Implementing the IMIST-AMBO tool for paramedic to trauma team handovers: a video review analysis.

OBJECTIVE: Patient handover between paramedics and the trauma team is vulnerable to communication errors that may adversely affect patient care. This study assesses the feasibility of a handover tool, IMIST-AMBO (acronym of categories), implementation in the trauma bay and evaluates the degree to which it improves handover metrics. METHODS: This is a prospective observational cohort study conducted at Canada's largest level-one trauma center. Feasibility of the tool implementation and improvement in handover metrics were assessed. Strategies for implementation included distribution of an educational video and posters, and point-of-care reminders in the trauma bay. Two reviewers independently assessed video recordings of handovers to evaluate handover metrics. Findings were compared to data obtained during a knowledge gap analysis conducted prior to the initiation of this study at the same institution. RESULTS: Over 13 weeks (August to November 2020), 140 videos were recorded, of which 80 used the IMIST-AMBO tool (compliance of 57%). Paramedic adherence to the handover structure occurred in 70.4% of cases, with greater adherence to the IMIST (82.2%) compared to the AMBO (47.1%) section. The mean (± standard deviation) handover duration was shorter (1 min:58 s ± 0:44 s during implementation vs. 2 min:47 s ± 1:14 s pre-implementation, [p < 0.001]). Frequency of parallel conversations and informal handovers improved (61% to 30% and 65% to 13%, [p < 0.001], respectively). Interruptions during the handover decreased from 3.05 (± 1.95) to 1.5 (± 1.7), p < 0.001. The tool was received favorably among study participants. CONCLUSION: The IMIST-AMBO tool reduced the frequency of interruptions, parallel conversations, and informal handovers during paramedic-trauma team handovers at our institution. The quality and amount of information communicated per handover improved, all with a decrease in handover duration. The IMIST-AMBO tool may be applied to other trauma centers across Canada, or more broadly on an international scale.

RéSUMé: OBJECTIFS: Le transfert des patients entre les ambulanciers paramédicaux et l'équipe de traumatologie est vulnérable aux erreurs de communication qui peuvent nuire aux soins aux patients. Cette étude évalue la faisabilité d'un outil de transfert, IMIST-AMBO (acronyme des catégories), mis en œuvre dans le service de traumatologie et évalue dans quelle mesure il améliore les paramètres de transfert. MéTHODES: Il s'agit d'une étude de cohorte observationnelle prospective menée dans le plus grand centre de traumatologie de niveau 1 du Canada. La faisabilité de la mise en œuvre de l'outil et l'amélioration des paramètres de transfert ont été évaluées. Les stratégies de mise en œuvre comprenaient la distribution d'une vidéo et d'affiches éducatives, ainsi que des rappels au point de service dans la salle de traumatologie. Deux examinateurs ont évalué indépendamment les enregistrements vidéo des transferts pour évaluer les paramètres de transfert. Les résultats ont été comparés aux données obtenues lors d'une analyse des lacunes en matière de connaissances réalisée avant le lancement de cette étude dans le même établissement. RéSULTATS: Sur 13 semaines (août à novembre 2020), 140 vidéos ont été enregistrées, dont 80 ont utilisé l'outil IMIST-AMBO (conformité de 57%). L'adhésion des ambulanciers paramédicaux à la structure de transfert s'est produite dans 70.4% des cas, avec une plus grande adhésion à l'IMIST (82.2%) que l'AMBO (47,1%). La durée moyenne (± écart-type) du transfert était plus courte (1 min: 58 s ± 0: 44 s pendant la mise en œuvre contre 2 min: 47 s ± 1: 14 s avant la mise en œuvre, p < 0.001). La fréquence des conversations parallèles et des transferts informels s'est améliorée (de 61% à 30% et de 65% à 13%, [p < 0.001], respectivement). Les interruptions pendant le transfert ont diminué de 3.05 (± 1.95) à 1.5 (± 1.7), p < 0.001. L'outil a été accueilli favorablement par les participants à l'étude. CONCLUSION: L'outil IMIST-AMBO a réduit la fréquence des interruptions, des conversations parallèles et des transferts informels pendant les transferts de l'équipe paramédicale de traumatologie dans notre établissement. La qualité et la quantité d'informations communiquées par transfert se sont améliorées, tout en réduisant la durée du transfert. L'outil IMIST-AMBO peut être appliqué à d'autres centres de traumatologie à travers le Canada, ou plus largement à l'échelle internationale.

