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Emergency Medical Services Time on Scene Associated with Reduced Dead-on-Arrival Status Among Pediatric Patients with
Vikas N Vattipally1, Kathleen R Ran1, Saket Myneni1
1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
Longer emergency medical services (EMS) scene times for pediatric severe traumatic brain injury (TBI) patients were linked to lower odds of being dead on arrival. This suggests on-scene stabilization may improve outcomes, challenging rapid transport assumptions.
Area of Science:
- Pediatric emergency medicine
- Trauma surgery
- Public health
Background:
- Severe traumatic brain injury (TBI) is a major cause of death in children.
- The influence of emergency medical services (EMS) prehospital times on pediatric TBI survival is not well understood.
- Investigating prehospital care practices is crucial for improving outcomes in pediatric severe TBI.
Purpose of the Study:
- To examine the association between EMS time on scene and mortality (dead-on-arrival status) in pediatric severe TBI patients.
- To explore how social determinants of health may impact prehospital care for these patients.
- To understand the relationship between EMS scene duration and survival probability.
Main Methods:
- Retrospective cohort study utilizing data from the American College of Surgeons Trauma Quality Improvement Program (2017-2022).
- Inclusion of pediatric patients (<18 years) with severe TBI (Glasgow Coma Scale ≤8).
- Hierarchical logistic regression and random forest models were used to analyze the association between EMS time on scene and dead-on-arrival status, with LOESS plots for visualization.
Main Results:
- Of 1,225 pediatric severe TBI patients, 5.6% were dead on arrival.
- Increased EMS time on scene was associated with decreased odds of being dead on arrival (OR, 0.92; P=0.025).
- A non-linear relationship was observed, with survival probability increasing up to ~12 minutes on scene before plateauing and decreasing; racial disparities in scene times and air medical dispatch were noted.
Conclusions:
- EMS time on scene, up to a certain duration, is associated with reduced mortality in pediatric severe TBI patients, likely due to on-scene stabilization.
- These findings question the sole reliance on rapid transport and highlight the importance of prehospital interventions.
- Significant racial disparities in EMS scene times and ambulance dispatch necessitate further investigation into equitable prehospital care practices.
Objectives:
Severe traumatic brain injury (TBI) is a leading cause of mortality among the pediatric population, and the impact of emergency medical services (EMS) prehospital times on patient survival remains unclear. The objective of this study was to determine associations between EMS time-on-scene and mortality during transport (i.e., dead-on-arrival [DOA] status) among pediatric patients with severe TBI. We also sought to investigate potential effects of social determinants of health on prehospital care practices.
Methods:
This was a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program (2017-2022). Pediatric (<18 years old) patients with severe (Glasgow Coma Scale ≤8) TBI were included in our analyses. We constructed a hierarchical logistic regression model for associations with DOA status. Expecting a potential non-linear relationship between EMS time on scene and odds of presenting DOA, we trained a random forest model to predict survival probability as a function of time on scene and visualized the results with a locally estimated scatterplot smoothing (LOESS) plot. Secondary analyses were performed to investigate demographic associations with EMS time on scene and dispatch of a helicopter ambulance.
Results:
Among 1,225 pediatric patients with severe TBI (median age, 13 years), 5.6% (N = 69) presented with DOA status. Longer EMS time on scene was associated with decreased odds of DOA (odds ratio [OR], 0.92; 95% CI, 0.85-0.99; p = 0.025). The LOESS plot revealed a non-linear relationship between EMS time on scene and survival probability, with EMS times associated with increasing survival up to approximately 12 min, then plateauing and subsequently decreasing. Black and Hispanic patients experienced shorter EMS scene times (p = 0.008 and p = 0.018, respectively), and all non-White patients had lower odds of air medical service dispatch (all p < 0.001).
Conclusions:
Longer EMS time on scene, to a certain point, was associated with lower odds of presenting DOA among pediatric patients with severe TBI, potentially due to increased stabilization measures performed on scene. These results challenge the assumption that expedited transport to a trauma center alone optimizes patient outcomes. Moreover, racial disparities in EMS scene times and ambulance dispatch type highlight a need for further research into prehospital care practices.
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