Prehospital Emergency Care最新文献

{"title":"Consensus Guidelines for Prehospital Transfusion in Children: A Modified Delphi Study.","authors":"Christyn F Magill, Hanna Heintz, Joseph Finney, Mark Nimmer, Peter M Antevy, Lindsay D Clukies, Francis X Guyette, Romeo C Ignacio, Kathryn M Kothari, Manish I Shah, Jeffrey E Siegler, Jonathan R Studnek, John Su, Lorin R Browne","doi":"10.1080/10903127.2026.2729895","DOIUrl":"10.1080/10903127.2026.2729895","url":null,"abstract":"<p><strong>Objectives: </strong>Hemorrhagic shock is a leading cause of early trauma-related mortality in children, yet implementation of prehospital blood transfusion (PHT) in children is heterogenous and without consistent guidance. Limited pediatric-specific evidence and physiologic differences from adults have contributed to substantial variability among existing emergency medical services (EMS) protocols. The objective of this study was to develop expert consensus recommendations for identifying pediatric patients who may benefit from PHT.</p><p><strong>Methods: </strong>We conducted a modified Delphi consensus study using a multidisciplinary panel of 20 experts in pediatric surgery, pediatric emergency medicine, and EMS medicine. Investigators compiled candidate criteria from existing PHT protocols and expert input. We conducted iterative electronic surveys to achieve expert consensus. We predefined consensus thresholds as ≥80% agreement for inclusion and <50% for exclusion. We employed descriptive statistics to summarize responses across rounds.</p><p><strong>Results: </strong>The panel evaluated 208 candidate items and accepted 35 recommendations for inclusion over six rounds of voting. Consensus defined eligibility for PHT in children consisting of (1) known or suspected severe hemorrhage or major blood loss, (2) at least one indicator of shock following first-line hemorrhage control, and (3) EMS clinical judgment of the need for transfusion. Shock indicators included physiologic compromise, hemodynamic instability, poor perfusion, low cardiac output, or an abnormal validated pediatric shock index. Contraindications included do not resuscitate orders prohibiting transfusion and non-hemorrhagic shock. We were unable to reach consensus on routine inclusion of end-tidal carbon dioxide as an indication for transfusion.</p><p><strong>Conclusions: </strong>Experts came to consensus on pediatric-focused, pragmatic criteria to guide prehospital blood product transfusion in children. Implementation of these recommendations may reduce practice variability, support protocol development, and inform future prospective validation studies.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-8"},"PeriodicalIF":2.0,"publicationDate":"2026-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148945616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Robust Educational Initiative for EMS Clinicians Focusing on Pit-Crew CPR Improves Neurologically Intact Survival.","authors":"David H Yang, Yi-Hsuan Yen, Ross Logan, Joseph DeAngelis, Thomas Lardaro, Katherine Couturier, Daniel Joseph, Sarah Perman, Alexander R Nelson","doi":"10.1080/10903127.2026.2739421","DOIUrl":"10.1080/10903127.2026.2739421","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate whether the implementation of a region-wide pit-crew cardiopulmonary resuscitation (CPR) initiative was associated with improved survival to hospital discharge with good neurological function among adults with non-traumatic out-of-hospital cardiac arrest (OHCA) in a heterogenous, multi-agency emergency medical services (EMS) system in south-central Connecticut.</p><p><strong>Methods: </strong>We conducted a retrospective, before-and-after observational study using the Cardiac Arrest Registry to Enhance Survival (CARES). The pit-crew CPR intervention, comprising structured didactic and hands-on simulation-based training was delivered across 27 EMS agencies from September 28, 2021 through August 2, 2022. The primary outcome was survival to hospital discharge with good neurological function (Cerebral Performance Category 1-2). Secondary outcomes included survival to hospital discharge and sustained return of spontaneous circulation (ROSC). We performed an interrupted time series analysis using the beginning of our intervention (September 28, 2021) as the interruption to model. Multivariable logistic regression models were adjusted for age, sex, race, shockable initial rhythm, witnessed arrest, arrest location, and bystander CPR.