EMS systems in China

Current status of emergency medical service use in ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry

BACKGROUND

The mortality rate of myocardial infarction in China has increased dramatically in the past three decades. Although emergency medical service (EMS) played a pivotal role for the management of patients with ST-segment elevation myocardial infarction (STEMI), the corresponding data in China are limited.

METHODS

An observational analysis was performed in 26,305 STEMI patients, who were documented in China acute myocardial infarction (CAMI) Registry and treated in 162 hospitals from January 1st, 2013 to January 31th, 2016. We compared the differences such as demographic factors, social factors, medical history, risk factors, socioeconomic distribution and treatment strategies between EMS transport group and self-transport group.

RESULTS

Only 4336 patients (16.5%) were transported by EMS. Patients with symptom onset outside, out-of-hospital cardiac arrest and presented to province-level hospital were more likely to use EMS. Besides those factors, low systolic blood pressure, severe dyspnea or syncope, and high Killip class were also positively related to EMS activation. Notably, compared to self-transport, use of EMS was associated with a shorter prehospital delay (median, 180 vs. 245 min, P < 0.0001) but similar door-to-needle time (median, 45 min vs. 52 min, P = 0.1400) and door-to-balloon time (median, 105 min vs. 103 min, P = 0.1834).

CONCLUSIONS

EMS care for STEMI is greatly underused in China. EMS transport is associated with shorter onset-to-door time and higher rate of reperfusion, but not substantial reduction in treatment delays or mortality rate. Targeted efforts are needed to promote EMS use when chest pain occurs and to set up a unique regionalized STEMI network focusing on integration of prehospital care procedures in China.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01874691), retrospectively registered June 11, 2013.

Implementation of basic life support education for the lay public in China: barriers, enablers, and possible solutions

Background

Education for the lay public in basic life support (BLS) is critical for increasing bystander cardiopulmonary resuscitation (CPR) rates and improving survival from out-of-hospital cardiac arrest (OHCA). Despite years of implementation, the BLS training rate in China has remained modest. The aim of this study was to investigate the factors influencing the implementation of BLS training programs in emergency medical service (EMS) centers in China and to identify specific barriers and enablers.

Methods

Qualitative interviews were conducted with key informants from 40 EMS centers in Chinese cities. The participants included 11 directors/deputy directors, 24 training department leaders, and 5 senior trainers. The interview guide was based on the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Thematic content analysis was used to identify themes and patterns across the interviews.

Results

We identified 16 factors influencing the implementation of BLS training programs encompassing the outer content, inner context, innovation and bridging factors. Some factors acted as either barriers or enablers at different EPIS stages. The main implementation barriers included limited external leadership, insufficient government investment, low public awareness, a shortage of trainers, an absence of incentives, an absence of authoritative courses and guidelines, a lack of qualification to issue certificates, limited academic involvement, and insufficient publicity. The main enablers were found to be supportive government leaders, strong public demand, adequate resources, program champions, available high-quality courses of high fitness within the local context, the involvement of diverse institutions, and effective publicity and promotion.

Conclusion

Our findings emphasize the diversity of stakeholders, the complexity of implementation, and the need for localization and co-construction when conducting BLS training for lay public in city EMS centers. Improvements can be made at the national level, city level, and EMS institutional level to boost priority and awareness, promote legislation and policies, raise sustainable resources, and enhance the technology of BLS courses.

The development history, current state, challenges, and future directions of the BASIC-OHCA registry in China: A narrative review

Out-of-hospital cardiac arrest is a major public health problem worldwide due to its high burden and poor outcomes. Despite progress in treatment, patient outcomes remain unsatisfactory, particularly in low-resource settings. The establishment of a registry is the first step towards gaining a comprehensive understanding of prevailing local conditions and identifying potential opportunities for improving patient survival. Here, we provide a narrative review of the BASeline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA), the first national OHCA registry in China, to introduce its development history, current state, challenges and future directions. We aim to enhance cross-cultural understanding by providing insights from China, while also serving as a reference for the implementation of large-scale registries in low-resource settings.

The temporal trend of road traffic mortality in China from 2004 to 2020

Background

Road traffic accidents are one of the critical disasters that cause massive negative influences to the social economy and people's property, health and life safety. The purpose of this study is to analyze the temporal trend of road traffic mortality in China from 2004 to 2020, and further analyze the key factors that the influencing changes in China's road traffic mortality and provides information for the development of targeted interventions to reduce the number of preventable deaths.

Methods

The data were retrieved from the Chinese Death Cause Monitoring Data Set from 2004 to 2020. The road traffic mortality rates were standardized by the Sixth National Population Census (6th NPC) data. Joinpoint regression method was manipulated to analyze temporal trends of standardized road traffic mortality. The study used annual percentage change (APC) and average annual percentage change (AAPC) calculated by the Joinpoint regression model to describe trends in road traffic mortality rates.

