Trends of pre-hospital emergency medical services activity over 10 years: a population-based registry analysis

Competence expected from advanced-level paramedics by emergency medical services managers in Finland: a modified Delphi study

BACKGROUND

Competence is a critical attribute for paramedics in emergency medical services (EMSs) because of the complex and diverse demands of the prehospital environment. This study aimed to identify and rank the key competencies expected of advanced-level paramedics as perceived by EMS managers.

METHODS

The modified Delphi study included three rounds conducted between October 2022 and June 2023. The panel consisted of 44 EMS managers, all working as superiors in EMS organizations across Finland.

RESULTS

In Round 1, 44 experts (100% response rate) evaluated 43 claims, with a consensus (≥ 75%) reached on five claims. The open-ended responses generated seven additional claims. In Round 2, 45 claims were reviewed; however, no consensus was reached. In Round 3, the top 15 claims from previous rounds were reevaluated (95% response rate), with assessment of patient conditions via the ABCDE protocol ranking highest. The experts also emphasized patient-centered care, safe environments, and systematic approaches in EMS.

CONCLUSIONS

This study used the Delphi method to identify essential competencies for advanced-level paramedics, emphasizing patient assessment via the ABCDE protocol. This highlights the importance of core skills and nontechnical competencies such as supervision and well-being, stressing the need for continuous updates in paramedic training.

Strengthening the WHO Emergency Care Systems Framework: insights from an integrated, patient-centered approach in the Copenhagen Emergency Medical Services system-a qualitative system analysis

BACKGROUND

The World Health Organization Emergency Care Systems Framework (WHO ECSF) was designed to offer guidance in establishing and developing effective Emergency Medical Services (EMS) systems. However, evolving disease patterns, changing community needs, and a rising demand for emergency care services, highlight the need for more integrated and patient-centered EMS systems. This evolution should be mirrored in the WHO ECSF. Hence, this study explores system components of the Copenhagen (CPH) EMS that may enhance the WHO ECSF´s emphasis on integrated and patient-centered care.

METHODS

A qualitative case study was conducted from April through June 2021, including (i) semi-structured interviews with researchers and professionals at the CPH EMS and (ii) a scoping literature review using PubMed, Google Scholar, expert recommendations and snowballing.

RESULTS

Thirteen expert interviews and 35 records were analyzed, revealing key integrated care components within the CPH EMS. These include education and citizen participation programs, early triaging, differentiated care pathways coordinated with primary care and out-of-hours services, and specialized mobile care units complementing "traditional" ambulance services. Technology supports integrated and patient-centered care by facilitating early differentiation of care, efficient dispatching, and communication. Data-driven approaches were fostered through technology-aided data collection, supporting research, quality improvement, and patient safety. The identified components were mapped within the WHO ECSF´s four domains: scene, transport, facility, and cross-cutting elements. Due to the prehospital focus of the CPH EMS, limited data was available for the "facility" site.

CONCLUSIONS

The CPH EMS demonstrates an integrated, patient-centered systems approach that emphasizes seamless coordination along the patient care pathway, bridging EMS with broader health and social systems. Research-informed initiatives and intelligent technology solutions underscore the potential for enhancing the WHO ECSF. These findings highlight the importance of continued system integration and a holistic health perspective, including in emergency settings. Further research is needed to assess the transferability of these components across diverse global contexts.

TRIAL REGISTRATION

Not applicable.

Is non-conveyance solo-ambulances a useful mean to meet the increasing demand for emergency medical services in Denmark?

BACKGROUND

The growing demand for acute medical assistance creates an increasing pressure on emergency medical services (EMS) and emergency departments. This calls for initiatives to prevent avoidable admissions. A novel non-conveyance solo-ambulance was introduced in the Central Denmark Region; the Prehospital Visitation Unit (PVU). We investigated patient characteristics and prehospital management by the PVU, while exploring employee perspectives on the implementation process and how they perceived their expanded role and responsibilities working with the PVU.

METHODS

This mixed-methods study had a convergent parallel design. Patient data was collected on all patients assessed by the PVU between April 1st 2022 and April 1st 2023. Furthermore, 19 semi-structured interviews with paramedics, EMS dispatchers and technical dispatchers partaking in the operation of the PVU were conducted. Interviews were analyzed using thematic analysis with an inductive approach, drawing on principles from grounded theory.