Effect of special operational forces surgical resuscitation teams on combat casualty survival: A narrative review.

IMPORTANCE: The most common cause of preventable death on the conventional battlefield or on special operations force (SOF) missions is hemorrhage. SOF missions may take place in remote and austere locations. Many preventable deaths in combat occur within 30 min of wounding. Therefore, SOF damage control resuscitation (DCR) and damage control surgery (DCS) teams may improve combat casualty survival in the SOF environment. OBJECTIVE: To determine the effect of SOF DCR and DCS teams on combat casualty survival. Also, to describe commonalities in team structure, logistics, and blood product usage. DESIGN: A narrative review of the English literature used a Medline and Embase search strategy. The authors were contacted for more details as required. The risk of bias was assessed using the Cochrane Collaboration's ROBINS-I tool. Pooling of data was not done to the heterogeneity of studies. RESULTS: Weak evidence was identified showing a clinical benefit of SOF DCR and DCS teams. Conflicting evidence from less rigorous studies was also found. The overall risk of bias using ROBINS-I was serious to critical. Several commonalities in team structure, training, and logistics were found. CONCLUSIONS AND RELEVANCE: There is conflicting evidence regarding the effect SOF DCR and DCS teams have on combat casualty survival. There is no strong evidence that SOF DCR and DCS teams cause harm. More robust data collection is recommended to evaluate these teams.

Closed loop communication in the trauma bay: identifying opportunities for team performance improvement through a video review analysis.

OBJECTIVES: Communication among trauma team members in the trauma bay is vulnerable to errors, which may impact patient outcomes. We used the previously validated trauma-non-technical skills (T-NOTECHS) tool to identify communication gaps during patient management in the trauma bay and to inform development strategies to improve team performance. METHODS: Two reviewers independently assessed non-technical skills of team members through video footage at Sunnybrook Health Sciences Centre. Team performance was measured using T-NOTECHS across five domains using a five-point Likert scale (lower score indicating worse performance): (1) leadership; (2) cooperation and resource management; (3) communication and interaction; (4) assessment and decision making; (5) situation awareness/coping with stress. Secondary outcomes assessed the number of callouts, closed loop communications and parallel conversations. RESULTS: The study included 55 trauma activations. Injury severity score (ISS) was used as a measure of trauma severity. A case with an ISS score ≥ 16 was considered severe. ISS was ≥ 16 in 37% of cases. Communication and interaction scored significantly lower compared to all other domains (p < 0.0001). There were significantly more callouts and completed closed loop communications in more severe cases compared to less severe cases (p = 0.017 for both). Incomplete closed loop communications and parallel conversations were identified, irrespective of case severity. CONCLUSION: A lower communication score was identified using T-NOTECHS, attributed to incomplete closed loop communications and parallel conversations. Through video review of trauma team activations, opportunities for improvement in communication can be identified by the T-NOTECHS tool, as well as specifically identifying callouts and closed loop communication. This process may be useful for trauma programs as part of a quality improvement program on communication skills and team performance.

