Emergency Medical Service (EMS) systems in developed and developing countries

Ambulance services for road traffic injury (RTI) victims in Bangladesh: a cross-sectional study on the ground realities and the way forward

INTRODUCTION

Swift and safe transport of road traffic injury patients for life-saving interventions requires a functioning ambulance system which is largely lacking in the low- and middle-income countries. This study explored the current situation of ambulance-based prehospital care services in Bangladesh to inform the development of an evidence-based national ambulance system.

METHODS

A cross-sectional study conducted in five selected districts of Bangladesh, employing qualitative and quantitative approaches, elicited data on the 29 ambulances and the knowledge and skills of their operators. Findings were validated through 32 key informant interviews with relevant stakeholders on their experiences and insights towards developing a national ambulance system in the country.

RESULTS

Most of the ambulances were 'makeshift ambulances' (converted microbus) and commonly lacked the necessary supplies and equipment, including a Global Positioning System tracker or location identifier system. Around 20 drivers had 10+years of work experience, but none were trained in first-aid. Some drivers developed a few life-saving skills like removing foreign bodies from the airway or immobilising fractured limbs, etc from work experiences. The public sector ambulances were mostly used for transporting referral patients and, quite frequently, for transporting staff. Public ambulances had government-determined fixed rates, whereas private ambulances did not. The responsible authority/operator for the public sector ambulances was ambiguous and not coordinated by any local/central authority.

CONCLUSION

The 'ambulance' service in the country is rudimentary, fragmented and poorly resourced, lacking any central/regional level coordination. A recommendation is made to develop a national ambulance service, integrating public and private sectors and operating under a central/regional authority.

Comparison of Interfacility Transfer of Critically Ill Pediatric Patients by Helicopter Versus Ground Ambulance in a Remote and Rural Domain

OBJECTIVE

Since 2018, Thailand's helicopter emergency medical service (HEMS) has been used to transport critically ill pediatric patients from Tak Province's community hospitals to the tertiary care hospital. This article describes a pilot study to look at the feasibility of comparing mortality rates and complications during transport.

METHODS

This retrospective pilot study used data from the medical records of the referring and receiving hospitals. Participants were critically ill patients under 18 years of age who were transferred between facilities using HEMS or ground emergency medical services (GEMS) between January 2018 and December 2022. HEMS transported 9 patients, whereas GEMS transported 52.

RESULTS

The predominant age group was newborns. Respiratory-related conditions were the most common diagnoses. The majority of patients underwent intubation and displayed abnormal respiratory rates and levels of consciousness before flight. Approximately one third were hypotensive or required vasoactive drugs. Cardiac arrest requiring cardiopulmonary resuscitation was the most common significant complication during transport in the HEMS group (22.2%). Meanwhile, changing hospital destination because of an unstable patient condition was the most common complication during transport in the GEMS group (3.9%). Hypotension was the most common complication upon arrival at the receiving hospital in both groups (25% versus 8%). HEMS demonstrated shorter transport times.

CONCLUSION

HEMS reduced transport times compared with GEMS. However, there was a higher incidence of cardiac arrest requiring cardiopulmonary resuscitation during transfer and hypotension upon arrival.

Consequences of the COVID-19 pandemic on the mental health of nurses in the Spanish out-of-hospital Emergency Service

OBJECTIVE

To analyse the impact of the COVID-19 pandemic on the mental health of nurses in Spanish out-of-hospital Emergency Services, identifying predictor factors of greater severity.

METHOD

A multicentre cross-sectional descriptive study was designed, including all nurses working in any Spanish out-of-hospital Emergency Services between 01/02/2021 and 30/04/2021. The main outcomes were the level of depression, anxiety and stress assessed through the DASS-21 scale. Sociodemographic, clinical, and occupational information was also collected. Univariate and multivariate analyses were conducted to determine possible associations between variables.

RESULTS

The sample included 474 nurses. 32.91%, 32.70% and 26.33% of the participants had severe or extremely severe levels of depression, anxiety and stress, respectively. Professionals with fewer competencies to handle stressful situations, those who had used psychotropic drugs and/or psychotherapy on some occasion before the pandemic onset, or those who had changed their working conditions presented more likelihood of developing more severe levels of depression, anxiety and/or stress.

CONCLUSION

Nurses in Spanish out-of-hospital Emergency Services have presented medium levels of depression, anxiety and stress during the pandemic. Clinical and occupational factors have been associated with a higher degree of psychological distress. It is necessary to adopt strategies that promote professionals' self-efficacy and mitigate the triggers of negative emotional states.

Epidemiology of prehospital emergency calls according to patient transport decision in a middle eastern emergency care environment: Retrospective cohort-based

Background and Aim

Though emergency medical services (EMS) respond to all types of emergency calls, they do not always result in the patient being transported to the hospital. This study aimed to explore the determinants influencing emergency call-response-based conveyance decisions in a Middle Eastern ambulance service.

Methods

This retrospective quantitative analysis of 93,712 emergency calls to the Hamad Medical Corporation Ambulance Service (HMCAS) between January 1 and May 31, 2023, obtained from the HMCAS electronic system, was analyzed to determine pertinent variables. Sociodemographic, emergency dispatch-related, clinical, and miscellaneous predictors were analyzed. Descriptive, bivariate, ridge logistic regression, and combination analyses were evaluated.

Results

23.95% (N = 21,194) and 76.05% (N = 67,285) resulted in patient nontransport and transportation, respectively. Sociodemographic analysis revealed that males predominantly activated EMS resources, and 60% of males (n = 12,687) were not transported, whilst 65% of females (n = 44,053) were transported. South Asians represented a significant proportion of the transported patients (36%, n = 24,007). "Home" emerged as the primary emergency location (56%, n = 37,725). Bivariate analysis revealed significant associations across several variables, though multicollinearity was identified as a challenge. Ridge regression analysis underscored the role of certain predictors, such as missing provisional diagnoses, in transportation decisions. The upset plot shows that hypertension and diabetes mellitus were the most common combinations in both groups.

Conclusions

This study highlights the nuanced complexities governing conveyance decisions. By unveiling patterns such as male predominance, which reflects Qatar's expatriate population, and specific temporal EMS activity peaks, this study accentuates the importance of holistic patient assessment that transcends medical histories.

Predictive Dispatch of Volunteer First Responders: Algorithm Development and Validation

BACKGROUND

Smartphone-based emergency response apps are increasingly being used to identify and dispatch volunteer first responders (VFRs) to medical emergencies to provide faster first aid, which is associated with better prognoses. Volunteers' availability and willingness to respond are uncertain, leading in recent studies to response rates of 17% to 47%. Dispatch algorithms that select volunteers based on their estimated time of arrival (ETA) without considering the likelihood of response may be suboptimal due to a large percentage of alerts wasted on VFRs with shorter ETA but a low likelihood of response, resulting in delays until a volunteer who will actually respond can be dispatched.

OBJECTIVE

This study aims to improve the decision-making process of human emergency medical services dispatchers and autonomous dispatch algorithms by presenting a novel approach for predicting whether a VFR will respond to or ignore a given alert.

METHODS

We developed and compared 4 analytical models to predict VFRs' response behaviors based on emergency event characteristics, volunteers' demographic data and previous experience, and condition-specific parameters. We tested these 4 models using 4 different algorithms applied on actual demographic and response data from a 12-month study of 112 VFRs who received 993 alerts to respond to 188 opioid overdose emergencies. Model 4 used an additional dynamically updated synthetic dichotomous variable, frequent responder, which reflects the responder's previous behavior.

RESULTS

The highest accuracy (260/329, 79.1%) of prediction that a VFR will ignore an alert was achieved by 2 models that used events data, VFRs' demographic data, and their previous response experience, with slightly better overall accuracy (248/329, 75.4%) for model 4, which used the frequent responder indicator. Another model that used events data and VFRs' previous experience but did not use demographic data provided a high-accuracy prediction (277/329, 84.2%) of ignored alerts but a low-accuracy prediction (153/329, 46.5%) of responded alerts. The accuracy of the model that used events data only was unacceptably low. The J48 decision tree algorithm provided the best accuracy.

CONCLUSIONS

VFR dispatch has evolved in the last decades, thanks to technological advances and a better understanding of VFR management. The dispatch of substitute responders is a common approach in VFR systems. Predicting the response behavior of candidate responders in advance of dispatch can allow any VFR system to choose the best possible response candidates based not only on ETA but also on the probability of actual response. The integration of the probability to respond into the dispatch algorithm constitutes a new generation of individual dispatch, making this one of the first studies to harness the power of predictive analytics for VFR dispatch. Our findings can help VFR network administrators in their continual efforts to improve the response times of their networks and to save lives.