Results

The overall age-adjusted road traffic mortality in China showed a declining trend from 2004 to 2020 (AAPC2004-2020 = - 4.2%), from 20.9 to 12.92 per 100,000. Rural road traffic mortality rates were generally higher than the one in urban areas, and males were generally higher than females. There was an overall downward trend of the standardized road traffic mortality in the East and Central regions between 2004 and 2020. It was worth noting that the road traffic mortality rates in the Western region showed an upward trend from 2006 to 2011 (APC2006-2011 = 3.3%) and continued to decline after 2011 (APC2011-2020 = - 6.7%). The road traffic mortality rates of aged 65 years and older was highest, which required focused attention.

Conclusions

From 2004 to 2020, the road traffic mortality rates in China generally declined. At the same time, there was a slow reduction or even an upward trend in road traffic mortality rates among the elderly and in western regions. Rural males are a priority group for road traffic injury prevention.

Ambulance referral of more than 2 hours could result in a high prevalence of medical-device-related pressure injuries (MDRPIs) with characteristics different from some inpatient settings: a descriptive observational study

BACKGROUND

Medical device-related pressure injuries(MDRPI) are prevalent and attracting more attention. During ambulance transfer, the shear force caused by braking and acceleration; extensive medical equipment crowed in a narrow space add external risk factors for MDRPIs. However, there is insufficient research on the relationship between MDRPIs and ambulance transfers. This study aims to clarify the prevalence and characteristics of MDRPI during ambulance transfer.

METHOD

A descriptive observational study was conducted with convenience sampling. Before starting the study, six PI specialist nurses certified by the Chinese Nursing Association trained emergency department nurses for three MDRPI and Braden Scale sessions, one hour for each session. Data and images of PIs and MDRPIs are uploaded via the OA system by emergency department nurses and reviewed by these six specialist nurses. The information collection begins on 1 July 2022 and ends on 1 August 2022. Demographic and clinical characteristics and a list of medical devices were collected by emergency nurses using a screening form developed by researchers.

RESULTS

One hundred one referrals were eventually included. The mean age of participants was (58.3 ± 11.69) years, predominantly male (67.32%, n = 68), with a mean BMI of 22.48 ± 2.2. The mean referral time among participants was 2.26 ± 0.26 h, the mean BRADEN score was 15.32 ± 2.06, 53.46% (n = 54) of participants were conscious, 73.26% (n = 74) were in the supine position, 23.76% (n = 24) were in the semi-recumbent position, and only 3 (2.9%) were in the lateral position. Eight participants presented with MDRPIs, and all MDRPIs are stage 1. Patients with spinal injuries are most prone to MDRPIs (n = 6). The jaw is the area most prone to MDRPIs, caused by the cervical collar (40%, n = 4), followed by the heel (30%, n = 3) and nose bridge (20%, n = 2) caused by the respiratory devices and spinal board.

CONCLUSION

MDRPIs are more prevalent during long ambulance referrals than in some inpatient settings. The characteristics and related high-risk devices are also different. The prevention of MDRPIs during ambulance referrals deserves more research.

Under the chest pain center mechanism, whether the nursing handover affects the nursing efficiency and the outcomes of patients with STEMI in the emergency department? A retrospective study

BACKGROUND

The introduction of chest pain centers (CPC) in China has achieved great success in shortening the duration of nursing operations to significantly improve the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The nursing handover period is still considered the high incidence period of adverse events because of the distractibility of nurses' attention, potential interruption, and unclear responsibilities. Under the CPC mechanism, the nursing efficiency and patients' outcome, whether affected by the nursing handover, is still a knowledge gap in research. This is also the aim of this study.

METHODS

A retrospective study was conducted with data from STEMI patients from a tertiary hospital in the north of Sichuan Province from January 2018 to December 2019 through the Chinese CPC database. Patients are divided into handover and non-handover groups according to the time they presented in the Emergency Department. D2FMC, FMC2FE, FMC2BS, FMC2CBR, FMC2FAD, and D2W were selected to measure nursing efficiency. The occurrence of major adverse cardiovascular events, the highest troponin values within 72 h of hospitalization, and the length of hospitalization were selected to measure the patient outcomes. Continuous variables are summarized as mean ± SD, and t-tests of the data were performed. P-values < 0.05 (two-tailed) were considered statistically significant.

RESULTS

A total of 231 cases were enrolled, of which 40 patients (17.3%) were divided into the handover period group, and 191 (82.6%) belonged to the non-handover period group. The results showed that the handover period group took significantly longer on items FMC2BS (P < 0.001) and FMC2FAD (P < 0.001). Still, there were no significant differences in D2FMC and FMC2FE, and others varied too little to be clinically meaningful, as well as the outcomes of patients.