RESULTS

Throughout the study period, the PVU served 1510 patients (median age: 60, IQR: 33-77). Among these, 83.6% were assigned an urgency level B, indicating acute, but not life-threatening, situations. Patients presented with a broad range of complaints, including a high number of patients with non-specific complaints. Paramedics completed treatment on-scene for 29.1% of all patients, spending a median time of 49 min (IQR: 33-64) on-scene. In the interviews, four themes were identified: (1) The implementation strategy had gaps, but was supported by ongoing adjustments, (2) Facilitating a patient-centered approach for the benefit of the patient and the system, (3) Community partnership and internal collaboration enabled paramedics as healthcare facilitators, and (4) Flexible workflows were needed to maintain professional agency.

CONCLUSIONS

The PVU seems to offer a valuable alternative within the EMS, particularly for patients with non-specific complaints and conditions manageable at a lower level of care. Strong collaboration allowed paramedics to take on a facilitating role, creating appropriate pathways and providing patient-centered care. However, for successful implementation, ongoing adjustments were required, particularly in maintaining the professional autonomy of the healthcare professionals. As prehospital EMS increasingly respond to non-acute medical needs, initiatives like the PVU can play an important role in meeting growing demands.

An analysis of ambulance re-contacts after non-conveyance: a retrospective cohort study in the Netherlands

BACKGROUND

Non-conveyance is an increasing part of ambulance care and has to be safe. One of the indicators to measure safety is an ambulance re-contact within 72 h. However, solely measuring the percentage of re-contacts has limited validity as it lacks insight in actual reasons of an ambulance re-contact. Therefore, the aim of our study was to analyze the incidence, reasons and outcomes of ambulance re-contacts within 72 h after non-conveyance.

METHODS

We conducted a one year (2022) retrospective study in one EMS region in the Netherlands. Medical records of all non-conveyance runs with a re-contact were analyzed using a framework to categorize re-contact reasons in illness-related, patient-related, professional-related, and unrelated. Re-contact outcomes were measured in terms of (non-)conveyance and mortality.

RESULTS

585/13.879 (4.2%) non-conveyance runs had a re-contact within 72 h. 547/585 (93.5%) re-contacts could be categorized with the framework. Re-contacts were related to the illness (n = 267, 48.8%), the patient (n = 130, 23.8%), the professional (n = 106, 19.4%) and unrelated (n = 44, 8.0%). Four subreasons accounted for 68.5% of reasons for re-contacts: progression of disease (19.4%), recurrent disease process/exacerbation (18.6%), reassessment and ambulance request by another medical professional (15.9%), and psychiatric disorder and/or substance abuse (14.6%). 403/547 (73.7%) patients with a re-contact were conveyed to the hospital. Mortality rate for patients with a re-contact was 0.5%.

CONCLUSIONS

Re-contact incidence after non-conveyance is relatively low, with a very small part of re-contacts related to ambulance care professionals making errors in diagnosis or treatment. Combined with low re-contact mortality, this indicates safe non-conveyance decisions. Re-contacts as quality indicator cover a variety of reasons, with almost half of the re-contacts being related to illness. Four subcategories accounted for the majority of all reasons for re-contacts: progression of disease, recurrent disease process/exacerbation, reassessment and ambulance request by another medical professional, and psychiatric disorder and/or substance abuse. Three-quarters of the patients were conveyed, although more re-contacts due to patient related reasons ended in non-conveyance again.

Patient complaints are not common in emergency medical services: A mixed methods study

INTRODUCTION

Patient safety has become a central research theme in emergency medical services (EMS). The population age structure is changing in high-income countries, potentially causing increases in the need for EMS. As the number of EMS missions is growing, the safety of non-conveyance has become the topic of wide discussion. Managing adverse events is part of quality management and safety improvement. This study aimed to examine the incidence, reasons, and process of complaints related to EMS.

METHODS

A retrospective mixed methods study was conducted on EMS-related complaints that were evaluated by Regional State Administrative Agency during 2013-2019. The data was classified according to conveyance and authority's decision, and finally analysed thematically.

RESULTS

The data included 73 complaints, 39 of which were included in the study. There were more complaints related to non-conveyance than conveyance. The authority provided administrative guidance in approximately half of the cases in both groups. One of the most common event types in both groups was related to ethical competence and conduct.