Exploring Disparities in Self-Reported Mental Health Symptoms Across Professional Categories in Spain's Emergency Medical Services: A Nationwide Cross-Sectional Study

OBJECTIVE

This study aimed to analyze stress, anxiety, depression, and self-efficacy levels among Spanish out-of-hospital emergency medical professionals from February 1, 2021, to April 30, 2021.

METHODS

A nationwide survey was completed by 1666 Emergency Medical Services (EMS) workers. The Depression, Anxiety, and Stress Scale (DASS-21) and the General Self-Efficacy Scale (GSE) were used. Data analysis used chi-squared, análisis of variance (ANOVA), and logistic regressions.

RESULTS

The sample comprised 833 (50%) men, with an average age of 44.3 ± 9.9 y (range: 19-67 y). Occupational distribution included 453 (27.2%) physicians, 474 (28.4%) nurses, and 739 (44.4%) emergency medical technicians (EMTs). EMTs exhibited higher odds of severe or extremely severe depression compared with physicians (odds ratio [OR]: 1.569; 95% confidenceinterval [95% CI]: 1.213-2.030) and nurses (OR: 1.561; 95% CI: 1.211-2.012). EMTs also displayed higher probabilities of severe or extremely severe anxiety compared with nurses (OR: 1.944; 95% CI: 1.529-2.701). Furthermore, EMTs demonstrated elevated probabilities of severe or extremely severe stress compared with physicians (OR: 1.387; 95% CI: 1.088-1.770). However, no significant differences were found in self-efficacy, with a median value of 73 [20].

CONCLUSIONS

Out-of-hospital EMS workers experienced mental health challenges, showing varying levels of depression, stress, and anxiety across different occupational groups. EMTs were particularly affected.

Pediatric trauma mortality in India and the United States: A comparison and risk-adjusted analysis

BACKGROUND

There is a paucity of research comparing pediatric risk-adjusted trauma mortality between high-income and low- and middle-income countries. This limits identification of populations and injury patterns for targeted interventions. We aim to compare independent predictors of pediatric trauma mortality between India and the United States (US).

METHODS

A retrospective cohort study was conducted for pediatric patients (age <18 years) in India's Towards Improved Trauma Care Outcomes (TITCO) project database and the US National Trauma Data Bank (NTDB) from 2013 to 2015. Demographic, injury, physiologic, anatomic and outcome data were analyzed. Multivariable regressions were used to determine independent predictors of mortality.

RESULTS

126,678 pediatric trauma patients were included (India 3,373; US 123,305). Pediatric patients in India were on average significantly younger, with a higher median injury severity score (ISS), had lower systolic blood pressure, and suffered a higher case fatality rate (13.0% vs. 1.0%). When controlling for demographic, mechanism, physiologic, and anatomic injury characteristics, sustaining an injury in India was the strongest predictor of mortality (OR 22.70, 95% CI 18.70-27.56). On subgroup analysis, the highest relative odds of mortality in India was seen in children with lower injury and physiologic severity.

CONCLUSIONS

Risk-adjusted pediatric trauma-related mortality is significantly higher in India compared to the US. The comparative odds of mortality are highest among children with lower injury and physiologic severity. This suggests that low-cost targeted interventions focused on standard timely trauma care, protocols, training and early imaging could improve pediatric injury mortality in India.

TYPE OF STUDY

Retrospective Prognosis Study LEVEL OF EVIDENCE: II.

Emergency services utilization in Jakarta (Indonesia): a cross-sectional study of patients attending hospital emergency departments

BACKGROUND

Pre-hospital and emergency services in Indonesia are still developing. Despite recent improvements in the Indonesian healthcare system, issues with the provision of pre-hospital and emergency services persist. The demand for pre-hospital and emergency services has not been the subject of previous research and, therefore, has not been fully understood. Our research explored the utilization of emergency medical services by patients attending hospital emergency departments in Jakarta, Indonesia.

METHODS

The study used a cross-sectional survey design involving five general hospitals (four government-funded and one private). Each patient's demographic profile, medical conditions, time to treatment, and mode of transport to reach the hospital were analysed using descriptive statistics.

RESULTS

A total of 1964 (62%) patients were surveyed. The median age of patients was 44 years with an interquartile range (IQR) of 26 to 58 years. Life-threatening conditions such as trauma and cardiovascular disease were found in 8.6 and 6.6% of patients, respectively. The majority of patients with trauma travelled to the hospital using a motorcycle or car (59.8%). An ambulance was used by only 9.3% of all patients and 38% of patients reported that they were not aware of the availability of ambulances. Ambulance response time was longer as compared to other modes of transportation (median: 24 minutes and IQR: 12 to 54 minutes). The longest time to treatment was experienced by patients with neurological disease, with a median time of 120 minutes (IQR: 78 to 270 minutes). Patients who used ambulances incurred higher costs as compared to those patients who did not use ambulances.

CONCLUSION

The low utilization of emergency ambulances in Jakarta could be contributed to patients' lack of awareness of medical symptoms and the existence of ambulance services, and patients' disinclination to use ambulances due to high costs and long response times. The emergency ambulance services can be improved by increasing population awareness on symptoms that warrant the use of ambulances and reducing the cost burden related to ambulance use.

The association of crash response times and deaths at the crash scene: A cross-sectional analysis using the 2019 National Emergency Medical Service Information System

BACKGROUND

Deaths at the crash scene (DAS) are crash deaths that occur within minutes after a crash. Rapid crash responses may reduce the occurrence of DAS.

OBJECTIVES

This study aims to assess the association of crash response time and DAS during the rush and nonrush hour periods by rurality/urbanicity.

METHOD

This single-year cross-sectional study used the 2019 National Emergency Medical Services (EMS) Information System. The outcome variable was DAS. The predictor variables were crash response measures: EMS Chute Initiation Time (ECIT) and EMS Travel Time (ETT). Age, gender, substance use, region of the body injured, and the revised trauma score were used as potential confounders. Logistic regression was used to assess the unadjusted and adjusted odds of DAS.

RESULTS

A total of 654,675 persons were involved in EMS-activated road crash events, with 49.6% of the population exposed to crash events during the rush hour period. A total of 2,051 persons died at the crash scene. Compared to the baseline of less than 1 minute, ECIT ranging from 1 to 5 minutes was significantly associated with 58% (95% CI: 1.45-1.73) increased odds of DAS. Also, when compared to the baseline of less than 9 minutes, ETT ranging between 9 and 18 minutes was associated with 34% (95% CI: 1.22-1.47) increased odds of DAS. These patterns were consistent during the rush and nonrush hour periods and across rural and urban regions.

CONCLUSION

Reducing crash response times may reduce the occurrence of DAS.

"Trauma-the forgotten pandemic?"

Global annual deaths from Trauma are greater than any other single cause in the global working population, and, more than all contagious diseases added together including COVID-19. The number of people injured, either temporarily or permanently, is greater than any other medical condition. This problem affects Low and Middle Income Countries (LMICs) disproportionately. The numbers are so great as to cause "zone out" and present a human rights issue. This is a particular issue as Trauma presently receives less than 1% of global healthcare funding. This article will highlight and discuss many of the issues and raise some uncomfortable arguments showing that improvement is needed, necessary and achievable.

Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis

Objectives

Comparisons of risk-adjusted trauma mortality between high-income countries and low and middle-income countries (LMICs) can be used to identify specific patient populations and injury patterns for targeted interventions. Due to a paucity of granular patient and injury data from LMICs, there is a lack of such comparisons. This study aims to identify independent predictors of trauma mortality and significant differences between India and the USA.

Methods

A retrospective cohort study of two trauma databases was conducted. Demographic, injury, physiologic, anatomic and outcome data were analyzed from India’s Towards Improved Trauma Care Outcomes project database and the US National Trauma Data Bank from 2013 to 2015. Multivariate logistic regression analyses were performed to determine significant independent predictors of mortality.

Results

687 407 adult trauma patients were included (India 11 796; USA 675 611). Patients from India were significantly younger with greater male preponderance, a higher proportion presented with physiologic abnormalities and suffered higher mortality rates (23.2% vs. 2.8%). When controlling for age, sex, physiologic abnormalities, and injury severity, sustaining an injury in India was the strongest predictor of mortality (OR 13.85, 95% CI 13.05 to 14.69). On subgroup analyses, the greatest mortality difference was seen in patients with lower Injury Severity Scores.

Conclusion

After adjusting for demographic, physiologic abnormalities, and injury severity, trauma-related mortality was found to be significantly higher in India. When compared with trauma patients in the USA, the odds of mortality are most notably different among patients with lower Injury Severity Scores. While troubling, this suggests that relatively simple, low-cost interventions focused on standard timely trauma care, early imaging, and protocolized treatment pathways could result in substantial improvements for injury mortality in India, and potentially other LMICs.

Level of evidence

Level 3, retrospective cohort study.