CONCLUSION

This study confirms that nursing handover impacts the nursing efficiency of STEMI patients, especially in FMC2BS and FMC2FAD. Hospitals should also reform the nursing handover rules after the construction of CPC and enhance the triage training of nurses to assure nursing efficiency so that CPC can play a better role.

Urban-suburb disparities in pre-hospital emergency medical resources and response time among patients with out-of-hospital cardiac arrest: A mixed-method cross-sectional study

Aim

To investigate (1) the association between pre-hospital emergency medical resources and pre-hospital emergency medical system (EMS) response time among patients with Out-of-hospital cardiac arrest (OHCA); (2) whether the association differs between urban and suburbs.

Methods

Densities of ambulances and physicians were independent variables, respectively. Pre-hospital emergency medical system response time was dependent variable. Multivariate linear regression was used to investigate the roles of ambulance density and physician density in pre-hospital EMS response time. Qualitative data were collected and analyzed to explore reasons for the disparities in pre-hospital resources between urban areas and suburbs.

Results

Ambulance density and physician density were both negatively associated with call to ambulance dispatch time, with odds ratios (ORs) 0.98 (95% confidence interval [CI] 0.96-0.99; P = 0.001) and 0.97 (95% CI; 0.93-0.99; P < 0.001), respectively. ORs of ambulance density and physician density in association with total response time were 0.99 (95% CI: 0.97-0.99; P = 0.013) and 0.90 (95% CI: 0.86-0.99; P = 0.048). The effect of ambulance density on call to ambulance dispatch time in urban areas was 14% smaller than that in suburb areas and that on total response time in urban areas was 3% smaller than the effect in suburbs. Similar effects were identified for physician density on urban-suburb disparities in call to ambulance dispatch time and total response time. The main reasons summarized from stakeholders for a lack of physicians and ambulances in suburbs included low income, poor personal incentive mechanisms, and inequality in financial distribution of the healthcare system.

Conclusion

Improving pre-hospital emergency medical resources allocation can reduce system delay and narrow urban-suburb disparity in EMS response time for OHCA patients.

Quantity and Quality of Healthcare Professionals, Transfer Delay and In-hospital Mortality Among ST-Segment Elevation Myocardial Infarction: A Mixed-Method Cross-Sectional Study of 89 Emergency Medical Stations in China

Background

Transfer delay provokes prolongation of prehospital time, which contributes to treatment delay that endangers patients with ST-segment elevation myocardial infarction (STEMI). A key constraint in reducing transfer delay is the shortage of emergency healthcare workers. This study was to explore the influence of the quality and quantity of healthcare professionals at emergency medical stations on transfer delay and in-hospital mortality among STEMI patients.

Methods

A cross-sectional study using mixed methods was conducted at 89 emergency stations in 9 districts in China's Shenzhen province. Based on a sample of 31 hospitals, 1,255 healthcare professionals, and 3,131 patients with STEMI, a generalized linear model was used to explore the associations between the quality and quantity of healthcare professionals and transfer delay and in-hospital mortality among STEMI patients. Qualitative data were collected and analyzed to explore the reasons for the lack of qualified healthcare professionals at emergency medical stations.

Results

The analysis of the quantity of healthcare professionals showed that an increase of one physician per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 5.087 min (95% CI −6.722, −3.452; P &lt; 0.001). An increase of one nurse per 100,000 individuals was associated with decreased transfer delay by 1.471 min (95% CI −2.943, 0.002; P=0.050). Analysis of the quality of healthcare professionals showed that an increase of one physician with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 8.508 min (95% CI −10.457, −6.558; P &lt; 0.001). An increase of one nurse with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay by 6.645 min (95% CI −8.218, −5.072; P &lt; 0.001). Qualitative analysis illustrated that the main reasons for low satisfaction of healthcare professionals at emergency medical stations included low income, limited promotion opportunities, and poor working environment.

Conclusions

The quantity and quality of emergency healthcare professionals are key factors influencing transfer delay in STEMI patients. The government should increase the quantity of healthcare professionals at emergency medical stations, strengthen the training, and improve their performance by linking with clinical pathways to enhance job enthusiasm among emergency healthcare professionals.

Terrorism in China and the Emerging Needs for Counter- Terrorism Medicine Following a Decade of Deaths and Injuries

BACKGROUND

China is ranked 42nd on the Global Terrorism Index (2019), a scoring system of terrorist activities. While China has a relatively low terrorism risk, events globally have wide-ranging repercussions for future attacks, putting first responders and emergency health workers at risk. This study aims to provide the epidemiological context for the past decade detailing the unique injury types responders are likely to encounter and to develop training programs utilizing these data.