RéSUMé: OBJECTIFS : La communication entre les membres de l'équipe de traumatologie dans la salle de traumatologie est vulnérable aux erreurs, ce qui peut avoir un impact sur les résultats des patients. Nous avons utilisé l'outil de compétences non techniques en traumatologie (T-NOTECHS) précédemment validé pour identifier les lacunes en matière de communication pendant la prise en charge des patients dans la salle de traumatologie et pour informer les stratégies de développement visant à améliorer les performances de l'équipe. MéTHODES: Deux examinateurs ont évalué de manière indépendante les compétences non techniques des membres de l'équipe au moyen de séquences vidéo réalisées au Sunnybrook Health Sciences Centre. La performance de l'équipe a été mesurée à l'aide de la T-NOTECHS dans cinq domaines à l'aide d'une échelle de Likert à cinq points (un score plus bas indiquant une performance plus faible) : (1) leadership ; (2) coopération et gestion des ressources ; (3) communication et interaction ; (4) évaluation et prise de décision ; (5) conscience de la situation/ gestion du stress. Les résultats secondaires ont évalué le nombre d'appels, de communications en boucle fermée et de conversations parallèles. RéSULTATS: L'étude a porté sur 55 activations de traumatismes. Le score de gravité des blessures (ISS) a été utilisé comme mesure de la gravité du traumatisme. Un cas présentant un score ISS ≥ 16 était considéré comme grave. L'ISS était ≥ 16 dans 37 % des cas. La communication et l'interaction ont obtenu des scores significativement plus faibles par rapport à tous les autres domaines (p<0,0001). Il y avait significativement plus d'appels et de communications en boucle fermée terminées dans les cas plus graves que dans les cas moins graves (p = 0.017 pour les deux). Des communications incomplètes en boucle fermée et des conversations parallèles ont été identifiées, indépendamment de la gravité du cas. CONCLUSION: Un score de communication plus faible a été identifié en utilisant le T-NOTECHS, attribué à des communications incomplètes en boucle fermée et à des conversations parallèles. Grâce à l'examen vidéo des activations de l'équipe de traumatologie, les possibilités d'amélioration de la communication peuvent être identifiées par l'outil T-NOTECHS, ainsi que l'identification spécifique des appels et de la communication en boucle fermée. Ce processus peut être utile pour les programmes de traumatologie dans le cadre d'un programme d'amélioration de la qualité sur les compétences de communication et la performance de l'équipe.

A Quantitative Study of Particle Dispersion due to Respiratory Support Modalities in PC-12 Aircraft: Prehospital Patient Transport.

OBJECTIVE: It is unclear whether supplemental oxygen and noninvasive ventilation respiratory support devices increase the dispersion of potentially infectious bioaerosols in a pressurized air medical cabin. This study quantitatively compared particle dispersion from respiratory support modalities in an air medical cabin during flight. METHODS: Dispersion was measured in a fixed wing air ambulance during flight with a breathing medical mannequin simulator exhaling nebulized saline from the lower respiratory tract with the following respiratory support modalities: a nasal cannula with a surgical mask, high-flow nasal oxygen (HFNO) with a surgical mask, and noninvasive bilevel positive airway pressure (BiPAP) ventilation. RESULTS: Nasal cannula oxygen with a surgical mask was associated with the highest particle concentrations. In the absence of mask seal leaks, BiPAP was associated with 1 order of magnitude lower particle concentration compared with a nasal cannula with a surgical mask. Particle concentrations associated with HFNO with a surgical mask were lower than a nasal cannula with a surgical mask but higher than BiPAP. CONCLUSIONS: Particle dispersion associated with the use of BiPAP and HFNO with a surgical mask is lower than nasal cannula oxygen with a surgical mask. These findings may assist air medical organizations with operational decisions where little data exist about respiratory particle dispersion.

Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research.

OBJECTIVES: The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS: Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS: The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE: Systematic review, level III.

Protocol for a multicentre, randomised, parallel-control, superiority trial comparing administration of clotting factor concentrates with a standard massive haemorrhage protocol in severely bleeding trauma patients: the FiiRST 2 trial (a 2020 EAST multicentre trial).

INTRODUCTION: Acute traumatic coagulopathy (ATC) in bleeding trauma patients increase in-hospital mortality. Fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC) are two purified concentrates of clotting factors that have been used to treat ATC. However, there is a knowledge gap on their use compared with the standard of care, the transfusion of plasma. METHODS AND ANALYSIS: The factors in the initial resuscitation of severe trauma 2 trial is a multicentre, randomised, parallel-control, single-blinded, phase IV superiority trial. The study aims to address efficacy and safety of the early use of FC and PCC compared with a plasma-based resuscitation. Adult trauma patients requiring massive haemorrhage protocol activation on hospital arrival will receive FC 4 g and PCC 2000 IU or plasma 4 U, based on random allocation. The primary outcome is a composite of the cumulative number of all units of red cells, plasma and platelets transfused within 24 hours following admission. Secondary outcomes include measures of efficacy and safety of the intervention. Enrolment of 350 patients will provide an initial power >80% to demonstrate superiority for the primary outcome. After enrolment of 120 patients, a preplanned adaptive interim analysis will be conducted to reassess assumptions, check for early superiority demonstration or reassess the sample size for remainder of the study. ETHICS AND DISSEMINATION: The study has been approved by local and provincial research ethics boards and will be conducted according to the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. As per the Tri-Council Policy Statement, patient consent will be deferred due to the emergency nature of the interventions. If superiority is established, results will have a major impact on clinical practice by reducing exposure to non-virally inactivated blood products, shortening the time for administration of clotting factors, correct coagulopathy more efficaciously and reduce the reliance on AB plasma. TRIAL REGISTRATION NUMBER: NCT04534751, pre results.