Preventable deaths following road traffic collisions in Botswana: A retrospective review

Road traffic collisions (RTC) are a major cause of mortality and morbidity in Botswana. To our knowledge no research has been conducted in Botswana to investigate preventable deaths that occur as a result of RTCs. The aim of this study is to establish the rate of preventable deaths from RTCs in the greater Gaborone area in Botswana. This was a 5-year retrospective study conducted at the forensic pathology department for the greater Gaborone area, in Botswana. Nine hundred and nine (909) forensic pathology reports were retrieved. Sixty-eight percent (68.2%) of RTC deaths were considered preventable. Head injury in isolation and in combination with other injuries accounted for 87.6% (796/909) of deaths. Haemorrhagic shock was present in 70.2% (638) of all documented injuries. Another documented injury contributing to fatal RTCs was high spinal cord injury. This injury was documented in 13.1% (119/909) of all deaths. We recommend the implementation of a comprehensive trauma system in Botswana to reduce the number of deaths from RTCs.

Trends of Emergency Calls During the Coronavirus Disease-19 Pandemic in Nur-Sultan

BACKGROUND: The new coronavirus infection (coronavirus disease [COVID]-19) has become a serious obstacle on the health-care systems in Kazakhstan, as well as throughout the world. Certainly, the extent of emergency medical services (EMSs) use at some stage within the COVID-19 pandemic has been increased. However, the impact on the use of EMS in Kazakhstan during the COVID-19 pandemic has not been studied. AIM: The aim of this study was to analyze the dynamics of changes in the number of emergency medical calls during the COVID-19 pandemic, depending on the time of year, day of the week, and the causes for the calls. METHODS: This study retrospectively evaluated the Nur-Sultan (capital of Kazakhstan) EMS data for the period after the pandemic was first seen in Kazakhstan. The necessary permissions for the study were obtained from the Nur-Sultan City Public Health Department. EMS data for the same time interval (February 1–May 1) in the past 3 years (2018, 2019, and 2020) were compared. The data were taken from the database of the automated control system “Komek 103,” which is used in the ambulance station since the end of 2019, and the automated dispatch information systems “ADIS” used by the ambulance station in Nur-Sultan. RESULTS: During the COVID-19 pandemic, EMS call rates had been maximum common on Mondays and Thursdays by 13, 75%. The evaluation suggests that the quantity of male sufferers extended by 14, 05% in the course of the pandemic length, as compared to the pre-pandemic length. The quantity of patients with inside the 65+ age group in the course of the pandemic length has extended by 31.5%. During the pandemic, the signs and symptoms of fever enlarged significantly by 83%. Moreover, suicides elevated by 61% during the pandemic period. During the COVID‐19 pandemic, using EMS particularly for time touchy illnesses, which include hypertension (−31%), surgical emergencies (acute abdomen) (−40%), cerebrovascular illnesses (−11%), and other heart illnesses (−29%) decreased. CONCLUSIONS: During the pandemic period, there was an increase in the calls from male patients, compared to the pre-pandemic period. Moreover, during the COVID-19 pandemic, EMS call rates had been increased on Mondays and Thursdays. We found an alteration with inside the sample of obtained calls. Furthermore, the quantity of patients with inside the 65+ age group in the course of the pandemic length has extended.

Coverage versus response time objectives in ambulance location

Background

This paper deals with the location of emergency medical stations where ambulances waiting to be dispatched are parked. The literature reports a lot of mathematical programming models used to optimize station locations. Most studies evaluate the models only analytically applying the same simplifying assumptions that were used in the modelling phase. In addition, they concentrate on systems operating one type of emergency units in homogeneous urban areas. The goal of our study is to identify which optimization criterion the emergency medical service (EMS) outcomes benefit from the most and which model should be used to design tiered systems in large urban–rural areas.

Methods

A bi-criteria mathematical programming model is proposed. The criteria include the accessibility of high-priority patients within a short time limit and average response time to all patients. This model is being compared to the p-median model with a single response time objective and to a hierarchical pq-median model that considers two different vehicle types. A detailed computer simulation model is used to evaluate the solutions. The methodology is verified in the conditions of the Slovak Republic using real historical data on 149,474 ambulance trips performed in 2015.

Results

All mathematical models improve EMS performance by relocating some stations compared to the current distribution. The best results are achieved by the hierarchical median-type model. The average response time is reduced by 58 s, the number of calls responded to within 15 min is increased by 5% and the number of high-priority calls responded to within 8 min by 6%.

Conclusions

The EMS systems operating in heterogeneous areas should be designed to minimize response times, and not to maximize the number of calls served within a given time limit.

An online emergency medical management information system using mobile computing

Purpose

The purpose of this paper is to investigate the way technology affects the provision of prehospital emergency care, upgrading the quality of services offered and significantly reducing the risk of premature termination of the patients.

Design/methodology/approach

The paper presents the development of the eEKAB, a pilot emergency medical information system that simulates the main services offered by the Greek National Instant Aid Centre (EKAB). The eEKAB was developed on an agile system methodology. From a technical perspective, the features and the technology were mainly chosen to provide reliable and user-friendly interfaces that will attract many users. eEKAB is based on three important pillars for offering health care to the patients: the “On-time Incident Reporting”, the “On-time Arrival at the Incident” and “Transfer to the Health Center”. According to the literature review, the emergency medical services (EMS) systems that combine all the features are very few.

Findings

It reduces the total time of the EMS procedures and it allows for an easier management of EMS, by providing a better allocation of human resources and a better geographical distribution of ambulances. The evaluation displayed that it is a very helpful application for the ambulance drivers as it reduces the ambulance response time to arrive in the patient's location and contributes significantly to the general performance of the prehospital medical care system. Also, the survey verified the importance of implementing eEKAB on a larger scale beyond the pilot usage. It is worth mentioning that the younger ambulance drivers had a more positive view for the purpose of the application.

Research limitations/implications

The paper clearly identifies implications for further research. Regarding interoperability, the mobile app cooperates with the Operational Center of EKAB, while further collaboration could be achieved with other operational ambulance handling center, mainly, of the private sector. The system can evolve to include better communications among the EKAB departments. Particularly, the ambulance crew as well as the doctors should be informed with more incident features such as the emergency signal so that they know whether to open the siren, the patient's name, etc. The authors are currently working on implementing some features to provide effective medical health services to the patient in the ambulance.

Practical implications

eEKAB will have very significant implications in case of its enforcement, such as the reduction of the total time of EMS procedures with a corresponding reduction of the operating costs of an accident management system and an ambulance fleet handling system while in parallel informing in time the doctors/clinics. It will provide better distribution of ambulances as well as of total human resources. It will greatly assist ambulance drivers, while reducing ambulance response time to reach the patient's location. In other words, the authors will have a better performance of the whole prehospital care system.

Social implications

Providing emergency care before the hospital is of great importance for upgrading the quality of health services provided at the accident site, thus significantly reducing the risk of premature death of patients. This in itself has a significant social implication.

Originality/value

The paper demonstrates a solid understanding in the field of the EMS systems and the corresponding medical services offered. It proposes the development of an effective, feasible and innovative EMS information system that will improve the existing emergency health care system in Greece (EKAB). An in depth literature review and presentation of the adopted new technologies and the respective architecture take place. An evaluation and statistical validation were conducted for proving the high applicability of eEKAB in case of real-life running.

Effects of COVID-19 Pandemic on Emergency Medical Services

INTRODUCTION

In this study, we aimed to analyse the changes that occurred after the COVID-19 pandemic using the data of EMS of Ankara province.

MATERIALS AND METHODS

EMS data for the same time interval (March 11-April 24) in the last 3 years (2018, 2019 and 2020) were compared.

RESULTS

While the number of calls increased by 90.9% during the pandemic period (from 2019 to 2020), the number of cases increased by 9.8%. Of all cases transported to hospital, 15.2% were suspected of and 2.9% were diagnosed with COVID-19. In the pandemic period, case frequency decreased in the 0-6 age group (-4.1%) and 7-18 age group (-39.9%) while the number of patients in the 19-65 age group (12.9%) and 65+ age group (21.5%) increased. There was a statistically significant difference between pre-pandemic and pandemic period in terms of rural area case frequency. During the pandemic period, case frequency of angina pectoris (-35.2%), myocardial infarction (-45%), acute abdomen (-23.8%) and cerebrovascular diseases (-2.9%) decreased contrary to pre-pandemic period (2019). During the same period, symptoms of fever (+14.1%) and cough (+956.3%) increased. There was a statistically significant difference between pre-pandemic and pandemic period in terms of forensic case frequency (P < .05). In addition, there was a statistically significant difference between these periods in terms of the frequency of patients who died at the scene.

CONCLUSION

Although the use of ambulances has increased in the pandemic process, the use of EMS for time-sensitive diseases has decreased.