METHODS

The Global Terrorism Database (GTD) was searched for all attacks in China between the years 2008-2018. Attacks met inclusion criteria if they fulfilled the terrorism-related criteria as set by the GTD's Codebook. Ambiguous events, as defined by the GTD's Codebook, were excluded. English language grey literature was searched to ensure no events meeting these criteria were missed. A focused search of online English language newspaper articles was also performed for any terrorist events between 2008-2018.

RESULTS

One-hundred and eight terrorist events occurred in the study time period. Of the 108 incidents, forty-seven (43.5%) involved Explosives/Bombs/Dynamite (E/B/D) only, with an average fatality count of 2.9 and injury count of 7.5 per event. Twenty-seven (25.0%) used bladed or blunt weapons in melees with an average fatality count of 9.7 and an injury count of 8.8 per event. Five (4.6%) involved incendiary weapons with an average fatality count of 2.4 and an injury count of 7.2 per event. Two used only chemical weapons (1.8%) with no recorded deaths and an injury count of 27.0 per event. Two events had unknown weapon types (1.8%) with one recorded death and no injury count. One event used a firearm (0.9%) and led to one death and no injuries. One event used a vehicle (0.9%), which also led to one death and no recorded injuries. Twenty-three attacks used a mix of weapons (21.2%) with an average fatality count of 17.1 and an injury count of 12.0 per event.

CONCLUSIONS

One-hundred and eight terrorist attacks were recorded between 2008-2018 on Chinese soil using well-understood modalities. This resulted in a total of 809 recorded fatalities with 956 non-fatal injuries. The most commonly chosen methodology was E/B/D, followed by melees and the use of bladed weapons. Three events individually recorded a combined casualty toll of over 100 people.

Trends and challenges of emergency and acute care in Chinese mainland: 2005-2017

BACKGROUND

Emergency medical service system (EMSS) is essential in providing acute care services for health conditions. However, trends of emergency and acute care in China haven't been studied systematically.

METHODS

Relevant literature was carefully reviewed, including original and review articles, letters, government reports, yearbooks, both in Chinese and in English. Data on the number of emergency visits, physicians and beds in emergency departments (EDs), and the workforce of pre-hospital emergency care were summarized and analyzed from China Health and Family Planning Statistical Yearbooks (2006-2018).

RESULTS

Over the past decade, the number of ED visits tripled from 51.9 million to 166.5 million; and utilization of pre-hospital emergency care increased from 3.2 million to 6.8 million. In response to rapid increases in demand, the number of licensed emergency physicians raised from 20,058 to 59,409; the beds' number increased from 10,783 to 42,367. For pre-hospital emergency care, the volume of health workforce increased from 3,687 to 8,671, with a 109% increase in the number of physicians from 1,774 to 3,712. However, overcrowding, the long length of stay in EDs, poor work environment, and work exhaustion were still the critical challenges faced by China's EMSS.

CONCLUSIONS

The number of emergency visits has grown with continual capability enhancement during the past decade. However, overcrowding, the long length of stay in EDs, poor work environment, and work exhaustion still need to be solved by China's EMSS. These findings and comparison with the USA could offer experiences and lessons to EMSS development worldwide, especially for developing countries.

Death and dying in prehospital care: what are the experiences and issues for prehospital practitioners, families and bystanders? A scoping review

OBJECTIVE

To identify the factors that shape and characterise experiences of prehospital practitioners (PHPs), families and bystanders in the context of death and dying outside of the hospital environment where PHPs respond.

DESIGN

A scoping review using Arksey and O'Malley's five-stage framework. Papers were analysed using thematic analysis.

DATA SOURCES

MEDLINE; Embase; CINAHL; Scopus; Social Sciences Citation Index (Web of Science), ProQuest Dissertations & Theses A&I (Proquest), Health Technology Assessment database; PsycINFO; Grey Literature Report and PapersFirst were searched from January 2000 to May 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Qualitative and mixed methods studies reporting the experiences of PHPs, families and bystanders of death and dying in prehospital settings as a result of natural causes, trauma, suicide and homicide, >18 years of age, in Europe, USA, Canada, Australia and New Zealand.

RESULTS

Searches identified 15 352 papers of which 51 met the inclusion criteria. The review found substantial evidence of PHP experiences, except call handlers, and papers reporting family and bystander experiences were limited. PHP work was varied and complex, while confident in clinical work, they felt less equipped to deal with the emotion work, especially with an increasing role in palliative and end-of-life care. Families and bystanders reported generally positive experiences but their support needs were rarely explored.

CONCLUSIONS

To the best of our knowledge this is the first review that explores the experiences of PHPs, families and bystanders. An important outcome is identifying current gaps in knowledge where further empirical research is needed. The paucity of evidence suggested by this review on call handlers, families and bystanders presents opportunities to investigate their experiences in greater depth. Further research to address the current knowledge gaps will be important to inform future policy and practice.