</p><p><strong>Results: </strong>A total of 1917 adult non-traumatic OHCA patients (922 pre-intervention; 995 post-intervention) were resuscitated by EMS clinicians in the study period. In progression since intervention, there was a significant increase in neurologically intact survival per 4-month interval (adjusted odds ratio [OR] 1.20; 95% confidence interval [CI], 1.01-1.44), suggesting a gradual improvement in outcomes over time after protocol implementation. At intervention start, there was a significant increase in ROSC (aOR 1.41; 95% CI, 1.1-1.81). There was no change in survival to hospital discharge prior to the intervention, at the time of the intervention, or following the intervention.</p><p><strong>Conclusions: </strong>Implementation of a pit-crew CPR model across a heterogenous, multi-agency EMS system was associated with a significant gradual increase in neurologically intact survival in the post-intervention period, as well as a significant immediate improvement in ROSC at the time of protocol implementation. These findings support structured, team-based resuscitation as a feasible and effective strategy to improve cardiac arrest outcomes within existing EMS systems.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-7"},"PeriodicalIF":2.0,"publicationDate":"2026-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149040248","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Repeat 9-1-1 Calls and Clinical Outcomes of Children After Non-transport by Emergency Medical Services.","authors":"Jessica E P Williams, Trang Ha, James M Chamberlain, Caleb E Ward","doi":"10.1080/10903127.2026.2737688","DOIUrl":"10.1080/10903127.2026.2737688","url":null,"abstract":"<p><strong>Objectives: </strong>Pediatric non-transport by emergency medical services (EMS) is common but there are limited data assessing patient outcomes. Our primary objective was to determine the proportion of children not transported by EMS who have a repeat 9-1-1 call and transport within 72 h. Our secondary objective was to determine whether patient demographic or clinical characteristics are associated with repeat 9-1-1 call and transport.</p><p><strong>Methods: </strong>We conducted a retrospective cross-sectional study using the 2018-2022 ESO Data Collaborative research dataset. Of these records, one third are linked to hospital data which allowed for inclusion of discharge and ICD-10 diagnosis codes for some of the cases. We used descriptive statistics to compare cases (non-transported children aged 0-17 years with repeat 9-1-1 call and transport within 72 h) to controls (no repeat 9-1-1 call or repeat 9-1-1 call with non-transport). We conducted a multivariable logistic regression analysis to evaluate factors associated with a repeat 9-1-1 call and transport within 72 h. We generated descriptive statistics summarizing emergency department (ED) dispositions for the subset of patients where this data was available.</p><p><strong>Results: </strong>Of 1,849,925 pediatric 9-1-1 calls, 732,525 (40%) were not transported by EMS. Within 72 h, 7,544 (1%) had repeat 9-1-1 call with transport to the ED. Repeat 9-1-1 call was associated with young age (0-4 years), Black, non-Hispanic race, male sex, calls from areas with a very low Child Opportunity Index (Opportunity Index), calls during out-of-office hours, and neurologic primary impressions. There were 11 (0.1%) deaths on scene upon repeat 9-1-1 call within 72 h of initial non-transport. Of the 1,001 (13%) patients with hospital-linked data, 814 (89%) were discharged from the ED, 162 (16%) were hospitalized, and two (0.2%) died.</p><p><strong>Conclusions: </strong>Only 1% of children not transported by EMS had a repeat 9-1-1 call and transport within 72 h. Hospitalization and death after non-transport were rare. These results may inform the development of safe and efficient pediatric non-transport protocols.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-8"},"PeriodicalIF":2.0,"publicationDate":"2026-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149031224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Practice Patterns and Performance of Pediatric Air Medical Tracheal Intubation: A National Multisite Cohort Study.","authors":"Jeffrey Cloyd, Blake Briggs, Morgan Anderson, Jonathan Powell, Macall Leslie Salewon, Justin Gerard","doi":"10.1080/10903127.2026.2733969","DOIUrl":"10.1080/10903127.2026.2733969","url":null,"abstract":"<p><strong>Objectives: </strong>Pediatric prehospital advanced airway management is high-stakes and low-frequency. Prior analyses have been limited to single-agency air medical groups or ground emergency medical services cohorts. National air medical performance is not well described. The aim of this study is to characterize practice patterns and outcomes of pediatric air medical intubation across a national multisite cohort.