State of Post-injury First Response Systems in Nepal-A Nationwide Survey

Injuries account for 9.2% of all deaths and 9.9% of the total disability-adjusted life years in Nepal. To date, there has not been a systematic assessment of the status of first response systems in Nepal. An online survey was cascaded through government, non-governmental organisations and academic networks to identify first response providers across Nepal. Identified organisations were invited to complete a questionnaire to explore the services, personnel, equipment, and resources in these organisations, their first aid training activities and whether the organisation evaluated their first response services and training. Of 28 organisations identified, 17 (61%) completed the questionnaire. The range of services offered varied considerably; 15 (88.2%) provided first aid training, 9 (52.9%) provided treatment at the scene and 5 (29.4%) provided full emergency medical services with assessment, treatment and transport to a health facility. Only 8 (47.1%) of providers had an ambulance, with 6 (35.3%) offering transportation without an ambulance. Of 13 first aid training providers, 7 (53.8%) evaluated skill retention and 6 (46.2%) assessed health outcomes of patients. The length of a training course varied from 1 to 16 days and costs from US$4.0 to 430.0 per participant. There was a variation among training providers in who they train, how they train, and whether they evaluate that training. No standardisation existed for either first aid training or provision of care at the scene of an injury. This survey suggests that coordination and leadership will be required to develop an effective first response system across the country.

The costs of delivering emergency care at regional referral hospitals in Uganda: a micro-costing study

BACKGROUND

Uganda experiences a high morbidity and mortality burden due to conditions amenable to emergency care, yet few public hospitals have dedicated emergency units. As a result, little is known about the costs and effects of delivering lifesaving emergency care, hindering health systems planning, budgeting and prioritization exercises. To determine healthcare costs of emergency care services at public facilities in Uganda, we estimate the median cost of care for five sentinel conditions and 13 interventions.

METHODS

A direct, activity-based costing was carried out at five regional referral hospitals over a four-week period from September to October 2019. Hospital costs were determined using bottom-up micro-costing methodology from a provider perspective. Resource use was enumerated via observation and unit costs were derived from National Medical Stores lists. Cost per condition per patient and measures of central tendency for conditions and interventions were calculated. Kruskal-Wallis H-tests and Nemyeni post-hoc tests were conducted to determine significant differences between costs of the conditions.

RESULTS

Eight hundred seventy-two patient cases were captured with an overall median cost of care of $15.53 USD ($14.44 to $19.22). The median cost per condition was highest for post-partum haemorrhage at $17.25 ($15.02 to $21.36), followed by road traffic injuries at $15.96 ($14.51 to $20.30), asthma at $15.90 ($14.76 to $19.30), pneumonia at $15.55 ($14.65 to $20.12), and paediatric diarrhoea at $14.61 ($13.74 to $15.57). The median cost per intervention was highest for fracture reduction and splinting at $27.77 ($22.00 to $31.50). Cost values differ between sentinel conditions (p < 0.05) with treatments for paediatric diarrhoea having the lowest median cost of all conditions (p < 0.05).

CONCLUSION

This study is the first to describe the direct costs of emergency care in hospitals in Uganda by observing the delivery of clinical services, using robust activity-based costing and time motion methodology. We find that emergency care interventions for key drivers of morbidity and mortality can be delivered at considerably lower costs than many priority health interventions. Further research assessing acute care delivery would be useful in planning wider health care delivery systems development.

The accuracy of preliminary diagnoses made by paramedics - a cross-sectional comparative study

Background

Clinical decision-making skills of paramedics have been emphasized because of the growing complexity of emergency medicine nursing. A preliminary diagnosis made by a paramedic has an essential role in directing the subsequent care. An accurate preliminary diagnosis improves the patient’s outcome. The research in this area is relatively scarce and there are no previous studies in Finland describing the accuracy of preliminary diagnoses made by paramedics. The aim of this study was to evaluate whether paramedics are making accurate preliminary diagnoses for the patients they are transporting to hospital. In addition, the aim was to describe the variables related to an accurate preliminary diagnosis.

Methods

A cross-sectional comparative approach was used and conducted through a questionnaire to gather data from the paramedics. A total of 71 paramedics participated in the study and 378 patient cases were included. The paramedics were asked to describe the basic information of a case, to state their preliminary diagnosis, and give their own educational background. The accuracy of the paramedic’s preliminary diagnosis was compared with the discharge diagnosis of the ED physicians retrieved from hospital’s patient records. Logistic regression analysis and a binomial test were used to test the statistical significance.

Results

The agreement between the paramedics’ preliminary diagnosis vs. hospital diagnosis was 70% (n = 261). Diagnostic accuracy varied according to the medical condition from mental diseases and intoxication (86%, p = 0,000), cerebral strokes (81%, p = 0,007) to infections (31% p = 0,029). The educational background of a bachelor-degree-level paramedic (p = 0,016, 95% Cl 1,7-139,6) and a good self-assessment value (p = 0,003, 95% Cl 1,2-2,7) were related to making a correct diagnosis.

Conclusions

Paramedics are able to determine preliminary diagnoses at satisfactory level. The relationship between educational background and diagnostic accuracy suggests that there is a definitive need for a specific pre-hospital nursing education.

Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review

BACKGROUND

Neurotrauma is an important global health problem. The largest cause of neurotrauma worldwide is road traffic collisions (RTCs), particularly in low- and middle-income countries (LMICs). Neurotrauma and RTCs are preventable, and many preventative interventions have been implemented over the last decades, especially in high-income countries (HICs). However, it is uncertain if these strategies are applicable globally due to variations in environment, resources, population, culture and infrastructure. Given this issue, this scoping review aims to identify, quantify and describe the evidence on approaches in neurotrauma and RTCs prevention, and ascertain contextual factors that influence their implementation in LMICs and HICs.

METHODS

A systematic search was conducted using five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health on EBSCO host, Cochrane Database of Systematic Reviews), grey literature databases, government and non-government websites, as well as bibliographic and citation searching of selected articles. The extracted data were presented using figures, tables, and accompanying narrative summaries. The results of this review were reported using the PRISMA Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

A total of 411 publications met the inclusion criteria, including 349 primary studies and 62 reviews. More than 80% of the primary studies were from HICs and described all levels of neurotrauma prevention. Only 65 papers came from LMICs, which mostly described primary prevention, focussing on road safety. For the reviews, 41 papers (66.1%) reviewed primary, 18 tertiary (29.1%), and three secondary preventative approaches. Most of the primary papers in the reviews came from HICs (67.7%) with 5 reviews on only LMIC papers. Fifteen reviews (24.1%) included papers from both HICs and LMICs. Intervention settings ranged from nationwide to community-based but were not reported in 44 papers (10.8%), most of which were reviews. Contextual factors were described in 62 papers and varied depending on the interventions.

CONCLUSIONS

There is a large quantity of global evidence on strategies and interventions for neurotrauma and RTCs prevention. However, fewer papers were from LMICs, especially on secondary and tertiary prevention. More primary research needs to be done in these countries to determine what strategies and interventions exist and the applicability of HIC interventions in LMICs.

Developing an integrated emergency medical services in a low-income country like Nepal: a concept paper

BACKGROUND

The main aim of emergency medical services (EMS) should be to provide universal emergency medical care which is EMS system available to all those who need it. Most of the developed countries have an integrated EMS system that is accessible by a single dial number in the whole country. Nepal does not have a proper EMS system. We conducted a literature review regarding methods of developing an integrated EMS system in Nepal.

RESULT

The fragmented system, high demand-low supply, inequity with the service, and inadequately trained responders are major problems associated with EMS in Nepal. Nepal too should develop an integrated single dial number EMS system to meet the current demand of EMS. Having a paramedic in ambulances as the first responders will prevent chaos and save critical time. Funding models have to be considered while developing an EMS considering the capital as well as operational cost.

CONCLUSION

Nepal can develop a public private partnership model of EMS where capital cost is provided by the government and operational cost by other methods. Community-based insurance system looks more feasible in a country like Nepal for generating operational cost.

Physician Prehospital Care in Mexico City: Retrospective Analysis of Endotracheal Intubation in Patients with Severe Head Trauma

INTRODUCTION

In Mexico, physicians have become part of public service prehospital care. Head injured patients are a sensitive group that can benefit from early advanced measures to protect the airway, with the objective to reduce hypoxia and maintain normocapnia.

PROBLEM

The occurrence of endotracheal intubation to patients with severe head injuries by prehospital physicians working at Mexico City's Service of Emergency Medical Care (SAMU) is unknown.

METHODS

A retrospective analysis of five-year data (2012-2016) from Mexico City's Medical Emergencies Regulation Center was performed. Only SAMU ambulance services were analyzed. Adult patients with a prehospital diagnosis of head injury based on mechanism of injury and physical examination with a Glasgow Coma Scale (GCS) <nine were included.