Hourly associations between ambient temperature and emergency ambulance calls in one central Chinese city: Call for an immediate emergency plan

BACKGROUND

Most studies examining the short-term effects of temperature on health were based on the daily scale, few were at the hourly level. Revealing the relationship between unfavorable temperatures on an hourly basis and health is conducive to the development of more accurate extreme temperature early warning systems and reasonable dispatch of ambulances.

METHODS

Hourly data on temperature, air pollution (including PM_2.5, O₃, SO₂ and NO₂) and emergency ambulance calls (EACs) for all-cause, cardiovascular and respiratory diseases from January 16, 2014 to December 31, 2016 were obtained from Luoyang, China. A distributed lag non-linear model (DLNM) was used to assess the association between hourly temperature and ambulance calls after adjusting for potential confounding factors. The fractions of EACs attributable to non-optimum temperatures were also estimated.

RESULTS

Hourly temperature was associated with increased ambulance calls with a varying lag pattern. Extreme hot temperature (>32.1 °C) was positively associated with all-cause, cardiovascular diseases at lag 0-30 h and lag 0-9 h, while no significant effects were found for respiratory morbidity. Extreme cold temperature (<-2.5 °C) was positively associated with all-cause, cardiovascular and respiratory morbidity at lag 56-157 h, 50-145 h and 123-170 h. An overall EACs fraction of 6.84% [Backward estimate, 95% confidence interval (CI): 5.01%, 8.59%] could be attributed to non-optimum temperatures, and more contributions were caused by cold [Backward estimate: 6.06% (95% CI: 5.10%, 8.48%)] than by heat [Backward estimate: 0.79% (95% CI: 0.12%, 1.45%)].

CONCLUSIONS

Extreme hot temperature may lead to increased ambulance calls within a few hours, while extreme cold temperature may not increase ambulance calls until more than 2 days later. Effective measures, such as forming hourly temperature warning standards, optimizing ambulance services at extreme temperatures, etc., should be taken to reduce the unfavorable temperature - associated EACs burden.

The MEDEA FAR-EAST Study: Conceptual framework, methods and first findings of a multicenter cross-sectional observational study

BACKGROUND

The substantial increase in cardiovascular diseases (CVD) in China over the last three decades warrants comprehensive preventive primary and secondary strategies. Prolonged prehospital delay (PHD) has been identified as a substantial barrier to timely therapeutic interventions for acute myocardial infarction (AMI). Despite worldwide efforts to decrease the patient's decision-making time, minimal change has been achieved so far. Here, we aim to describe the conceptual framework and methods and outline key data of the MEDEA FAR-EAST Study, which aimed to elucidate in-depth barriers contributing to delay in Chinese AMI-patients.

METHODS

Data sources of this multicenter cross-sectional observational study are a standardized bedside interview, a self-administered tailored questionnaire tool and the patient chart. PHD was defined as the main outcome and triangulated at bedside. Standard operation procedures ensured uniform data collection by trained study personnel. The study was ethically approved by Tongji-Hospital and applied to all participating hospitals.

RESULTS

Among 379 consecutively screened patients, 296 (78.1%) fulfilled eligibility criteria. A total of 241 (81.4%) AMI-patients were male and 55 (18.6%) female. Mean age was 62.9 years. Prehospital delay time was assessed for 294 (99.3%) patients. Overall median PHD was 151 min with no significant sex difference. Symptom mismatch was present in 200 (69.7%) patients and 106 (39.0%) patients did not attribute their symptoms to cardiac origin. A total of 33 (12.4%) patients suffered from depression, 31 (11.7%) from anxiety and 141 (53.2%) patients employed denial as their major coping style.

CONCLUSION

This is the first study on prehospital delay with emphasis on psychological variables in Chinese AMI-patients. A comprehensive assessment tool to measure clinical and psychological factors was successfully implemented. Socio-demographic key data proved a good fit into preexisting Chinese literature. Potential barriers including cardiac denial and symptom-mismatch were assessed for the first time in Chinese AMI-patients. The pretested selection of instruments allows future in depth investigations into barriers to delay of Chinese AMI-patients and enables inter-cultural comparisons.

The equity of China's emergency medical services from 2010-2014

Background

With the depth development of health care system reform in China, emergency medical services (EMS) is confronted with challenges as well as opportunities. This study aimed to analyze the equity of China’s EMS needs, utilization, and resources distribution, and put forward proposal to improve the equity.

Method

Three emergency needs indicators (mortality rate of cardiovascular and cerebrovascular diseases, harm, and digestive system disease), two utilization indicators (emergency outpatient visits and rate of utilization) and one resource allocation indicator (number of EMS facilities) were collected after the review of the China Statistical Yearbook and the National Disease Surveillance System. Next, EMS related indicators were compared among 31 provinces from the eastern, central, and western regions of the country. Concentration Index (CI) were used to measure the equity of EMS needs and utilization among the western, central, and eastern regions. The Gini coefficient of demographic and geographic distribution of facilities represented the equity of resource allocation.

