Redlener, Michael

Previous studies about the COVID-19 pandemic on STEMI patient outcomes have conflicting results. It remains unclear if this may be attributed to regional differences and/or differences during COVID-19 wave periods. Using the American Heart Association Get With The Guidelines–Coronary Artery Disease registry data, we evaluated (1) time metrics related to STEMI system goals and (2) regional variation in STEMI incidence and in-hospital mortality during pandemic wave time periods. The study included all patients 18–100 years old admitted with STEMI (n = 72,516) to 1 of 435 American Heart Association Get With The Guidelines–Coronary Artery Disease hospitals (1 October 2019–31 December 2021). Of these, 70.8% were male and 73.0% non-Hispanic White, with a median age of 63 (IQR 18) years. Compared to pre-pandemic time frames, patients with STEMI had a higher risk profile, delayed time to treatment, were treated with fibrinolytic therapy or primary PCI, and were transferred for primary PCI at similar rates, and had higher adjusted in-hospital mortality (during the second wave in the South and Midwest). Preservation of STEMI systems of care resulted in an overall lower in-hospital mortality rate than predicted, although opportunities exist to improve treatment delays. Regional differences in mortality rates require further study.

Introduction: There has been a shift in prehospital systems of care to prioritize transporting acute ischemic stroke (AIS) patients with suspected emergent large vessel occlusion (ELVO) stroke to thrombectomy capable stroke centers (TSCs), as opposed to primary stroke centers (PSCs) which may be closer and offer intravenous thrombolysis faster. Large scale data on clinical outcomes in direct triage are lacking. Methods: We conducted a systematic review and meta-analysis using PRISMA guidelines with the Nested Knowledge AutoLit platform to search PubMed for relevant terms from 01/2015 to 05/2022. Our primary endpoint was proportion of patients with a good clinical outcome [modified Rankin Score (mRS) 0-2] at 90 days. Results: We identified 390 studies, 16 of which compared direct triage to various models and were included. Amongst these, Mobile Stroke Unit (MSU; n=1), Mothership only (n=1), Drip-and-Ship only (n=3), and Mothership + Drip-and-Ship (n=11) were compared to Direct Triage. Among the eleven that reported 90-day functional status outcomes, there were no discernible trends. Four studies that compared 90-day functional outcomes amongst patients who received EVT and compared Direct Triage to Drip-and-Ship + Mothership models were analyzed. Baseline age, sex, and presenting NIHSS were similar. Patients who underwent Direct Triage were more likely to have a good outcome (mRS 0-2) at 90-days (OR 1.35, 95% CI 1.03-1.76). Conclusions: Amongst patients who received EVT, patients who underwent Direct Triage were more likely to have better functional outcomes at 90 days. Direct Triage of AIS patients is a promising strategy to improve clinical outcomes in patients who undergo EVT. More research is needed in patients who do not receive EVT.

AbstractObjectivesParamedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is a need for disaster triage training. Live simulation training is costly and difficult to deliver. Screen‐based simulations may overcome these training barriers. We hypothesized that a screen‐based simulation, 60 Seconds to Survival (60S), would be associated with in‐game improvements in triage accuracy.MethodsThis was a prospective cohort study of a screen‐based simulation intervention, 60S. Participants included emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participants performed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in each scenario and assigned color‐coded triage levels (red, yellow, green, or black) to each patient. Participants received on‐screen feedback about triage performance immediately after each scenario. A scoring system was designed to encourage accurate and timely triage decisions. Participants who played 60S included practicing EMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the game at least three times over 13 weeks.ResultsIn total, 2,234 participants began game play and 739 completed the study and were included in the analysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three or more plays) with a median of four plays during the study period (interquartile range [IQR] = 3–7). There was a significant difference in triage accuracy from the first play of the game to the last play of the game. Median baseline triage accuracy in the game was 89.7% (IQR = 82.1%–94.9%), which then increased to a median of 100% at the last game play (IQR = 87.5%–100.0%; p < 0.001). There was some variability in median triage accuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, the median accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3% (IQR = 5.1%–18.0%) to 0 (IQR = 0%–12.5%; p < 0.001).Conclusion60 Seconds to Survival is associated with improved in‐game triage accuracy. Further study of the correlation between in‐game triage accuracy and improvements in live simulation or real‐world triage decisions is warranted.