CONCLUSIONS

The number of complaints was very low. A considerable portion of the complaints related to paramedics' behavior and patient treatment. Respecting and actively listening to patients may further decrease these complaints. No administrative caveats to paramedics were observed in our data.

Factors affecting emergency medical dispatchers decision making in stroke calls - a qualitative study

OBJECTIVES

Emergency Medical Communication Centers (EMCC) have a key role in the prehospital chain-of-stroke-survival by recognizing stroke patients and reducing prehospital delay. However, studies on EMCC stroke recognition report both substantial undertriage and overtriage. Since mis-triage at the EMCC challenges the whole chain-of-stroke-survival, by occupying limited resources for non-stroke patients or failing to recognize the true stroke patients, there is a need to achieve a more comprehensive understanding of the dispatchers' routines and experiences. The aim of this study was to explore factors affecting EMCC dispatcher's decision-making in stroke calls.

MATERIALS AND METHODS

A qualitative exploratory study, based on individual semi-structured interviews of 15 medical dispatchers from EMCC Oslo, Norway. Interviews were conducted during August and October 2022 and analyzed using the principles of thematic analysis.

RESULTS

We identified four themes: [1] Pronounced stroke symptoms are easy to identify [2]. Non-specific neurological symptoms raise suspicion of acute stroke but are difficult to differentiate from other medical conditions [3]. Consistent use of the Criteria Based Dispatch (CBD) protocol may increase EMCC overtriage [4]. Contextual conditions at EMCC can affect dispatchers' decision-making process and the ability for experiential learning.

CONCLUSIONS

Medical dispatchers at the EMCC perceive vague and non-specific stroke symptoms, such as dizziness, confusion or altered behaviour, challenging to differentiate from symptoms of other less time-critical medical conditions. They also perceive the current CBD protocol in use as less supportive in assessing such symptoms. High workload and strict EMCC response time interval requirements hinder the gathering of essential patient information and the ability to seek guidance in cases of doubt, potentially exacerbating both EMCC undertriage and overtriage. The absence of feedback loops and other strategies for experiential learning in the EMCC hampers the medical dispatcher's ability to evaluate their own assessments and improve dispatch accuracy.

Final diagnoses and mortality rates in ambulance patients administered nebulized β2-agonists bronchodilators

To assess final diagnoses and mortality rates (30 day and 1 year) in patients treated with the inhaled bronchodilator salbutamol by ambulance personnel, and to establish its role as an identifier of moderate to severe respiratory distress in the prehospital phase of treatment. In a descriptive retrospective observational study, patients experiencing respiratory distress and treated with inhaled bronchodilators, specifically salbutamol, in the prehospital setting within the Central Denmark Region during 2018-2019 were included. The study included 6318 ambulance transports, comprising 3686 cases of acute exacerbation of chronic obstructive pulmonary disease (AECOPD), 234 with community-acquired pneumonia (CAP), 320 with heart disease (HD), 233 adults with asthma, 1674 with various other primary ICD-10 diagnoses (other ≥ 18 years), and 171 patients under 18 years. The 30 day mortality rate for all patients was 10.7% (95% CI 9.8-11.6), with zero deaths within 30 days among adults with asthma and those under 18. Excluding low mortality groups, AECOPD patients had the lowest 30 day mortality at 10.2% (95% CI 9.1-11.3), and HD patients the highest at 15.3% (95% CI 10.6-19.9). The 1-year overall mortality rate increased to 32.1% (95% CI 30.2-34.0), with mortality staying low for asthma and under-18 groups, while differences between other groups lessened and became insignificant. Patients requiring inhaled bronchodilator treatment in ambulances exhibit notably high mortality rates at 30 days and 1 year, except for those with asthma or under 18. The need for prehospital bronchodilators could serve as a clear and unmistakable marker for moderate to severe respiratory distress, enabling early intervention.

A retrospective analysis of the need for on-site emergency physician presence and mission characteristics of a rural ground-based emergency medical service

BACKGROUND

This study aimed to address the challenges faced by rural emergency medical services in Europe, due to an increasing number of missions and limited human resources. The primary objective was to determine the necessity of having an on-site emergency physician (EP), while the secondary objectives included analyzing the characteristics of rural EP missions.

