Drip ‘n Ship Versus Mothership for Endovascular Treatment Modeling the Best Transportation Options for Optimal Outcomes

786 patients met criteria for previous criteria of severe sepsis (2+ elements of SIRS and blood lactate > 2mmol/L). In-hospital mortality across the study group was 8%. Patients with qSOFA scores <2 had a mortality rate of 3% (95% confidence interval [CI] 2%-5%) vs 24% (95% CI 18%-30%) for patients with qSOFA score of >/= 2. The qSOFA score demonstrated a sensitivity of 70% (95% CI 59%-80%) and specificity of 79% (76%-82%) for predicting in-hospital mortality when compared to SOFA (sensitivity 73%, 95% CI 61%-83%) and specificity of 70% (95% CI 67%-73%). The study determined that a qSOFA score of 2 or higher was associated with in-hospital mortality with a hazard ratio (HR) of 6.2 (95% CI 3.8-10.3). The authors concluded that the qSOFA score demonstrated superior prognostic accuracy of in-hospital mortality for patients presenting to the ED with suspected infection when compared to SIRS or severe sepsis scoring. These findings further support the use of Sepsis-3 criteria in the ED. [Christian Magallanes, MD Denver Health Medical Center, Denver, CO] Comments: This study provides significant support for the work presented by the Sepsis-3 task force for the application of qSOFA to patients in the ED. Previous efforts by the Sepsis-3 task force were not prospectively validated resulting in reluctance of some ED clinicians to implement their proposed prognostic strategy. Future investigation specific to patients that were discharged home from the ED may be useful in determining the efficacy of qSOFA as a screening tool. , DRIP ‘N SHIP VERSUS MOTHERSHIP FOR ENDOVASCULAR TREATMENT MODELING THE BEST TRANSPORTATION OPTIONS FOR OPTIMAL OUTCOMES. Milne, M , Holodinsky J, Hill M, et al. Stroke. 2017;48:791-794 Ambiguity exists surrounding the optimal modality for stroke patients without access to Comprehensive Stroke Centers (CSC) to access endovascular therapy for acute ischemic stroke. The purpose of this study was to compare the level of benefit between early administration of alteplase at a Primary Stroke Center (PSC) [prior to transport to a CSC for endovascular treatment (EVT) (Drip ‘n Ship approach)] and the alternative of PSC bypass for direct transport to a CSC for EVT (Mothership approach). The authors generated mathematical models derived from the decay curves (onset-to-reperfusion / onset-to-treatment) for EVT/thrombolysis and generated visual data that modeled optimal forms of transportation as well the likelihood of positive outcomes. Emergency medical services (EMS) transport times were calculated using web-based software estimating models. Results of the study were generated as maps of Alberta and Ontario, Canada; as well as California, United States demonstrating the probability of favorable outcomes based upon the alternative transportation/management alternatives previously discussed. The Drip ‘n Ship model demonstrated similar outcomes to the CSC option when alteplase was administered

Abstracts at a PSC within 30 minutes of hospital arrival. Estimated probability of positive outcomes declined as distance to CSC increases. Confounding factors included door to needle time (DNT) at both PSC and CSC depending on facility capabilities and workflow. Results varied based upon regional access to PSC and CSC as well as local EMS capabilities. The authors concluded that the Drip ‘n Ship model was superior to the CSC only modality when door-to-reperfusion times were greater than or equal to 70 minutes. Proximity of PSC to CSC was only significant when PSC demonstrated capability of DNT less than/equal to 30 minutes. [Christian Magallanes, MD Denver Health Medical Center, Denver, CO] Comment: This study helps to highlight the significance and efficacy of treatment of acute ischemic stroke when access to a CSC is limited. Additional studies comparing rotary wing / fixed wing transport times and alteplase decay curves for large vessel occlusion may add significant data to the model derived by the authors in this study. , EVALUATION OF RURAL VS URBAN TRAUMA PATIENTS SERVED BY 9-1-1 EMERGENCY MEDICAL SERVICES. Newgard CD, Fu R, Bulger E, et al. JAMA Surg. 2017;152:11-18 Previous studies have demonstrated a discrepancy in outcomes for trauma patients injured in rural versus urban settings. However many of the studies were outdated, retrospective or lacked the detail needed for an in-depth analysis. This study investigated differences in injury severity, triage ability, location of treatment and mortality for trauma patients injured in rural and urban settings. This was a preplanned secondary analysis of a prospective, consecutive patient cohort of 44 emergency medical services (EMS) and 28 hospitals located in 2 rural and 5 urban counties in Oregon and Washington between January and December 2011. Rural counties were defined by more than 60 minutes driving time to a level I or II trauma center and/or rural designation by Centers for Medicare & Medicaid Ambulance Fee Schedule by zip code. All injured children and adults utilizing 9-1-1 were included in the initial sample. The primary outcome was mortality. A representative sample was created using probability sampling design which included geographic region, triage status, age group and type of receiving hospital. Data was extracted from EMS reports, base calls, hospital records and trauma registries. Missing data was handled using multiple imputation. Confidence intervals were calculated using Rubin’s rules. The full EMS sample was 67,047 patients of which 1,971 patients were injured in rural areas and 65,076 patients were injured in urban areas. A total of 53,487 patients were transported to the hospital. From this subset, a probability sample of 17,633 patients was selected to describe emergency department (ED) and in-hospital care. The follow-up rate was 78.9%. The sensitivity of EMS field identification of patients who ultimately needed critical resources was 65.2% in rural settings and 80.5% in urban settings. The proportion of patients