trauma centres manage severely injured patients using multi-disciplinary teams but the evidence-base that targeted Trauma Team Training (TTT) improves patients' outcomes is unclear. This systematic review aimed to identify the association between the implementation of TTT programs and patient outcomes. Methods: We searched OVID Medline, PubMed and The Cochrane Library (CENTRAL) from the date of the database commencement until 10 of April 2019 for a combination of Medical Subject Headings (MeSH) terms and keywords relating to TTT and clinical outcomes. Reference lists of appraised studies were also screened for relevant articles. We extracted data on the study setting, type and details about the learners, as well as clinical outcomes of mortality and/or time to critical interventions. A meta-analysis of the association between TTT and mortality was conducted using a random effects model. Results: The search yielded 1136 unique records and abstracts, of which 18 full texts were reviewed. Nine studies met final inclusion, of which seven were included in a meta-analysis of the primary outcome. There were no randomised controlled trials. TTT was not associated with mortality (Pooled overall odds ratio (OR) 0.83; 95% Confidence Interval; 0.64-1.09). TTT was associated with improvements in time to operating theatre and time to first computerized tomography (CT) scanning. Conclusions: Despite few publications related to TTT, its introduction was associated with improvements in time to critical interventions. Whether such improvements can translate to improvements in patient outcomes remains unknown. Further research focusing on the translation of standardised trauma team reception "actions" into TTT is required to assess the association between TTT and patient outcome.