Result

During 2010–2014, the CI of cardiovascular and cerebrovascular disease mortality changed from positive to negative, which indicates that the concentrated trend transferred from richer regions to the poorer area. Injury mortality (CI: range from − 0.1241to −0.1504) and digestive disease mortality (CI: range from − 0.1921 to − 0.2279) consistently concentrated in the poorer region, and the inequity among regions became more obviously year-by-year. The utilization of EMS (CI: range from 0.1074 to 0.0824) showed an improvement; however, the inequity reduced gradually. The EMS facilities distribution by population (Gini coefficient: range from 0.0922 to 0.1200) showed high equitability but the EMS facilities distribution by geography (Gini coefficient: range from 0.0922 to 0.1200) suggested a huge gap between regions because the Gini coefficients were greater than 0.5 in the past 5 years.

Conclusion

There are some inequities of needs, utilization, and resource allocation in the China EMS. The government needs to stick to the principle of increasing investment in poorer regions, perfecting ambulance configuration and improving health workers’ professional skills to improve the equity and quality of EMS.

Instrument development and validation of the stroke pre-hospital delay behavior intention scale in a Chinese urban population

Background

Several stroke impairment scales are currently available for stroke patients but none of them provide information regarding the pre-stroke behavioral intentions of high-risk stroke patients and their relatives. This study’s objective was to generate and validate a new written tool, the Stroke Pre-hospital Delay Behavior Intention (SPDBI) scale. It is suitable for use with high-risk stroke patients and their relatives to predict the likelihood of pre-hospital delay.

Methods

From a review of related studies, we formulated a prototype scale. We interviewed ten stroke patients in a semi-structured iterative process that included interviews with experts, high-risk patients, and their family members. Then, we pretested and filtered items. We next used a large sample size and factor analysis to determine the scale’s structure. Finally, we checked the reliability and validity of the scale.

Results

We identified five sub-domains (stroke warning signs, non-treatment justification, symptom attributions, habitual response style, and emergency system use). The SPDBI demonstrated good internal consistency and test-retest reliability (Cronbach’s α =0.808; Intraclass Correlation Coefficient [ICC] =0.797).

Conclusions

This SPDBI scale is a reliable, and valid measure of the likeliness of pre-hospital delay in high-risk stroke patients and their family members. It may provide scientific assessment for targeted health education intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-014-0170-8) contains supplementary material, which is available to authorized users.

Overview of the shenzhen emergency medical service call pattern

BACKGROUND

In Shenzhen, the Emergency Medical Service (EMS) system has been in service since 1997. This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS.

METHODS

In this retrospective quantitative descriptive study, the data from the Shenzhen 120 EMS registry in 2011 were analyzed.

RESULTS

Shenzhen 120 EMS center is a communication command center. When the number of 120 are dialed, it is forwarded to the closest appropriate hospital for ambulance dispatch. In 2011, the Shenzhen 120 EMS center received 153 160 ambulance calls, with an average of 420 calls per day. Calling emergency services was mainly due to traffic accidents. Trauma and other acute diseases constituted a majority of ambulance transports. The adult patients aged 15-60 years are the principal users of EMS. There are no recognized 'paramedic' doctors and nurses. The pre-hospital emergency service is under the operation of emergency departments of hospitals. Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in post-trauma management. Moreover, specialized pre-hospital training, financial support, and public health education on proper use of EMS should be emphasized.

CONCLUSION

The Shenzhen 120 EMS center has its own epidemiology characteristics. Traumatic injury and traffic accident are the main reasons for calling ambulance service. In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.

Progress and challenges of disaster health management in China: a scoping review

Background

Despite the importance of an effective health system response to various disasters, relevant research is still in its infancy, especially in middle- and low-income countries.

Objective

This paper provides an overview of the status of disaster health management in China, with its aim to promote the effectiveness of the health response for reducing disaster-related mortality and morbidity.

Design

A scoping review method was used to address the recent progress of and challenges to disaster health management in China. Major health electronic databases were searched to identify English and Chinese literature that were relevant to the research aims.

Results

The review found that since 2003 considerable progress has been achieved in the health disaster response system in China. However, there remain challenges that hinder effective health disaster responses, including low standards of disaster-resistant infrastructure safety, the lack of specific disaster plans, poor emergency coordination between hospitals, lack of portable diagnostic equipment and underdeveloped triage skills, surge capacity, and psychological interventions. Additional challenges include the fragmentation of the emergency health service system, a lack of specific legislation for emergencies, disparities in the distribution of funding, and inadequate cost-effective considerations for disaster rescue.