RESULTS

A total of 293 cases met the inclusion criteria; the mean GCS was five points. Of those, 150 (51.1%) patients were intubated. There was no difference in the occurrence of intubation among the different GCS scales, or if the patient was considered to have isolated head trauma versus polytrauma. Fifteen patients were intubated using sedation and neuromuscular blockage. Four patients were intubated with sedation alone and six patients with neuromuscular blockage alone. One patient was intubated using opioid analgesia, sedation, and neuromuscular blockage.

CONCLUSIONS

Patients with severe head injuries cared by prehospital physicians in Mexico City were intubated 51.1% of the time and were more likely to be intubated without the assistance of anesthetics.

Childhood maltreatment compromises resilience against occupational trauma exposure: A retrospective study among emergency medical service personnel

BACKGROUND

Childhood maltreatment (CM) compromises resilience against stress and trauma throughout life. Therefore, it could present a major risk factor for the health of frequently trauma-exposed professionals such as emergency medical service (EMS) personnel.

OBJECTIVE

We investigated, whether EMS personnel's history of CM increased their risk for mental and physical stress symptoms after occupational trauma exposure.

PARTICIPANTS AND SETTING

Data from 103 German EMS personnel (age: Mdn±QD = 26.00 ± 8.50 years) were collected as part of a cross-sectional survey distributed among employees of the regional German Red Cross EMS division (response rate 46.6%). The sample corresponded well to the division's entire staff in terms of socio-anagraphic characteristics.

METHODS

CM and occupational trauma exposure as well as posttraumatic, depressive, and somatic symptoms were assessed with self-report questionnaires.

RESULTS

Moderation analyses indicated stronger positive associations between occupational trauma exposure and the severity of posttraumatic (β = .30, p < .001), depressive (β = .20, p = .026), and somatic symptoms (β = .18, p = .059) among EMS personnel who reported a higher exposure to CM.

CONCLUSIONS

Our study provides initial evidence that CM could increase the EMS personnel's vulnerability to the detrimental consequences of critical incidents on duty. Future research is needed (i) to replicate and generalize our observation on various trauma-exposed professions as well as (ii) to develop preventive measures for targeting the mediating and protective factors which influence the relationship between CM and the negative consequences of occupational trauma exposure.

Promotion of prehospital emergency care through clinical decision support systems: opportunities and challenges

Clinical decision support systems are interactive computer systems for situational decision making and can improve decision efficiency and safety of care. We investigated the role of these systems in enhancing prehospital care. This narrative review included full-text articles published since 2000 that were available in databases/e-journals including Web of Science, PubMed, Science Direct, and Google Scholar. Search keywords included "clinical decision support system," "decision support system," "decision support tools," "prehospital care," and "emergency medical services." Non-journal articles were excluded. We revealed 14 relevant studies that used such a support system in prehospital emergency medical service. Owing to the dynamic nature of emergency situations, decision timing is critical. Four key factors demonstrated the ability of clinical decision support systems to improve decision-making, reduce errors, and improve the safety of prehospital emergency activity: computer-based, offer support as a natural part of the workflow, provide decision support in the time and place of decision making, and offer practical advice. The use of clinical decision support systems in prehospital care resulted in accurate diagnoses, improved patient triage and patient outcomes, and reduction of prehospital time. By improving emergency management and rescue operations, the quality of prehospital care will be enhanced.

The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi, India

INTRODUCTION

Ambulance-based emergency medical systems (EMS) are expensive and remain rare in low- and middle-income countries, where trauma victims are usually transported to hospital by passing vehicles. Recent developments in transportation network technologies could potentially disrupt this status quo by allowing coordinated emergency response from layperson networks. We sought to understand the barriers to bystander assistance for trauma victims in Delhi, India, and implications for a layperson-EMS.

METHODS

We used qualitative methods to analyse data from 50 interviews with frontline stakeholders (including taxi drivers, medical professionals, legal experts and police), one stakeholder consultation and a review of documents.

RESULTS

Respondents noted that most trauma victims in Delhi are rapidly brought to hospital by bystanders, taxis and police. While ambulances are common, they are primarily used for interfacility transfers. Entrenched medico-legal practices result in substantial police presence at the hospital, which is a major source of harassment of good Samaritans and interferes with patient care. Trauma victims are often turned away by for-profit hospitals due to their inability to pay, leading to delays in treatment. Recent policy efforts to circumscribe the role of police and force for-profit hospitals to stabilise patients appear to have been unsuccessful.

CONCLUSIONS

Existing healthcare and medico-legal practices in India create large systemic impediments to improving trauma outcomes. Until India's ongoing health and transport sector reforms succeed in ensuring that for-profit hospitals reliably provide care, good Samaritans and layperson-EMS providers should take victims with uncertain financial means to public facilities. To avoid difficulties with police, providers of a layperson-EMS would likely need official police sanction and carry visible symbols of their authority to provide emergency transport. Delhi already has several key components of an EMS (including dispatcher coordinated police response, large ambulance fleet) that could be integrated and expanded into a complete system of emergency care.

Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review protocol

INTRODUCTION

Neurotrauma is an important global health problem. This 'silent epidemic' is a major cause of death and disability in adolescents and young adults, with significant societal and economic impacts. Globally, the largest cause of neurotrauma is road traffic collisions (RTCs). Neurotrauma and RTCs are largely preventable, and many preventative strategies and interventions have been established and implemented over the last decades, particularly in high-income countries. However, these approaches may not be applicable globally, due to variations in environment, resources, population, culture and infrastructure. This paper outlines the protocol for a scoping review, which seeks to map the evidence on strategies and interventions in neurotrauma and RTCs prevention globally, and to ascertain contextual factors that influence their implementation.

METHODS AND ANALYSIS

This scoping review will use the established methodology by Arksey and O'Malley. Eligible studies will be identified from five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health/EBSCO and Cochrane Database of Systematic Reviews) and grey literature sources. We will also carry out bibliographical and citation searching of included studies. A two-stage selection process, which involves screening of titles and abstracts, followed by full-text screening, will be used to determine eligible studies which will undergo data abstraction using a customised, piloted data extraction sheet. The extracted data will be presented using evidence mapping and a narrative summary.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review, which is the first step in a multiphase public health research project on the global prevention of neurotrauma. The final review will be submitted for publication to a scientific journal, and results will be presented at appropriate conferences, workshops and meetings. Protocol registered on 5 April 2019 with Open Science Framework (https://osf.io/s4zk3/).

Traffic police officers' experience of post-crash care to road traffic injury victims: a qualitative study in Tanzania"

BACKGROUND

Recently, road traffic injuries (RTIs) have become a major health problem affecting health systems in many low- and middle-income countries. Regardless of whether an ambulance is available for evacuation, police officers have been shown to arrive at the crash scene first, becoming, in effect, the first responders to RTI victims. Therefore, the study aimed to explore the experiences of traffic police officers in regard to the provision of care to RTI victims in the prehospital environment, including the role of traffic police upon arriving at the crash scene, the challenges they face, and their opinions about how to improve care to RTI victims.

METHOD

The study used a qualitative approach in which data were obtained from 10 individual interviews and three focus group discussions. There were 41 participants, 27 of them were male and 14 were female. About half (48.7%) of the study participants were aged between 30 to 39 years. Qualitative content analysis was used to analyse all the materials.

RESULTS

Three themes emerged from the analysis. The theme "Maintain safety while saving injured victims' lives and facilitating access to a health facility" was comprised of safety, sorting, initial help, and assisting access to hospital care. "Overwhelmed working with limited resources and support" included limited care and transport resources, police fatigue, and little or no support. "Improving supportive system and empowering frontline personnel" included the need for an emergency care system, availability of resources and an emergency medical support system, and training for police and drivers regarding victims' first-aid care, and road safety.

CONCLUSION

The study findings characterize an environment in which the police first responders have no knowledge or skills and no equipment and supplies to provide care to RTI victims at the scene before rushing them to definitive care. The results suggest a favorable climate for training and equipping officers so that they can deliver competent postcrash care at the scene while emergency medical services are yet to be established. However, more research will be needed to determine the efficacy of such training and its acceptability in the Tanzanian context.

Childrens' and Parents' Willingness to Join a Smartphone-Based Emergency Response Community for Anaphylaxis: Survey

BACKGROUND

Medical emergencies such as anaphylaxis may require immediate use of emergency medication. Because of the low adherence of chronic patients (ie, carrying anti-anaphylactic medication) and the potentially long response time of emergency medical services (EMSs), alternative approaches to provide immediate first aid are required. A smartphone-based emergency response community (ERC) was established for patients with allergies to enable members to share their automatic adrenaline injector (AAI) with other patients who do not have their AAI at the onset of anaphylactic symptoms. The community is operated by a national EMS. In the first stage of the trial, children with food allergies and their parents were invited to join.

OBJECTIVE

This study aimed to identify the factors that influence the willingness to join an ERC for a group of patients at risk of anaphylaxis.