</p><p><strong>Methods: </strong>This was a retrospective cohort study of pediatric (<18 years) intubation encounters performed by air medical crews and recorded in ImageTrend Collaborate, a multisite prehospital clinical data repository, from 2021 to 2025. First-pass success, overall intubation success, and post-attempt physiology defined as a composite of hypoxia, age-adjusted hypotension, and age-adjusted bradycardia within 10 min after index attempt were summarized as <i>n</i>(%) or median (interquartile range [IQR]) and compared across four age groups (<1, 1-5, 6-10, 11-17 years) using chi-square or Fisher's exact tests. Site-level medication use was summarized among sites contributing 10 or more encounters.</p><p><strong>Results: </strong>Among 1,040 encounters from 39 contributing sites across four United States regions, median age was 13 years (IQR 5-16) and 57.7% involved trauma or burn. A sedative-plus-paralytic strategy was used in 77.8% (809/1,040) with ketamine the most common induction agent (43.5% ketamine-only, 31.9% etomidate-only). Video laryngoscopy was documented in 8.6% of intubations. First-pass success was 86.5% (898/1,038) and overall success was 93.3% (968/1,038). Performance varied significantly by age with first-pass success at 69.1% (47/68) in infants under 1 year versus 88.7% (535/603) in adolescents (<i>p</i> < 0.001), overall success 80.9% (55/68) versus 93.9% (566/603), respectively (<i>p</i> < 0.001), and post-attempt physiologic instability 53.6% (30/56) versus 31.3% (175/560) respectively (<i>p</i> = 0.008). Post-attempt end-tidal carbon dioxide (ETCO2) within 10 min was documented in 82.8% (861/1,040) overall, and 60.0% (42/70) in infants (<i>p</i> < 0.001). Among the 13 sites with 10 or more encounters, peri-attempt ketamine share ranged from 9% to 84% and succinylcholine share from 0% to 91%.</p><p><strong>Conclusions: </strong>In this national multisite air medical cohort, overall airway performance was favorable, but infants younger than 1 year had lower first-pass success, lower overall intubation success, and less frequent post-intubation ETCO2 documentation. Substantial practice variation across contributing sites suggests opportunity for both targeted training in the infant subgroup and benchmarking across sites.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-8"},"PeriodicalIF":2.0,"publicationDate":"2026-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148991081","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prehospital Minithoracostomy versus Chest Drainage for Emergency Pleural Decompression in Major Trauma.","authors":"Serena Tomasino, Daniele Orso, Maria Grandesso, Carlo Pegani, Annarita Tullio, Gabriele Simeoni, Chiara Molinari, Samantha Saffer, Sabrina Fantin, Alessio Sappada, Alessandra Spasiano, Giorgio Della Rocca","doi":"10.1080/10903127.2026.2739424","DOIUrl":"10.1080/10903127.2026.2739424","url":null,"abstract":"<p><strong>Objectives: </strong>Prehospital pleural decompression is life-saving in patients with suspected tension pneumothorax or other life-threatening thoracic pressure pathology after major trauma. Although prehospital minithoracostomy (PHMT) is increasingly adopted by physician-led helicopter emergency medical services (HEMS), comparative evidence with prehospital chest drainage (PHCD) remains limited.</p><p><strong>Methods: </strong>We conducted a retrospective observational cohort study of consecutive adult trauma patients undergoing prehospital pleural decompression within a physician-led HEMS between January 2018 and December 2024, managed with PHMT or PHCD according to clinical judgment. The primary outcome, scene time, was analyzed using Bayesian robust Student-t regression; recorded complications and survival were analyzed using Bayesian beta-binomial models, with posterior risk differences and credible intervals.</p><p><strong>Results: </strong>Ninety-four patients were included (66 PHMT; 28 PHCD). After excluding two implausible zero-minute scene-time records, the posterior median difference in scene time was -5.9 min (95% credible interval [CrI], -13.8 to 1.7; 94.0% probability PHMT was shorter). Complication status was evaluable in 50/66 PHMT and 10/28 PHCD patients. Recorded complications occurred in 0/50 evaluable PHMT and 6/10 evaluable PHCD patients (risk difference -58.7 percentage points, 95% CrI -83.9 to -29.3; probability >99.9% that recorded complications were less frequent with PHMT). Prehospital survival was lower with PHMT, reflecting greater baseline severity, whereas no clear differences were observed at 1, 30, or 90 days.