Conclusions

One solution identified to address these challenges appears to be through corresponding policy strategies at multiple levels (e.g. community, hospital, and healthcare system level).

System barriers to the evidence-based care of acute coronary syndrome patients in China: qualitative analysis

BACKGROUND

Organizational and wider health system factors influence the implementation and success of interventions. Clinical Pathways in Acute Coronary Syndromes 2 is a cluster randomized trial of a clinical pathway-based intervention to improve acute coronary syndrome care in hospitals in China. We performed a qualitative evaluation to examine the system-level barriers to implementing clinical pathways in the dynamic healthcare environment of China.

METHODS AND RESULTS

A qualitative descriptive analysis of 40 in-depth interviews with health professionals conducted in a sample of 10 hospitals purposively selected to explore barriers to implementation of the intervention. Qualitative data were analyzed using the Framework method. In-depth interviews identified 5 key system-level barriers to effective implementation: (1) leadership support for implementing quality improvement, (2) variation in the capacity of clinical services and quality improvement resources, (3) fears of patient disputes and litigation, (4) healthcare funding constraints and high out-of-pocket expenses, and (5) patient-related factors.

CONCLUSIONS

System-level barriers affect the ability of acute coronary syndrome clinical pathways to change practice. Addressing these barriers in the context of current and planned national health system reform will be critical for future improvements in the management of acute coronary syndromes, and potentially other hospitalized conditions, in China. Clinical Trial Registration- URL: http://www.anzctr.org.au/default.aspx. Register. Unique identifier: ACTRN12609000491268.

Neglected increases in rural road traffic mortality in China: findings based on health data from 2005 to 2010

BACKGROUND

Recent changes in rural road traffic mortality have not been examined in China although rural residents were reported as having greater risk of road traffic injury than urban residents. We aimed to examine changes in urban and rural road traffic mortality rates between 2005 and 2010 in China.

METHODS

Mortality rates came from the publicly available health data of the Ministry of Health-Vital Registration System that is based on a national representative sample (about 10% of total population), including 41 surveillance points in urban areas (15 large cities and 21 middle/small cities) and 85 surveillance points in rural areas. The causes of deaths were coded using the Tenth International Classification of Diseases (ICD-10). Linear regression was used to test the statistical significance of changes in mortality rates. We calculated the percent change in rates to quantify the change between 2005 and 2010, which was calculated as regression coefficient * 100 * 5 divided by the rate in 2005.

RESULTS

In rural areas, road traffic mortality increased by 70%, changing from 13.3 per 100,000 population in 2005 to 22.7 per 100,000 population in 2010. In contrast, the road traffic mortality merely increased by 4% in the study time period, rising from 13.1 to 13.9 per 100,000 population in urban areas. Both the increases in road traffic mortality from motor vehicle crashes and from non-motor vehicle crashes were larger in rural areas than in urban areas (106% vs. 4%; 29% vs. 3%).

CONCLUSION

The tremendous increase in road traffic mortality in rural areas calls for urgent actions to reduce road traffic injuries to motor vehicle occupants, motorcyclists, bicyclists and pedestrians in in rural areas.

Pre-hospital critical care by anaesthesiologist-staffed pre-hospital services in Scandinavia: a prospective population-based study

BACKGROUND

All Scandinavian countries provide anaesthesiologist-staffed pre-hospital services. Little is known of the incidence of critical illness or injury attended by these services. We aimed to investigate anaesthesiologist-staffed pre-hospital services in Scandinavia with special emphasis on incidence and severity.

METHODS

This population-based, prospective study recorded activity in 16 anaesthesiologist-staffed pre-hospital services in Denmark, Finland, Norway and Sweden serving half of the Scandinavian population. We calculated population incidence of medical conditions, and the proportion of patients with severely deranged vital signs and/or receiving advanced therapy.

RESULTS

Four thousand two hundred thirty-six alarm calls were recorded during 4 weeks. Two thousand two hundred fity-six alarms resulted in a patient encounter. The population incidence varied from 74.9 missions per 10,000 person-years (Denmark), followed by Finland with 14.6, Norway with 11, and Sweden with 5. Medical aetiology was most frequent (14.9 missions per 10,000 person-years, 95% CI: 14.2-15.8). Trauma was second (5.6 missions per 10,000 person-years, 95%CI: 5.12-6.09). Twenty-three per cent of patients had severely deranged vital functions, and advanced emergency medical procedures were performed in every four to twelve encounters (Denmark 8%, Sweden 15%, Norway 23%, and Finland 25%). The probability that the patient was physiologically deranged, received advanced medication, or procedure was 35%. Critical illness or injury occured at a rate of 25-30 per 10,000 person-years.

CONCLUSIONS

The incidence of pre-hospital anaesthesiologist patient encounters in Scandinavia varies. Medical aetiology is most frequent. Almost one-quarter of patients presents with deranged vital functions requiring emergency measures. The Scandinavian pre-hospital population incidence of critical illness and injury is 25-30 per 10,000 person-years.