METHODS

The willingness to join an ERC was studied from different perspectives: the willingness of children with severe allergies to join an ERC, the willingness of their parents to join an ERC, the willingness of parents to enroll their children in an ERC, and the opinions of parents and children about the minimum age to join an ERC. Several types of independent variables were used: demographics, medical data, adherence, parenting style, and children's autonomy. A convenience sample of children and their parents who attended an annual meeting of a nonprofit organization for patients with food allergies was used.

RESULTS

A total of 96 questionnaires, 73 by parents and 23 by children, were collected. Response rates were approximately 95%. Adherence was high: 22 out of 23 children (96%) and 22 out of 52 parents (42%) had their AAI when asked. Willingness to join the community was high among parents (95%) and among children (78%). Willingness of parents to enroll their children was 49% (36/73). The minimum age to join an ERC was 12.27 years (SD 3.02) in the parents' opinion and 13.15 years (SD 3.44) in the children's opinion.

CONCLUSIONS

Parents' willingness to join an ERC was negatively correlated with parents' age, child's age, and parents' adherence. This can be explained by the free-rider effect: parents who carried an AAI for their young child, but had low adherence, wanted to join the ERC to get an additional layer of emergency response. Children's willingness to join the community was positively correlated with age and negatively correlated with the child's emotional autonomy. Parents' willingness to enroll their children in an ERC was positively correlated with child's age and negatively correlated with parents' adherence: again, this can be explained by the aforementioned free-rider effect. Parents' and children's opinions about the minimum age to join an ERC were negatively correlated with protective parenting style and positively correlated with monitoring parenting style.

Indicators to measure prehospital care quality: a scoping review

OBJECTIVE

The purpose of this scoping review was to locate, examine and describe the literature on indicators used to measure prehospital care quality.

INTRODUCTION

The performance of ambulance services and quality of prehospital care has traditionally been measured using simple indicators, such as response time intervals, based on low-level evidence. The discipline of paramedicine has evolved significantly over the last few decades. Consequently, the validity of utilizing such measures as holistic prehospital care quality indicators (QIs) has been challenged. There is growing interest in finding new and more significant ways to measure prehospital care quality.

INCLUSION CRITERIA

This scoping review examined the concepts of prehospital care quality and QIs developed for ambulance services. This review considered primary and secondary research in any paradigm and utilizing any methods, as well as text and opinion research.

METHODS

Joanna Briggs Institute methodology for conducting scoping reviews was employed. Separate searches were conducted for two review questions; review question 1 addressed the definition of prehospital care quality and review question 2 addressed characteristics of QIs in the context of prehospital care. The following databases were searched: PubMed, CINAHL, Embase, Scopus, Cochrane Library and Web of Science. The searches were limited to publications from January 1, 2000 to the day of the search (April 16, 2017). Non-English articles were excluded. To supplement the above, searches for gray literature were performed, experts in the field of study were consulted and applicable websites were perused.

RESULTS

Review question 1: Nine articles were included. These originated mostly from England (n = 3, 33.3%) and the USA (n = 3, 33.3%). Only one study specifically aimed at defining prehospital care quality. Five articles (55.5%) described attributes specific to prehospital care quality and four (44.4%) articles considered generic healthcare quality attributes to be applicable to the prehospital context. A total of 17 attributes were identified. The most common attributes were Clinical effectiveness (n = 17, 100%), Efficiency (n = 7, 77.8%), Equitability (n = 7, 77.8%) and Safety (n = 6, 66.7%). Timeliness and Accessibility were referred to by four and three (44.4% and 33.3%) articles, respectively.Review question 2: Thirty articles were included. The predominant source of articles was research literature (n = 23; 76.7%) originating mostly from the USA (n = 13; 43.3%). The most frequently applied QI development method was a form of consensus process (n = 15; 50%). A total of 526 QIs were identified. Of these, 283 (53.8%) were categorized as Clinical and 243 (46.2%) as System/Organizational QIs. Within these categories respectively, QIs related to Out-of-hospital cardiac arrest (n = 57; 10.8%) and Time intervals (n = 75; 14.3%) contributed the most. The most commonly addressed prehospital care quality attributes were Appropriateness (n = 250, 47.5%), Clinical effectiveness (n = 174, 33.1%) and Accessibility (n = 124, 23.6%). Most QIs were process indicators (n = 386, 73.4%).

CONCLUSION

Whilst there is paucity in research aiming to specifically define prehospital care quality, the attributes of generic healthcare quality definitions appear to be accepted and applicable to the prehospital context. There is growing interest in developing prehospital care QIs. However, there is a need for validation of existing QIs and de novo development addressing broader aspects of prehospital care.

[The Emergency Medical System's response and its association with different outcomes in traffic accident victims in Mexican cities]

The aim of this article was to analyze the timeliness of emergency medical care (time transpired between the injury and the first contact with the Emergency Medical System) and its assocation with different negative health outcome in traffic accident victims treated at two Mexican hospitals, one in Guadalajara, Jalisco, and the other in León, Guanajuato, based on data from the Motor Vehicle Accident Epidemiological Surveillance System of the Bloomberg Philanthropies' Global Road Safety Program. Information was obtained on all patients treated for motor vehicle injuries in referral hospitals from May 2012 to November 2014. Multinomial logistic regression was used to model the health outcomes, categorized as short stay, prolonged hospitalization, disability, and death, compared to timeliness of care, adjusted by different target variables. A total of 2,575 patients were analyzed. Time from injury to care was 103.74 minutes (± 231.36) in León and 75.37 minutes (± 156.87) in Guadalajara; it was 38.02 and 36.23 minutes, respectively, in patients that received prehospital medical care. Timely care was associated with less prolonged hospital stay, but not with lower incidence of disability or death. Receiving prehospital medical care was associated statistically with negative health consequences. Timely care was associated with lower probability of prolonged hospitalization. Strategies are needed to evaluate and in turn improve the technical quality of prehospital medical care, including timeliness of care and adequate regulation.

A Sustainable Ambulance Operation Model in a Low-Resource Country (the Democratic Republic of Congo)

Due to an increase in traffic collisions, the demand for prehospital medical services is on the rise, even in low-resource countries where emergency ambulance services have not been previously provided. To build a sustainable and continuous prehospital ambulance operation model, it is necessary to consider the medical system and economic conditions of the corresponding country. In an attempt to construct a prehospital ambulance operation model that ensures continuous operation, a pilot "emergency patient transporting service from field to hospital" operation was established for approximately three months in Kinshasa, the capital of the DR Congo. To construct a continuously operating model even after the pilot operation, willingness to pay (WTP) by type of emergency medical and transport service was investigated by implementing the contingent valuation method (CVM). Using CVM, the WTP for prehospital emergency services targeting ambulance services personnel, patients, policemen, and hospital staff participating in the pilot operation was calculated. The results of the pilot operation revealed that there were a total of 212 patients with a mean patient number of 2.4 per day. A total of 155 patients used the services for hospital transport, while 121 patients used the services for traffic collisions. Traffic collisions were the category in which ambulance services were most frequently needed (66.2%). Pay services were most frequently utilized in the home-visit services category (40.9%). Based on these results, eight independently operated ambulance operation models and sixteen models that utilize hospital medical personnel and policemen already belonging to existing institutions were proposed. In an effort to implement emergency medical ambulance services in the DR Congo, medical staff receiving pay for performance (incentive pay) should be deployed in the field and on call. Accordingly, with respect to sustainable development goals, various pay-for-service models should be used.

Violence against emergency medical services personnel: A systematic review of the literature

BACKGROUND

Violence against emergency medical services (EMS) personnel is a growing concern. The aim of this systematic review is to synthesize the current literature on violence against EMS personnel.

METHODS

We examined literature from 2000 to 2016. Eligibility criteria included English-language, peer-reviewed studies of EMS personnel that described violence or assaults. Sixteen searches identified 2655 studies; 25 studies from nine countries met the inclusion criteria.

RESULTS

The evidence from this review demonstrates that violence is a common risk for EMS personnel. We identified three critical topic areas: changes in risk over time, economic impact of violence and, outcomes of risk-reduction interventions. There is a lack of peer reviewed research of interventions, with the result that current intervention programs have no reliable evidence base.

CONCLUSIONS

EMS leaders and personnel should work together with researchers to design, implement, evaluate and publish intervention studies designed to mitigate risks of violence to EMS personnel.

Quality Indicators for Evaluating Prehospital Emergency Care: A Scoping Review

Introduction Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC. Problem Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature.

METHODS

A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment.

RESULTS

The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review.

CONCLUSION

Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43-52.

Measurement of the potential geographic accessibility from call to definitive care for patient with acute stroke

BACKGROUND

The World Health Organization refers to stroke, the second most frequent cause of death in the world, in terms of pandemic. Present treatments are only effective within precise time windows. Only 10% of thrombolysis patients are eligible. Late assessment of the patient resulting from admission and lack of knowledge of the symptoms is the main explanation of lack of eligibility.

