Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon.
Prehosp Emerg Care. 2023;27(6):744-750. doi: 10.1080/10903127.2022.2113189. Epub 2022 Aug 29.
Direct medical oversight (DMO), where emergency medical services (EMS) clinicians contact a physician for real-time medical direction, is used by many EMS systems across the United States. Our objective was to characterize the recommendations made by DMO during out-of-hospital cardiac arrests (OHCA) and to determine their effect on EMS transport decisions and patient outcomes.
This is a secondary analysis of DMO call recordings from OHCA cases in the Portland, Oregon metropolitan area from January 1, 2018 to February 28, 2021. Data extracted from the audio recordings were linked to OHCA cases in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry). The primary outcomes are recommendations made by DMO: transport, continued field resuscitation, or termination of resuscitation (TOR). Secondary outcomes include EMS transport decisions, survival to hospital admission, and survival to hospital discharge. We used descriptive statistics, unpaired t-tests, and chi-square tests as appropriate for data analysis.
There were 239 OHCA cases for which DMO was contacted by EMS. The median time from EMS arrival to DMO contact was 25.6 min, and EMS requested TOR for 72.0% of patients. Compared to patients where EMS requested further treatment advice, patients for whom EMS requested TOR had poor prognostic signs including older age, asystole as an initial rhythm, and lower rates of transient return of spontaneous circulation prior to DMO call compared with cases where EMS did not request TOR. DMO recommended transport, continued field resuscitation, or TOR in 21.8%, 18.0%, and 60.2% of patients, respectively. Of the 239 patients, 59 (24.7%) were ultimately transported by EMS to the hospital, 14 (5.9%) survived to admission, and only 1 patient (0.4%) survived to hospital discharge and had an acceptable neurologic outcome (Cerebral Performance Category score of 2).
Patients for whom EMS contacts DMO for further treatment advice or requesting field TOR after prolonged OHCA resuscitation have poor outcomes, even when DMO recommends transport or further resuscitation, and may represent opportunities to reduce unnecessary DMO contact or patient transports. More research is needed to determine which OHCA patients benefit from DMO contact.
在美国，许多急救医疗服务（EMS）系统都采用直接医疗监督（DMO），即 EMS 临床医生实时联系医生以获得医疗指导。我们的目的是描述 DMO 在院外心脏骤停（OHCA）期间提出的建议，并确定这些建议对 EMS 转运决策和患者结局的影响。
这是对 2018 年 1 月 1 日至 2021 年 2 月 28 日波特兰，俄勒冈大都市区 OHCA 病例中 DMO 呼叫记录的二次分析。从音频记录中提取的数据与波特兰心脏骤停流行病学登记处（PDX Epistry）中的 OHCA 病例相关联。主要结局是 DMO 提出的建议：转运、继续现场复苏或终止复苏（TOR）。次要结局包括 EMS 转运决策、存活至入院和存活至出院。我们使用描述性统计、非配对 t 检验和卡方检验进行数据分析。
有 239 例 OHCA 病例由 EMS 联系 DMO。从 EMS 到达到 DMO 联系的中位时间为 25.6 分钟，EMS 请求 TOR 的患者占 72.0%。与 EMS 请求进一步治疗建议的患者相比，EMS 请求 TOR 的患者预后不良迹象更多，包括年龄较大、初始节律为心搏停止以及在 DMO 呼叫前短暂恢复自主循环的比例较低，与 EMS 未请求 TOR 的病例相比。DMO 分别建议转运、继续现场复苏或 TOR 的患者占 21.8%、18.0%和 60.2%。在 239 名患者中，59 名（24.7%）最终由 EMS 转运至医院，14 名（5.9%）存活至入院，只有 1 名患者（0.4%）存活至出院且神经功能结局可接受（Cerebral Performance Category 评分为 2）。
在长时间 OHCA 复苏后，EMS 联系 DMO 寻求进一步治疗建议或请求现场 TOR 的患者结局较差，即使 DMO 建议转运或进一步复苏，这可能代表减少不必要的 DMO 联系或患者转运的机会。需要进一步研究以确定哪些 OHCA 患者受益于 DMO 联系。