</p><p><strong>Conclusions: </strong>Prehospital minithoracostomy was not associated with longer scene time and was associated with fewer recorded complications than PHCD. Because allocation was nonrandomized, complication ascertainment differed between procedures, and few events occurred, these findings are hypothesis-generating rather than evidence of comparative safety. Prospective multicenter studies with standardized indications and systematic outcome assessment are warranted.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-7"},"PeriodicalIF":2.0,"publicationDate":"2026-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149040287","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"2026 Systematic Review of Evidence-Based Guidelines for Prehospital Care.","authors":"Christian Martin-Gill, P Daniel Patterson, Christopher T Richards, Samuel T Bishop, Benjamin T Potts, Rebecca E Cash","doi":"10.1080/10903127.2026.2731488","DOIUrl":"10.1080/10903127.2026.2731488","url":null,"abstract":"<p><strong>Objectives: </strong>Evidence-based guidelines (EBGs) are widely regarded as a valuable means of translating scientific evidence to clinical practice. Efforts continue to promote the development and implementation of new EBGs across all aspects of emergency medical services (EMS), but with variable quality and gaps in the content addressed by existing EBGs. We performed a biennial systematic review of prehospital EBGs to identify and assess the quality of EBGs published between 2023 and 2025 that can inform prehospital clinical care and operations.</p><p><strong>Methods: </strong>We used a systematic review study design and searched Ovid Medline, EMBASE, and CINAHL from January 1, 2023, to May 21, 2025, for prehospital EBGs providing recommendations following an organized review of relevant literature. We appraised the quality of published EBGs with adapted criteria of the National Academy of Medicine (NAM) and the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool.</p><p><strong>Results: </strong>In total, 71 new EBGs were identified. These addressed a variety of EMS clinical and operational topics. Most EBGs (<i>n</i> = 67, 94.4%) addressed clinical topics of EMS medicine, with a focus on time-life critical conditions (<i>n</i> = 45, 63.4%), along with injury and special clinical considerations (<i>n</i> = 37, 52.1% each). About half (<i>n</i> = 37, 52.1%) met all adapted NAM criteria for high-quality EBGs, of which 32 (86.5%) represented compilations of guidelines related to cardiopulmonary resuscitation, emergency cardiovascular care, and trauma. The mean AGREE II overall domain score was 70.9% (SD 11.4%), and 30 (42.3%) EBGs had an average domain score above 75%. These 71 new EBGs demonstrated incremental improvement in the NAM criteria and AGREE II scoring compared to the 178 EBGs identified in previous reviews.</p><p><strong>Conclusions: </strong>This updated systematic review identified many published EBGs intended for EMS. These EBGs were overall of higher quality than those previously published, and their appraisal continues to yield important findings that can serve to inform guideline developers on how to continually improve the quality of prehospital EBGs. The high-quality EBGs identified in this review should serve as targets to promote the dissemination and implementation of evidence-based recommendations, inform prehospital protocol development, and guide the initial certification and continuing education of EMS personnel.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-12"},"PeriodicalIF":2.0,"publicationDate":"2026-10-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148945644","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Response to: \"Performance of Termination-of-Resuscitation Rules in Foreign Body Airway Obstruction-Related Out-of-Hospital Cardiac Arrest: A Prospective Multicenter Registry Analysis\" by Soliven et al.","authors":"Chee-Fah Chong","doi":"10.1080/10903127.2026.2737694","DOIUrl":"10.1080/10903127.2026.2737694","url":null,"abstract":"","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-3"},"PeriodicalIF":2.0,"publicationDate":"2026-10-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149031246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Deviations From Recommended Drug Dosing in the Prehospital Treatment of Pediatric Patients.","authors":"Michael