METHODS

The aim is the measurement of the time of access to treatment facilities for stroke victims, using ambulances (firemen ambulances or EMS ambulances) and private car. The method proposed analyses the potential geographic accessibility of stroke care infrastructure in different scenarios. The study allows better considering of the issues inherent to an area: difficult weather conditions, traffic congestion and failure to respect the distance limits of emergency transport.

RESULTS

Depending on the scenario, access times vary considerably within the same commune. For example, between the first and the second scenario for cities in the north of Rhône county, there is a 10 min difference to the nearest Primary Stroke Center (PSC). For the first scenario, 90% of the population is 20 min away of the PSC and 96% for the second scenario. Likewise, depending on the modal vector (fire brigade or emergency medical service), overall accessibility from the emergency call to admission to a Comprehensive Stroke Center (CSC) can vary by as much as 15 min.

CONCLUSIONS

The setting up of the various scenarios and modal comparison based on the calculation of overall accessibility makes this a new method for calculating potential access to care facilities. It is important to take into account the specific pathological features and the availability of care facilities for modelling. This method is innovative and recommendable for measuring accessibility in the field of health care. This study makes possible to highlight the patients' extension of care delays. Thus, this can impact the improvement of patient care and rethink the healthcare organization. Stroke is addressed here but it is applicable to other pathologies.

Measurement of the potential geographic accessibility from call to definitive care for patient with acute stroke

BACKGROUND

The World Health Organization refers to stroke, the second most frequent cause of death in the world, in terms of pandemic. Present treatments are only effective within precise time windows. Only 10% of thrombolysis patients are eligible. Late assessment of the patient resulting from admission and lack of knowledge of the symptoms is the main explanation of lack of eligibility.

METHODS

The aim is the measurement of the time of access to treatment facilities for stroke victims, using ambulances (firemen ambulances or EMS ambulances) and private car. The method proposed analyses the potential geographic accessibility of stroke care infrastructure in different scenarios. The study allows better considering of the issues inherent to an area: difficult weather conditions, traffic congestion and failure to respect the distance limits of emergency transport.

RESULTS

Depending on the scenario, access times vary considerably within the same commune. For example, between the first and the second scenario for cities in the north of Rhône county, there is a 10 min difference to the nearest Primary Stroke Center (PSC). For the first scenario, 90% of the population is 20 min away of the PSC and 96% for the second scenario. Likewise, depending on the modal vector (fire brigade or emergency medical service), overall accessibility from the emergency call to admission to a Comprehensive Stroke Center (CSC) can vary by as much as 15 min.

CONCLUSIONS

The setting up of the various scenarios and modal comparison based on the calculation of overall accessibility makes this a new method for calculating potential access to care facilities. It is important to take into account the specific pathological features and the availability of care facilities for modelling. This method is innovative and recommendable for measuring accessibility in the field of health care. This study makes possible to highlight the patients' extension of care delays. Thus, this can impact the improvement of patient care and rethink the healthcare organization. Stroke is addressed here but it is applicable to other pathologies.

Titrating the Rig: How Paramedics Work in and on Their Ambulance

In this article, I take readers inside of an ambulance and explore how paramedics work in and on their "apparatus unit" to make it a workable fit. This taken-for-granted work is important because much is at stake in the back of the ambulance, particularly in relation to quality of care and safety. I draw on data from an institutional ethnography into the socially organized work and work settings of paramedics, which included more than 200 hr of observations and more than 100 interviews with paramedics. The findings shed light on the situated work processes of paramedics as they orient and respond to their "apparatus unit" and enact quality and safety in practice. This article adds to the sociological literature on work and occupations as well as safety and quality in health care of an increasingly important group of health care and emergency services professional.

Does prehospital management by doctors affect outcome in major trauma? A systematic review

BACKGROUND

There is substantial variation worldwide in prehospital management of trauma and the role of doctors is controversial. The objective of this review was to determine whether prehospital management by doctors affects outcomes in major trauma, including the prespecified subgroup of severe traumatic brain injuries when compared with management by other advanced life support providers.

METHODS

EMBASE, MEDLINE(R), PubMed, SciELO, Trip, Web of Science, and Zetoc were searched for published articles. HSRProj, OpenGrey, and the World Health Organization International Clinical Trials Registry Platform were searched for unpublished data. Relevant reference lists were hand-searched. There were no limits on publication year, but articles were limited to the English language. Authors were contacted for further information as required. Quality was assessed using the Downs and Black criteria. Mortality was the primary outcome, and disability was the secondary outcome of interest. Studies were subjected to a descriptive analysis alone without a meta-analysis due to significant study heterogeneity. All searches, quality assessment, data abstraction, and data analysis was performed by two reviewers independently.

RESULTS

Two thousand thirty-seven articles were identified, 49 full-text articles assessed and eight studies included. The included studies consisted of one randomized controlled trial with 375 participants and seven observational studies with over 4,451 participants. All included studies were at a moderate to high risk of bias. Six of the eight included studies showed an improved outcome with prehospital management by doctors, five in terms of mortality and one in terms of disability. Two studies found no significant difference.

CONCLUSION

There appears to be an association between prehospital management by doctors and improved survival in major trauma. There may also be an association with improved survival and better functional outcomes in severe traumatic brain injury. Further high-quality evidence is needed to confirm these findings.

LEVEL OF EVIDENCE

Systematic review, level III.

The Association of Psychological Empowerment and Job Burnout in Operational Staff of Tehran Emergency Center

BACKGROUND

Workers in social service professions are the first candidates for job burnout. The researchers believe this is due to daily exposure to stressful situations and lack of positive conditions in the workplace. It seems that psychological empowerment of staff can affect their job burnout. This study aimed to investigate the relationship between psychological empowerment and job burnout in operational staff of emergency center.

METHODS

This was a descriptive correlational study. A total of 1100 operational staff of emergency center were evaluated, and of which, 285 persons were selected by simple random sampling method. Data were collected using Spritzer's psychological empowerment and Maslach Burnout Inventory questionnaires. SPSS software, version 18, was used for data analysis along with descriptive analytical tests.

RESULTS

The findings of this study revealed that the majority of units (46%) were in intermediate level in terms of empowerment. Similarly, the majority of cases had intermediate level (77.5%), and a minor percentage (8.4%) had low levels of job burnout. Based on Pearson's correlation test, there was a significant invert correlation between psychological empowerment and job burnout. This inverse and significant relationship was also observed between the four components of psychological empowerment (competence, self-determination, impact, and meaning) and job burnout.

CONCLUSIONS

According to the results of the study, policy makers and health planners can take some measures in enhancing psychological empowerment to prevent problems associated with job burnout, by identifying stressors and strategies to deal with them.

Comparison of trauma care systems in Asian countries: A systematic literature review

OBJECTIVE

The study aims to compare the trauma care systems in Asian countries.

METHODS

Asian countries were categorised into three groups; 'lower middle-income country', 'upper middle-income country' and 'high-income country'. The Medline/PubMed database was searched for articles published from January 2005 to December 2014 using relevant key words. Articles were excluded if they examined a specific injury mechanism, referred to a specific age group, and/or did not have full text available. We extracted information and variables on pre-hospital and hospital care factors, and regionalised system factors and compared them across countries.

RESULTS

A total of 46 articles were identified from 13 countries, including Pakistan, India, Vietnam and Indonesia from lower middle-income countries; the Islamic Republic of Iran, Thailand, China, Malaysia from upper middle-income countries; and Saudi Arabia, the Republic of Korea, Japan, Hong Kong and Singapore from high-income countries. Trauma patients were transported via various methods. In six of the 13 countries, less than 20% of trauma patients were transported by ambulance. Pre-hospital trauma teams primarily comprised emergency medical technicians and paramedics, except in Thailand and China, where they included mainly physicians. In Iran, Pakistan and Vietnam, the proportion of patients who died before reaching hospital exceeded 50%. In only three of the 13 countries was it reported that trauma surgeons were available. In only five of the 13 countries was there a nationwide trauma registry.

CONCLUSION

Trauma care systems were poorly developed and unorganised in most of the selected 13 Asian countries, with the exception of a few highly developed countries.

The Burden of Spine Fractures in India: A Prospective Multicenter Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the association between patient or injury characteristics and outcomes after spinal trauma.

METHODS

In affiliation with the ongoing INternational ORthopaedic MUlticentre Study (INORMUS), 192 patients with spinal injuries were recruited during an 8-week period (November 2011 to June 2012) from 14 hospitals in India and followed for 30-days. The primary outcome was a composite of mortality, complications, and reoperation. This was regressed on a set of 13 predictors in a multiple logistic regression model.

RESULTS

Most patients were middle-aged (mean age = 51.0 years; median age = 55.5 years; range = 18.0 to 72.0 years), male (60.4%), injured from falls (72.4%), and treated in a private setting (59.9%). Fractures in the lumbar region (51.0%) were most common, followed by thoracic (30.7%) and cervical (18.2%). More than 1 in 5 (21.6%) patients experienced a treatment delay greater than 24 hours, and 36.5% arrived by ambulance. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR = 11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications.