METHODS

A retrospective study was conducted, examining rural EP missions carried out between January 1st, 2017, and December 2nd, 2021 in Burgenland, Austria. The need for physical presence of an EP was classified based on the National Advisory Committee for Aeronautics (NACA) score into three categories; category A: no need for an EP (NACA 1-3); category B: need for an EP (NACA 1-3 along with additional medical interventions beyond the capabilities of emergency medical technicians); and category C: definite need for an EP (NACA 4-7). Descriptive statistics were used for analysis.

RESULTS

Out of 16,971 recorded missions, 15,591 were included in the study. Approximately 32.3% of missions fell into category A, indicating that an EP's physical presence was unnecessary. The diagnoses made by telecommunicators matched those of the EPs in only 52.8% of cases.

CONCLUSION

The study suggests that about a third of EP missions carried out in rural areas might not have a solid medical rationale. This underscores the importance of developing an alternative care approach for these missions. Failing to address this could put additional pressure on already stretched EMS systems, risking their collapse.

Refining ambulance clinical response models: The impact on ambulance response and emergency department presentations

OBJECTIVE

The ambulance service in Victoria, Australia implemented a revised clinical response model (CRM) in 2016 which was designed to increase the diversion of low-acuity Triple Zero (000) calls to secondary telephone triage and reduce emergency ambulance dispatches. The present study evaluates the influence of the revised CRM on emergency ambulance response times and ED presentations.

METHODS

A retrospective study of emergency calls for ambulance between 1 January 2015 and 31 December 2018. Ambulance data were linked with ED presentations occurring up to 48 h after contact. Interrupted time series analyses were used to evaluate the impact of the revised CRM.

RESULTS

A total of 2 365 529 calls were included. The proportion allocated a Code 1 (time-critical, lights/sirens) dispatch decreased from 56.6 to 41.0% after implementation of the revised CRM. The proportion of calls not receiving an emergency ambulance increased from 10.4 to 19.6%. Interrupted time series analyses demonstrated an improvement in Code 1 cases attended within 15 min (Key Performance Indicator). However, for patients with out-of-hospital cardiac arrest or requiring lights and sirens transport to hospital, there was no improvement in response time performance. By the end of the study period, there was also no difference in the proportion of callers presenting to ED when compared with the estimated proportion assuming the revised CRM had not been implemented.

CONCLUSION

The revised CRM was associated with improved Code 1 response time performance. However, there was no improvement in response times for high acuity patients, and no change in the proportion of callers presenting to ED.

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.

ICD-10 Classification in the Practice of Emergency Medical Teams: New Insights

The role of the emergency medical system is to provide assistance to every person in a state in the event of a sudden threat to health and life. Emergency medical teams (EMTs) are an important element of this system, making diagnoses based on the International Classification of Diseases (ICD-10). The study was aimed at analysing the causes of EMT intervention based on groups of diagnoses codified according to the ICD-10. The analysis was based on data from 116,278 EMT interventions in central-eastern Poland in 2017-2019. The research showed that EMT most often made diagnoses based on groups of ICD-10 codes: R00-R99-Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (39.11%); S00-T98-Injury, poisoning, and certain other consequences of external causes (18.23%); and I00-I99-Diseases of the circulatory system (15.57%). The analysis of the obtained results showed statistically significant differences (p < 0.0001) regarding the area of intervention (urban, rural), sex, age of the patient, and the method of completion of the activities by EMTs in relation to the group of ICD-10 diagnoses for the diagnosis. The conducted study showed the actual reasons for EMT calls. The use of the ICD-10 classification has practical application in EMTs, as it enables the identification of a disease or health problem.

Optimizing remote and rural prehospital resources using air transport of thrombectomy candidates

BACKGROUND

In Finland, the yearly number of mechanical thrombectomies for acute stroke is increasing and more patients are transported over 100 km to the comprehensive stroke centre (CSC) for definitive care. This leaves the rural townships without immediate emergency medical services (EMS) for hours. In this study we compare the EMS' estimated return times to own station after the handover of a thrombectomy candidate between two transport methods: (1) using ground transportation with an ambulance to the CSC or (2) using a hydrid strategy starting the transportation with an ambulance and continuing by air with a helicopter emergency medical services unit (HEMS).