F Spigner, Mitchell W Butterbaugh, Nicholas A Genthe, Adam M Brown, Michael Lohmeier, Craig Tschautscher, Sriram Ramgopal, Megan Yank, Megan L Barthels, Gregory J Raupp, Joseph Stearns, Michael K Kim","doi":"10.1080/10903127.2026.2740143","DOIUrl":"10.1080/10903127.2026.2740143","url":null,"abstract":"<p><strong>Objectives: </strong>Pediatric medication safety is a priority area for research and quality improvement in emergency medical services (EMS). While medication errors may occur due to active failures, latent drivers of deviations from recommended dosages (DRD) are incompletely understood. We sought to understand the prevalence of DRDs and the factors associated with them.</p><p><strong>Methods: </strong>We performed a retrospective cohort study of patients included in a quality improvement registry for prehospital pediatric medication safety. We included nine EMS agencies with uniform patient care protocols providing 9-1-1 services to the metropolitan area of a midsized city in the U.S. Our primary outcome was the prevalence of DRDs (doses ≥20% above or below protocolized doses). We identified DRDs by checking weight-based doses against weight-based and absolute thresholds. We assessed the prevalence of DRDs by medication, age, clinician impression, and administration route. We assessed associations between these factors and DRDs with logistic regression, then performed adjusted analyses with generalized linear mixed models. We assessed the relationship between weight estimation error and DRDs with a linear mixed model. We explored the potential effect of fixed-dosage formulations, full-vial doses, and volumetric limits of intranasal administration on DRDs.</p><p><strong>Results: </strong>We analyzed 386 medication administrations for 240 patients. The overall prevalence of DRDs was 46.4% (<i>n</i> = 179), and most were underdoses (<i>n</i> = 143, 79.9%). Among common medications, the number and prevalence of DRDs were: ondansetron (<i>n</i> = 29, 85.3%), midazolam (<i>n</i> = 35, 50.0%), fentanyl (<i>n</i> = 55, 45.5%), and epinephrine (<i>n</i> = 26, 44.8%). The DRDs were most common <i>via</i> the intranasal route (<i>n</i> = 62, 69.7%) and among school-aged children (<i>n</i> = 50, 55.6%). Ondansetron (aOR 36.9, 95%CI 6.3-217.6) and the intranasal route (aOR 7.3, 95%CI 2.9-18.6) were associated with higher odds of DRDs. We found no association between weight estimation error and DRDs. Exclusion of potential fixed-dosage formulations and full-vial doses was associated with fewer DRDs (81.6% vs. 42.5%). Only 2% of intranasal fentanyl DRDs could be explained by volumetric limits.</p><p><strong>Conclusions: </strong>We observed DRDs to be common in the prehospital treatment of children, and they varied by medication and route. Possible latent sources of error include protocol design, medication formularies, and heuristics. The clinical significance of DRDs is uncertain.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-10"},"PeriodicalIF":2.0,"publicationDate":"2026-10-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149081845","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Redesigning 9-1-1 Paramedic Pathways: Evaluation of the IMPACC Model of Care.","authors":"Walter Tavares, Yousif Saad, Doris Xu, Natalie Kedzierski, Tarik Masud, Chris Spearen, Matthew Leyenaar, Sanne Kaas-Mason, Phil Moran, Pablo Galvez-Hernandez","doi":"10.1080/10903127.2026.2719958","DOIUrl":"10.1080/10903127.2026.2719958","url":null,"abstract":"<p><strong>Objectives: </strong>Paramedic services remain organized around rapid response, time-sensitive events, and hospital conveyance despite increasing 9-1-1 use for lower-acuity and undifferentiated presentations. There is a need to improve the alignment of paramedic services for patients seeking non-emergency care <i>via</i> the 9-1-1 system. A redesigned model of care to improve patient care in the community (IMPACC) was embedded within an existing 9-1-1 system to expand paramedic clinical care and decision architecture. This study evaluated whether IMPACC improved alignment between patient need and care pathway selection.</p><p><strong>Methods: </strong>We conducted a retrospective observational cohort study as an implementation evaluation of an embedded 9-1-1 model of care using encounters attended by IMPACC-trained paramedics from April 2024 to February 2026. Encounters were classified by IMPACC activation status and compared within the same operational environment. Analyses examined patient characteristics, clinical selectivity, disposition, care intensity, operational time, 72-h repeat contact, paramedic-level heterogeneity, and temporal trends. A secondary exact-matched analysis compared IMPACC activations with standard-practice controls.