Freeze-dried plasma for major trauma - Systematic review and meta-analysis.

BACKGROUND: Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma. STUDY DESIGN AND METHODS: Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile. RESULTS: Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP. CONCLUSION: Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality). LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

Pre-hospital hypothermia is associated with transfusion risk after traumatic injury.

OBJECTIVES: In traumatically injured patients, excessive blood loss necessitating the transfusion of red blood cell (RBC) units is common. Indicators of early RBC transfusion in the pre-hospital setting are needed. This study aims to evaluate the association between hypothermia (<36°C) and transfusion risk within the first 24 hours after arrival to hospital for a traumatic injury. METHODS: We completed an audit of all traumatically injured patients who had emergent surgery at a single tertiary care center between 2010 and 2014. Using multivariable logistic regression analysis, we evaluated the association between pre-hospital hypothermia and transfusion of ≥1 unit of RBC within 24 hours of arrival to the trauma bay. RESULTS: Of the 703 patients included to evaluate the association between hypothermia and RBC transfusion, 203 patients (29%) required a transfusion within 24 hours. After controlling for important confounding variables, including age, sex, coagulopathy (platelets and INR), hemoglobin, and vital signs (blood pressure and heart rate), hypothermia was associated with a 68% increased odds of transfusion in multivariable analysis (OR: 1.68; 95% CI: 1.11-2.56). CONCLUSIONS: Hypothermia is strongly associated with RBC transfusion in a cohort of trauma patients requiring emergent surgery. This finding highlights the importance of early measures of temperature after traumatic injury and the need for intervention trials to determine if strategies to mitigate the risk of hypothermia will decrease the risk of transfusion and other morbidities.

Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model.

BACKGROUND: The Focused Assessment with Sonography in Trauma (FAST) exam is a rapid ultrasound test to identify evidence of hemorrhage within the abdomen. Few studies examine the accuracy of paramedic performed FAST examinations. The duration of an ultrasound training program remains controversial. This study's purpose was to assess the accuracy of paramedic FAST exam interpretation following a one hour didactic training session. METHODS: The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model containing 300ml of free fluid following a one hour didactic training course. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. RESULTS: Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were mostly ultrasound-naive whereas the emergency physicians all had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups with accuracy of 85.6% and 87.5% (∆1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. CONCLUSIONS: This study determined that critical care paramedics were able to use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of prehospital ultrasound to aid in the triage and transport decisions of trauma patients while limiting the financial and logistical burden of ultrasound training.

Clinical handover from emergency medical services to the trauma team: A gap analysis.

OBJECTIVES: There has been limited evaluation of handover from emergency medical services (EMS) to the trauma team. We sought to characterize these handover practices to identify areas of improvement and determine if handover standardization might be beneficial for trauma team performance. METHODS: Data were prospectively collected over a nine-week period by a trained observer at a Canadian level one trauma centre. A randomized scheduled was used to capture a representative breadth of handovers. Data collected included outcome measures such as duration of handover, structure of the handover, and information shared, process measures such as questions and interruptions from the trauma team, and perceptions of the handover from nurses, trauma team leaders and EMS according to a bidirectional Likert scale. RESULTS: 79 formal verbal handovers were observed. Information was often missing regarding airway (present 22%), breathing (54%), medications (59%), and allergies (54%). Handover structure lacked consistency beyond the order of identification and mechanism of injury. Of all questions asked, 35% were questioning previously given information. The majority of handovers (61%) involved parallel conversations between team members while EMS was speaking. There was a statistically significant disparity between the self-evaluation of EMS handovers and the perceived quality determined by nurses and trauma team leaders. CONCLUSIONS: We have identified the need to standardize handover due to poor information content, a lack of structure and active listening, information repetition, and discordant expectations between team members. These data will guide the development of a co-constructed framework integrating the perspectives of all team members.

Primary aeromedical retrieval crew composition: Do different teams impact clinical outcomes? A descriptive systematic review.