METHODS

We reviewed retrospectively all thrombectomy candidates' transportations from the hospital district of South Ostrobothnia to definitive care at the nearest CSC, Tampere University Hospital from June 2020 to October 2022. The dispatch protocol stated that a thrombectomy candidate's transport begins immediately with an ambulance and if the local HEMS unit is available the patient is handed over to them at a rendezvous. If not, the patient is transported to the CSC by ground. Transport times and locations of the patient handovers were reviewed from the CSC's EMS database and the driving time back to ambulance station was estimated using Google maps. The HEMS unit's pilot's log was reviewed to assess their mission engagement time.

RESULTS

The median distance from the CSC to the ambulances' stations was 188 km (IQR 149-204 km) and from the rendezvous with the HEMS unit 70 km (IQR 51-91 km, p < 0.001). The estimated median driving time back to station after the patient handover at the CSC was 145 min (IQR 117-153 min) compared to the patient handover to the HEMS unit 53 min (IQR 38-68 min, p < 0.001). The HEMS unit was occupied in thrombectomy candidate's transport mission for a median of 136 min (IQR 127-148 min).

CONCLUSION

A hybrid strategy to transport thrombectomy candidates with an ambulance and a helicopter reallocates the EMS resources markedly faster back to their own district.

Using machine learning to assess the extent of busy ambulances and its impact on ambulance response times: A retrospective observational study

BACKGROUND

Ambulance response times are considered important. Busy ambulances are common, but little is known about their effect on response times.

OBJECTIVE

To assess the extent of busy ambulances in Central Norway and their impact on ambulance response times.

DESIGN

This was a retrospective observational study. We used machine learning on data from nearby incidents to assess the probability of up to five different ambulances being candidates to respond to a medical emergency incident. For each incident, the probability of a busy ambulance was estimated by summing the probabilities of candidate ambulances being busy at the time of the incident. The difference in response time that may be attributable to busy ambulances was estimated by comparing groups of nearby incidents with different estimated busy probabilities.

SETTING

Medical emergency incidents with ambulance response in Central Norway from 2013 to 2022.

MAIN OUTCOME MEASURES

Prevalence of busy ambulances and differences in response times associated with busy ambulances.

RESULTS

The estimated probability of busy ambulances for all 216,787 acute incidents with ambulance response was 26.7% (95% confidence interval (CI) 26.6 to 26.9). Comparing nearby incidents, each 10-percentage point increase in the probability of a busy ambulance was associated with a delay of 0.60 minutes (95% CI 0.58 to 0.62). For incidents in rural and urban areas, the probability of a busy ambulance was 21.6% (95% CI 21.5 to 21.8) and 35.0% (95% CI 34.8 to 35.2), respectively. The delay associated with a 10-percentage point increase in busy probability was 0.81 minutes (95% CI 0.78 to 0.84) and 0.30 minutes (95% CI 0.28 to 0.32), respectively.

CONCLUSION

Ambulances were often busy, which was associated with delayed ambulance response times. In rural areas, the probability of busy ambulances was lower, although the potentially longer delays when ambulances were busy made these areas more vulnerable.

[Implementation of procedures by the Mobile Emergency Care Service (SAMU 192) in Brazil: performance, benchmarking, and challenges]

The scope of this article is to describe and analyze the production of approved procedures carried out by regulation centers and mobile resources of SAMU 192 between 2015 and 2019, according to frequency, population-based indicators, and daily productivity, to establish a performance indicator. It consisted of an observational and descriptive census study, with production data drawn from the Outpatient Information System, and population data from the Brazilian Institute of Geography and Statistics and information from the Ministry of Health. The 116.8 million procedures analyzed resulted from a 28.5% increase in the period, while the population covered and mobile resources grew by 9.7% and 14.4%, respectively. Every 1,000 inhabitants covered generated 109.8 calls, resulting in 24.0 mobile resource dispatches per year. Basic support units performed 3.3 consultations, and 0.5 transfers daily, while advanced support performed 2.7 consultations and 0.9 transfers. The production of procedures exceeded the increase in the population covered, with variations between states, high incidence in populated areas, a strong presence of basic support and an increase in transfers, although national productivity was seen to be lower than international productivity.