</p><p><strong>Results: </strong>Of 7,382 encounters, IMPACC was activated in 9.9%, increasing to 12.6% among CTAS 3-5 encounters and 28.3% among the top quartile of paramedics. Activation was concentrated among clinically ambiguous complaints. Overall, IMPACC-activated encounters had lower hospital transport rates than non-activated encounters (36.4% vs. 81.7%) and greater clinical engagement. In the exact-matched analysis, IMPACC activations remained less likely to result in transport than standard-practice controls (42.9% vs. 79.2%). Median total time on task was longer under IMPACC in both the within-cohort comparison (90.0 vs. 66.5 min) and matched comparison (92.0 vs. 62.0 min) but narrowed over time. Repeat 72-h contact was 4.0%. Paramedic-level heterogeneity persisted after case-mix adjustment (ICC 0.33; MOR 3.39), and activation declined over time (OR per month 0.94).</p><p><strong>Conclusions: </strong>This study demonstrates that an embedded redesign of 9-1-1 paramedic care can expand pathway options at the point of emergency access and redistribute care from default hospital conveyance toward structured on-scene assessment, consultation, discharge, and referral pathways with an increase investment of time on task. Sustained impact will require implementation support and governance, cross-sector integration, and alignment-focused performance metrics.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-11"},"PeriodicalIF":2.0,"publicationDate":"2026-10-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148991113","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Combined NRB and Nasal Cannula Oxygen Delivery Is Inferior to Flush Rate NRB for Emergency Preoxygenation.","authors":"Andrew M Pearson, Eli R Haddorff, Alec J Bunting, Brian E Driver, Matthew E Prekker, Jake L Johnson, Aaron E Robinson","doi":"10.1080/10903127.2026.2739419","DOIUrl":"10.1080/10903127.2026.2739419","url":null,"abstract":"<p><strong>Objectives: </strong>Although preoxygenation with a non-rebreather (NRB) mask at flush rate (≥ 50 L/min) is an effective and straightforward technique, it is not always feasible in situations where airway management must be performed away from the ambulance, when only portable oxygen tanks are available. To achieve a combined total flow of ≥50 L/min, some experts have advocated the use of a NRB mask in combination with a nasal cannula, both at 25 L/min. This technique has not been compared to preoxygenation using flush rate oxygen. This study sought to determine whether preoxygenation using both a NRB mask and nasal cannula at total flow rates of up to 50 L/min is non-inferior to preoxygenation using a NRB mask alone at flush rate.</p><p><strong>Methods: </strong>We performed an experimental crossover study using healthy volunteers. Participants underwent the following 3-min preoxygenation trials: NRB at flush rate oxygen; NRB and nasal cannula each at 15 L/min; NRB and nasal cannula each at 25 L/min. Oxygen was delivered <i>via</i> a standard ambulance oxygen system and a wall-mounted flowmeter. The primary outcome was the fraction of expired oxygen (FeO₂), measured at the end of each trial. We compared the FeO₂ obtained using a NRB at flush rate to the other methods using a pre-specified non-inferiority margin of 10%.</p><p><strong>Results: </strong>We enrolled 30 participants. Mean FeO₂ values for NRB at flush rate, NRB + nasal cannula at 15 L/min, and NRB + nasal cannula at 25 L/min were 85% (95% confidence interval [CI] 83-87%), 68% (95% CI 66-71%), and 75% (95% CI 71-78%), respectively. The FeO₂ values achieved using the NRB + nasal cannula at 15 and 25 L/min were inferior to NRB at flush rate (FeO₂ differences of 16%, 95% CI 13% to 20%; and 10%, 95% CI 6% to 14%, respectively).</p><p><strong>Conclusions: </strong>In healthy volunteers, combining a NRB mask with nasal cannula with each at either 15 L/min or 25 L/min provides inferior preoxygenation compared with an NRB mask alone at flush rate oxygen. When available, flush rate NRB should remain the preferred preoxygenation strategy for spontaneously breathing patients in the prehospital setting.</p>","PeriodicalId":20336,"journal":{"name":"Prehospital Emergency Care","volume":" ","pages":"1-5"},"PeriodicalIF":2.0,"publicationDate":"2026-10-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149040314","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}