CONCLUSIONS

Treatment in the public health care system, increased severity of injury, and surgical intervention were associated with increased risk of major complications following spinal trauma. The need for a large-scale, prospective, multicenter study taking into account spinal stability and neurologic status is feasible and warranted.

The Impact of Trauma Care Systems in Low- and Middle-Income Countries

Injury is a leading cause of death globally, and organized trauma care systems have been shown to save lives. However, even though most injuries occur in low- and middle-income countries (LMICs), most trauma care research comes from high-income countries where systems have been implemented with few resource constraints. Little context-relevant guidance exists to help policy makers set priorities in LMICs, where resources are limited and where trauma care may be implemented in distinct ways. We have aimed to review the evidence on the impact of trauma care systems in LMICs through a systematic search of 11 databases. Reports were categorized by intervention and outcome type and summarized. Of 4,284 records retrieved, 71 reports from 32 countries met inclusion criteria. Training, prehospital systems, and overall system organization were the most commonly reported interventions. Quality-improvement, costing, rehabilitation, and legislation and governance were relatively neglected areas. Included reports may inform trauma care system planning in LMICs, and noted gaps may guide research and funding agendas.

Review of therapeutic agents employed by an Australian aeromedical prehospital and retrieval service

OBJECTIVE

There is little current evidence regarding which therapeutic agents are actually used within existing aeromedical services. The Greater Sydney Area Helicopter Emergency Medical Service operates a large, physician-staffed, multimodal, prehospital and interhospital retrieval service. The aim of the present study was to identify the range and frequency of drug, fluid and blood product use within our service.

METHODS

This was a retrospective cross-sectional study. Case sheets relating to a 12 month period were inspected to identify the therapeutic agents used by retrieval teams during each mission. Corresponding case notes, demographic data (age, sex) and case data (prehospital vs interhospital, trauma vs medical) were extracted from an electronic database.

RESULTS

Of 2566 missions, 848 were prehospital, 1662 interhospital and 56 mixed. Prehospital missions were associated with fewer agents per case (median, 2 vs 3) and a narrower range of agents overall (45 vs 117) compared to interhospital missions. In both mission types, the most frequently used agents included morphine, fentanyl, Hartmann's solution, ketamine, rocuronium, ondansetron and midazolam. Noradrenaline, propofol and metaraminol were used frequently in interhospital missions only. A number of stocked and unstocked agents were used less commonly, or not at all, over the study period.

CONCLUSIONS

The results of the present study form a practical guide to aid prehospital and retrieval services in establishing or reviewing their medical agent formularies. Key practice points illuminated by the data provide insights into current practice in critical care. There remains a clear need for similar studies from other services worldwide.

The scale, scope, coverage, and capability of childbirth care

All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Retrospective one-million-subject fixed-cohort survey of utilization of emergency departments due to traumatic causes in Taiwan, 2001-2010

BACKGROUND

Epidemiological study was needed to evaluate trends in emergency department (ED) utilization that could be taken into account when making policy decisions regarding the delivery and distribution of medical resources.

METHODS

A retrospective fixed-cohort study of emergency medical utilization from 2001 to 2010 was performed based on one-million people sampled in 2010 in Taiwan. Focusing on traumatic cases, the annual incidences in various groups split according to sex and age were calculated, and further information regarding location of trauma and type of trauma was obtained.

RESULTS

In 2010, significantly greater proportions of male and younger subjects were visitors to EDs with a traumatic injury. During 2001-2010, the number of both traumatic cases and non-traumatic cases presenting at EDs significantly increased (average annual percentage change, AAPC 4.7 and 3.6, respectively) and a significantly greater direct medical cost associated with traumatic cases than non-traumatic cases was noted. Focusing on traumatic cases, most of these cases were directed to highest-level hospitals, accounting for 73.5-78.8 % of all traumatic cases, with a significant AAPC of 5.6. The traumatic ED visit annual incidence in males was 58.63 in 2001, which significantly increased to 69.35 per 1000 persons in 2010 (AAPC 1.5); and in females was 38.96 in 2001, which significantly increased to 50.73 per 1000 persons in 2010 (AAPC 2.5). Most of the traumatic cases treated in EDs were minor injuries, such as contusion with the skin intact, open wound of the upper limbs, open wound of the head, neck, or trunk, and other superficial injury (accounting for about 60 % of all cases). The traumatic categories of sprains/strains of joints and adjacent muscles, fractures of upper limbs, fractures of lower limbs, and fractures of the spine/trunk required greater medical resources and significantly positive AAPC values (4.3, 4.0, 4.5 and 6.8, respectively).

CONCLUSIONS

Increased ED utilization due to traumatic causes, as assessed by the annual number of cases and incidence, average direct medical cost and highest-level hospital utilization, was observed from 2001 to 2010. Orthopedic-related injuries, including soft tissue trauma of extremities and various fractures, were the categories with the greatest increase in incidence.

Demographic Patterns and Outcomes of Patients in Level I Trauma Centers in Three International Trauma Systems

Introduction

Trauma systems were developed to improve the care for the injured. The designation and elements comprising these systems vary across countries. In this study, we have compared the demographic patterns and patient outcomes of Level I trauma centers in three international trauma systems.

Methods

International multicenter prospective trauma registry-based study, performed in the University Medical Center Utrecht (UMCU), Utrecht, the Netherlands, John Hunter Hospital (JHH), Newcastle, Australia, and Harborview Medical Center (HMC), Seattle, the United States. Inclusion: patients ≥18 years, admitted in 2012, registered in the institutional trauma registry.

Results

In UMCU, JHH, and HMC, respectively, 955, 1146, and 4049 patients met the inclusion criteria of which 300, 412, and 1375 patients with Injury Severity Score (ISS) > 15. Mean ISS was higher in JHH (13.5; p < 0.001) and HMC (13.4; p < 0.001) compared to UMCU (11.7). Unadjusted mortality: UMCU = 6.5 %, JHH = 3.6 %, and HMC = 4.8 %. Adjusted odds of death: JHH = 0.498 [95 % confidence interval (CI) 0.303–0.818] and HMC = 0.473 (95 % CI 0.325–0.690) compared to UMCU. HMC compared to JHH was 1.002 (95 % CI 0.664–1.514). Odds of death patients ISS > 15: JHH = 0.507 (95 % CI 0.300–0.857) and HMC = 0.451 (95 % CI 0.297–0.683) compared to UMCU. HMC = 0.931 (95 % CI 0.608–1.425) compared to JHH. TRISS analysis: UMCU: Ws = 0.787, Z = 1.31, M = 0.87; JHH, Ws = 3.583, Z = 6.7, M = 0.89; HMC, Ws = 3.902, Z = 14.6, M = 0.84.

Conclusion

This study demonstrated substantial differences across centers in patient characteristics and mortality, mainly of neurological cause. Future research must investigate whether the outcome differences remain with nonfatal and long-term outcomes. Furthermore, we must focus on the development of a more valid method to compare systems.

Pre-Hospital Emergency in Iran: A Systematic Review

CONTEXT

Pre-hospital care plays a vital role in saving trauma patients.

OBJECTIVES

This study aims to review studies conducted on the pre-hospital emergency status in Iran.

DATA SOURCES

Data were sourced from Iranian electronic databases, including SID, IranMedex, IranDoc, Magiran, and non-Iranian electronic databases, such as Medline, Embase, Cochrane Library, Scopus, and Google Scholar. In addition, available data and statistics for the country were used.

DATA SELECTION

All Persian-language articles published in Iranian scientific journals and related English-language articles published in Iranian and non-Iranian journals indexed on valid sites for September 2005 - 2014 were systematically reviewed.

DATA EXTRACTION

To review the selected articles, a data extraction form developed by the researchers as per the study's objective was adopted. The articles were examined under two categories: structure and function of pre-hospital emergency.

RESULTS

A total of 19 articles were selected, including six descriptive studies (42%), four descriptive-analytical studies (21%), five review articles (16%), two qualitative studies (10.5%), and two interventional (experimental) studies (10.5%). In addition, of these, 14 articles (73.5%) had been published in the English language. The focus of these selected articles were experts (31.5%), bases of emergency medical services (26%), injured (16%), data reviews (16%), and employees (10.5%). A majority of the studies (68%) investigated pre-hospital emergency functions and 32% reviewed the pre-hospital emergency structure.

CONCLUSIONS

The number of studies conducted on pre-hospital emergency services in Iran is limited. To promote public health, consideration of prevention areas, processes to provide pre-hospital emergency services, policymaking, foresight, systemic view, comprehensive research programs and roadmaps, and assessments of research needs in pre-hospital emergency seem necessary.