OBJECTIVES: Military Forward Aeromedical Evacuation and civilian Helicopter Emergency Medical Services are widely used to conduct Primary Aeromedical Retrieval. Crew composition in Primary Aeromedical Retrieval missions varies considerably. The ideal composition is unknown. Thus, we conducted a descriptive systematic review on mortality and other outcomes for different Primary Aeromedical Retrieval crew compositions. METHODS: Medline, Embase, and Cochrane Controlled Trials Register were searched up to January 2020. Results were reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Studies of adult trauma air transported by different crews were included. Population, injury severity, crew composition, procedures, and outcomes, including mortality, were abstracted. Risk of bias was assessed using previously validated tools. A lack of reported effect measures precluded a quantitative analysis. RESULTS: Sixteen studies met inclusion criteria (3 prospective studies, 1 case-control, and 12 retrospective). Overall, studies reported a mortality benefit associated with advanced health care providers. This was most apparent in patients with severe but survivable injuries. In this population, early rapid sequence induction, endotracheal intubation, mechanical ventilation, thoracostomies, blood products transfusion, and treatment of hemorrhagic shock are better performed by advanced providers and may improve outcomes. The quality of evidence reported a moderate risk of bias in the included studies. CONCLUSIONS: Overall, findings were divergent but showed a trend to decreased mortality in patients treated by advanced providers with interventions beyond the basic paramedic level. This trend was most significant in patients with severe but survivable injuries. These results should be cautiously interpreted because most studies were observational, had small sample sizes, and had a high potential for confounding factors.

Cryoprecipitate transfusion in bleeding patients.

OBJECTIVES: The management of acquired coagulopathy in multiple clinical settings frequently involves fibrinogen supplementation. Cryoprecipitate, a multidonor product, is widely used for the treatment of acquired hypofibrinogenemia following massive bleeding, but it has been associated with adverse events. We aimed to review the latest evidence on cryoprecipitate for treatment of bleeding. METHODS: We conducted a narrative review of current literature on cryoprecipitate therapy, describing its history, formulations and preparation, and recommended dosing. We also reviewed guideline recommendations on the use of cryoprecipitate in bleeding situations and recent studies on its efficacy and safety. RESULTS: Cryoprecipitate has a relatively high fibrinogen content; however, as it is produced by pooling fresh frozen donor plasma, the fibrinogen content per unit can vary considerably. Current guidelines suggest that cryoprecipitate use should be limited to treating hypofibrinogenemia in patients with clinical bleeding. Until recently, cryoprecipitate was deemed unsuitable for pathogen reduction, and potential safety concerns and lack of standardized fibrinogen content have led to some professional bodies recommending that cryoprecipitate is only indicated for the treatment of bleeding and hypofibrinogenemia in perioperative settings where fibrinogen concentrate is not available. While cryoprecipitate is effective in increasing plasma fibrinogen levels, data on its clinical efficacy are limited. CONCLUSIONS: There is a lack of robust evidence to support the use of cryoprecipitate in bleeding patients, with few prospective, randomized clinical trials performed to date. Clinical trials in bleeding settings are needed to investigate the safety and efficacy of cryoprecipitate and to determine its optimal use and administration.

Epidemiologic features of medical emergencies in remote First Nations in northern Ontario: a cross-sectional descriptive study using air ambulance transport data.

BACKGROUND: For about 25 000 Ontarians living in remote northern First Nations communities, seeing a doctor in an emergency department requires flying in an airplane or helicopter. This study describes the demographic and epidemiologic characteristics of patients transported from these communities to access hospital-based emergency medical care. METHODS: In this cross-sectional descriptive study, we examined primary medical data on patient transportation from Ornge, the provincial medical air ambulance service provider, for 26 remote Nishnawbe Aski Nation communities in northern Ontario from 2012 to 2016. We described these transports using univariate descriptive statistics. RESULTS: Over the 5-year study period, 10 538 patients (mean 2107.6 per year) were transported by Ornge from the 26 communities. Transport incidence ranged from 9.2 to 9.5 per 100 on-reserve population per year. Women aged 65 years or more had the highest transport incidence (25.9 per 100). Girls aged 5-9 years had the lowest mean incidence (2.1 per 100). Gastrointestinal issues accounted for 13.3% of transfers. Neurologic issues, respiratory issues and trauma each accounted for about 11% of transfers, and cardiac issues for 9.6%. Patients with obstetric issues accounted for 7.6% of transfers per year, and toxicologic emergencies for 7.5%. INTERPRETATION: This study provides the epidemiologic foundation to improve emergency care and emergency transport from remote First Nation communities in Ontario.