Prehospital emergency care in Shanghai: present and future

Background

In Shanghai, prehospital emergency medical services are provided by the public Ambulance Services. The 60th anniversary of the local Ambulance Services is a good opportunity to provide an overview of the current trends in prehospital emergency medical care in Shanghai.

Objectives

In this report, the features of Shanghai prehospital emergency medical care are described, as well as the Shanghai model of purely prehospital emergency medical care, including the communications and dispatch system, ambulance depots and ambulances, and prehospital rescue teams. Responses to major incidents including public health emergencies and natural disasters are also discussed, with the intention of highlighting future directions in emergency medical services, as well as the influence of international trends in emergency patient care.

Discussion

Although Shanghai has the most advanced dispatch system in China (equipped with a Global Positioning System, Global Information System, and more) and can be expanded quickly in case of mass casualty incidents, there is, as yet, no uniform Emergency Medical Service (EMS) dispatching for the entire city. Nor are there certifications, degrees, or special continuing education programs available for EMS dispatchers. Although there are more and more ambulance depots spread all over Shanghai, the city struggles with inadequate prehospital emergency caregivers, because every ambulance has to be staffed with a qualified Emergency Physician, and there are also recruitment problems for ambulance physicians.

Conclusions

Although faced with many challenges, substantial progress is expected in Shanghai prehospital emergency care.

Validation of the use of the ROSIER scale in prehospital assessment of stroke

AIM

To determine the utility of the Recognition of Stroke in the Emergency Room (ROSIER) scale as a stroke recognition tool among Chinese patients in the prehospital setting.

MATERIALS AND METHODS

Compared with the Cincinnati Prehospital Stroke Scale (CPSS), emergency physicians prospectively used the ROSIER as a stroke recognition tool on suspected patients in the prehospital setting. And, the final discharge diagnosis of stroke or transient ischemic attack made by neurologists, after assessment and review of clinical symptomatology and brain imaging findings, was used as the reference standard for diagnosis in the study. Then, the ROSIER and the CPSS like sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), related coefficient (r) and Kappa value were calculated.

RESULTS

In this study, 540 of 582 suspected stroke patients met the study criteria. The CPSS showed a diagnostic Se of 88.77% (95% confidence intervals [CI] 86.11-91.43%), Sp of 68.79% (95% CI 64.88-72.70%), PPV of 87.40% (95% CI 85.97-88.83%), NPV of 71.52% (95% CI 67.71-75.33%) and r of 0.503. Relatively, the ROSIER showed a diagnostic Se of 89.97% (95% CI 87.44-92.64%), Sp of 83.23% (95% CI 80.08-86.38%), PPV of 92.66% (95% CI 90.46-94.86%), NPV of 77.91% (95% CI 74.41-81.41%) and r of 0.584. According to the final discharge diagnosis, both the ROSIER and the CPSS were associated with the final discharge diagnosis (P < 0.05).The Kappa statistic value of the ROSIER and the CPSS were 0.718 and 0.582, respectively. However, there was no statistical significance of the positive rate between the ROSIER and the CPSS in this study (P > 0.05).

CONCLUSIONS

The ROSIER is a sensitive and specific stroke recognition tool for health providers' use among Chinese patients in the prehospital setting. However, it cannot be used to confidently rule out or identify stroke as a diagnosis. Comprehensive clinical assessment and further examination on potential stroke patients are still important and cannot be replaced. When it is difficult to objectively complete the ROSIER for patients, the CPSS could replace it in the prehospital setting.

Overview of the shenzhen emergency medical service call pattern

BACKGROUND

In Shenzhen, the Emergency Medical Service (EMS) system has been in service since 1997. This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS.

METHODS

In this retrospective quantitative descriptive study, the data from the Shenzhen 120 EMS registry in 2011 were analyzed.

RESULTS

Shenzhen 120 EMS center is a communication command center. When the number of 120 are dialed, it is forwarded to the closest appropriate hospital for ambulance dispatch. In 2011, the Shenzhen 120 EMS center received 153 160 ambulance calls, with an average of 420 calls per day. Calling emergency services was mainly due to traffic accidents. Trauma and other acute diseases constituted a majority of ambulance transports. The adult patients aged 15-60 years are the principal users of EMS. There are no recognized 'paramedic' doctors and nurses. The pre-hospital emergency service is under the operation of emergency departments of hospitals. Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in post-trauma management. Moreover, specialized pre-hospital training, financial support, and public health education on proper use of EMS should be emphasized.

CONCLUSION

The Shenzhen 120 EMS center has its own epidemiology characteristics. Traumatic injury and traffic accident are the main reasons for calling ambulance service. In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.