Cognitive behavioral therapy for suicide prevention in youth admitted to hospital following an episode of self-harm: A pilot randomized controlled trial.

BACKGROUND: Self-harm (SH) is among the strongest risk factors for eventual suicide death yet there are limited data on which interventions are most effective for treating SH in youth. METHODS: This single-blind, pilot randomized controlled trial examined brief cognitive behavioral therapy (BCBT) for suicide prevention vs. minimally-directive supportive psychotherapy in youth (aged 16-26) hospitalized following SH. Both therapies included 10 acute sessions over 15 weeks with three booster sessions occurring at three month intervals thereafter. The primary feasibility outcome was ≥70% retention at study endpoint. Efficacy measures, including repeat SH, were secondary outcomes. RESULTS: Twenty-four subjects were enrolled (12 per group) with one BCBT subject and two controls dropping out prior to the first therapy session. Five (45%) of the remaining BCBT subjects and seven (70%) control subjects completed all 10 acute therapy sessions. All subjects who completed five sessions went on to complete 10. There were significantly fewer instances of repeat SH in BCBT subjects (7 of 62 weeks of acute follow-up; 11%) compared to control subjects (24 of 79 weeks; 30%)(OR 0.34, 95%CI:0.13-0.92). Three subjects, all in the control condition, made a total of five suicide attempts during the study. LIMITATIONS: This study had a modest sample size and retention rate. CONCLUSIONS: This study failed to achieve its primary feasibility retention goal for BCBT. However, it did demonstrate that initial adherence to follow-up predicted study completion. Despite small numbers, it also found a significant reduction in repeat SH in the BCBT group, a finding which requires replication.

Risk Factors for Non-optimal Resource Utilization for Emergent Interfacility Transfers by Air Ambulance in Ontario.

Background: The use of air ambulance to facilitate interfacility transfer has been associated with improved mortality; however, air ambulance is a limited resource and sometimes the optimal resource to transport a patient is unavailable. When a non-optimal resource is used there is an inherent delay and critically unwell patients may deteriorate as a result. This study aimed to identify risk factors associated with non-optimal resource utilization for adult patients undergoing emergent interfacility transport by air ambulance in Ontario, Canada. A secondary objective was to determine if non-optimal resource utilization was associated with deterioration in clinical status by measuring a delta rapid emergency medicine score (REMS). Methods: This was a retrospective cohort study of all emergent, adult interfacility transfers transported by air ambulance over a 5-year period in Ontario, Canada. Determination of optimal resource use was based on distances and historic time data for all sending-receiving facility pairs. A logistic regression model was used to explore patient, provider and institutional risk factors for non-optimal resource use. To explore the secondary objective a linear regression model was used to explore impact of non-optimal resource use on deltaREMS. Results: There were a total of 9,687 patients included in the study cohort, with 4,984 having an optimal resource use and 4,703 having non-optimal resource. The median delay in interfacility transfer caused by a non-optimal transfer strategy was 35.7 minutes. Patients who required mechanical ventilation (OR 1.13, p = 0.031) and or were transferred out of nursing stations had higher odds of non-optimal resource use (OR 2.84, p = 0.019). Paramedic level of care of advanced (OR 0.37, p = < 0.001) and critical care (OR 0.28, p = < 0.001) as well as spring season (OR 0.75, p = < 0.001) had lower odds of non-optimal resource utilization. Optimal resource utilization did not significantly affect delta REMS (beta coefficient 0.002, p = 0.64). Conclusions: Patients who required mechanical ventilation and were transferred out from a nursing station had higher odds of non-optimal resource utilization while patients that required advanced or critical care level of care and spring season had lower odds of non-optimal resource use. Additionally, non-optimal resource use for air ambulance interfacility transfers did not result in patient deterioration as measured by a delta REMS score.

Causes of Delay During Interfacility Transports of Injured Patients Transported by Air Ambulance.

Background: Many severely injured patients are initially brought to a non-trauma centers for initial assessment and stabilization. Air ambulance services are commonly used to expedite interfacility transport of injured patients to trauma centers. Little is known of the types of delays experienced during interfacility transports. The purpose of this study was to identify specific causes of modifiable delays and estimate the attributable time associated with each of these delays.Methods: This was a retrospective cohort study of injured patients undergoing interfacility transfer to a trauma center who were transported by a provincial air ambulance service between January 1, 2014 and December 31, 2016. Electronic patient care records were screened and then manually reviewed to identify causes of delay during the interfacility transport process. The attributable time for each of these delays was also estimated.Results: There were 932 injured patients emergently transported by air ambulance from a community hospital to a trauma center over the 3-year study period from which 458 unique causes of delay that were identified. The most frequent cause of delays to sending facility were refueling (38%), waiting for land emergency medical services escort (25%) and weather (12%). The most common in-hospital delays included waiting for documentation (32%), delay to intubate (15%), medically unstable patient (13%) and waiting for diagnostic imaging (12%). The most frequent delays to receiving/handover included waiting for land EMS escort (31%), trauma team not assembled (24%) and weather (17%). In-hospital delays with the longest average length of delay included chest tube insertion (53 minutes), intubation (49 minutes) and delays for diagnostic imaging (46 minutes).Conclusions: In conclusion, we identified numerous modifiable causes of delay during interfacility transport. Efforts to reduce these delays can be made at both the air ambulance and hospital levels.

Patient, Paramedic and Institutional Factors Associated with Delays in Interfacility Transport of Injured Patients by Air Ambulance.

Background: Air ambulance services are commonly used to expedite interfacility transport of injured patients to trauma centers. There is a lack of evidence surrounding risk factors for delays in interfacility transport of these patients. The purpose of this study was to examine patient, paramedic, and institutional-related characteristics for delay and identify specific causes of delays in interfacility transfers by air ambulance. Methods: This was a retrospective cohort study of injured patients undergoing interfacility transfer to a trauma center who were transported by air ambulance. Quantile regression was used to evaluate the impact of patient, paramedic and institutional characteristics on various time intervals of the interfacility transport process. Results: There are three key findings in our study. First, the use of rotor-wing aircraft and hospital-based helipads had substantially lower transport times. Second, transports from academic centers take longer compared to sending facilities with fewer resources. Third, interfacility transport times are heavily skewed and delays disproportionately affect longer patient transports. Conclusions: Ventilator dependence, paramedic level of care, classification of sending facility and helipad availability are associated with delays to interfacility transport of injured patients. Efforts can be made at both the air ambulance and institutional levels to ensure timely and efficient transports.

Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses.

BACKGROUND: Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma. STUDY DESIGN AND METHODS: Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified. CONCLUSIONS: Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.

Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data.

OBJECTIVES: To compare the risk of death by suicide in male veterans with age-matched civilians. DESIGN: Retrospective cohort study linking provincial administrative databases between 1990 and 2013 with follow-up complete until death or December 31, 2015. SETTING: Population-based study in Ontario, Canada. PARTICIPANTS: Ex-serving Canadian Armed Forces and Royal Canadian Mounted Police veterans living in Ontario who registered for provincial health insurance were included. A civilian comparator group was matched 4:1 on age and sex. MAIN OUTCOME: Death by suicide was classified using standard cause of death diagnosis codes from a provincial registry of mandatory data collected from death certificates. Fine and Gray sub-distribution hazards regression compared the risk of death by suicide between veterans and civilians. Analyses were adjusted for age, residential region, income, rurality and major physical comorbidities. RESULTS: 20 397 male veterans released to Ontario between 1990 and 2013 and 81 559 age-sex matched civilians were included. 4.2% of veterans died during the study time frame, compared with 6.5% of the civilian cohort. Death by suicide was rare in both cohorts, accounting for 4.6% and 3.6% of veteran and civilian deaths, respectively. After adjustment for confounders, veterans had an 18% lower risk of dying from causes other than suicide (HR 0.82, 95% CI 0.76 to 0.89) and a similar risk of dying by suicide (HR 1.01, 95% CI 0.71 to 1.43), compared with civilians. CONCLUSIONS: Deaths by suicide were rare in male veterans residing in Ontario. Our findings demonstrate that veterans had a similar risk of suicide-related mortality as an age-matched civilian population. A better understanding of effective suicide prevention as well as clarifying pathways to seeking and receiving mental health supports and services are important areas for future consideration.