Patient factors associated with conveyance decision-making by Emergency Medical Services professionals in patients with a syncope: a cross-sectional factorial survey design

BACKGROUND

The clinical decision-making of non-conveyance is perceived as complex and difficult by emergency medical services (EMS) professionals. Patients with a transient loss of consciousness (TLOC) based on syncope constitute a significant part of the non-conveyance population. Risk stratification is the basis of the clinical decision-making process by EMS professionals. This risk stratification is based on various patient factors. This study aimed to explore patient factors significantly associated with conveyance decision-making by EMS professionals in patients with a TLOC based on syncope.

METHODS

A cross-sectional vignette study with a factorial survey design was conducted. Patient factors were derived from the "National Protocol Ambulance Care", and all possible combinations of these factors and underlying categories were combined, resulting in 256 unique vignettes (2*4*4*4*2 = 256). Patient factors presented either low-risk or high-risk factors for adverse events. Data were collected through an online questionnaire, in which participants received a random sample of 15 vignettes. For each vignette, the respondent indicated whether the patient would need to be conveyed to the emergency department or not. A multilevel logistic regression analysis with stepwise backward elimination was performed to analyse factors significantly associated with conveyance decision-making. In the logistic model, we modelled the probability of non-conveyance.

RESULTS

110 respondents were included, with 1646 vignettes being assessed. Mean age 45.5 (SD 9.3), male gender 63.6%, and years of experience 13.2 (SD 8.9). Multilevel analysis showed two patient factors contributing significantly to conveyance decision-making: 'red flags' and 'prehospital electrocardiogram (ECG)'. Of these patient factors, three underlying categories were significantly associated with non-conveyance: 'sudden cardiac death < 40 years of age in family history' (OR 0.33, 95% CI 0.22-0.50; p < 0.001), 'cardiovascular abnormalities, pulmonary embolism or pulmonary hypertension in the medical history' (OR 0.62, 95% CI 0.43-0.91; p = 0.01), and 'abnormal prehospital ECG' (OR 0.54, 95% CI 0.41-0.72; p < 0.001).

CONCLUSION

Sudden cardiac death < 40 years of age in family history, medical history, and abnormal ECG are significantly negatively associated with non-conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. Low-risk factors do not play a significant role in conveyance decision-making.

Artificial intelligence-based opportunistic detection of coronary artery stenosis on aortic computed tomography angiography in emergency department patients with acute chest pain

Aims

To evaluate a deep-learning model (DLM) for detecting coronary stenoses in emergency room patients with acute chest pain (ACP) explored with electrocardiogram-gated aortic computed tomography angiography (CTA) to rule out aortic dissection.

Methods and results

This retrospective study included 217 emergency room patients (41% female, mean age 67.2 years) presenting with ACP and evaluated by aortic CTA at our institution. Computed tomography angiography was assessed by two readers, who rated the coronary arteries as 1 (no stenosis), 2 (<50% stenosis), or 3 (≥50% stenosis). Computed tomography angiography was categorized as high quality (HQ), if all three main coronary arteries were analysable and low quality (LQ) otherwise. Curvilinear coronary images were rated by a DLM using the same system. Per-patient and per-vessel analyses were conducted. One hundred and twenty-one patients had HQ and 96 LQ CTA. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of the DLM in patients with high-quality image for detecting ≥50% stenoses were 100, 62, 59, 100, and 75% at the patient level and 98, 79, 57, 99, and 84% at the vessel level, respectively. Sensitivity was lower (79%) for detecting ≥50% stenoses at the vessel level in patients with low-quality image. Diagnostic accuracy was 84% in both groups. All 12 patients with acute coronary syndrome (ACS) and stenoses by invasive coronary angiography (ICA) were rated 3 by the DLM.

Conclusion

A DLM demonstrated high NPV for significant coronary artery stenosis in patients with ACP. All patients with ACS and stenoses by ICA were identified by the DLM.

Prehospital Misdiagnosed Acute Coronary Syndrome-Incidence, Discriminating Features, and Differential Diagnoses

Background

Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the western world. Classic angina pectoris (AP) is a common reason to request prehospital emergency medical services (EMS). Nevertheless, data on diagnostic accuracy and common misdiagnoses are scarce. Therefore, the aim of this study is to evaluate the amount and variety of misdiagnoses and assess discriminating features.

Methods

For this retrospective cohort study, all patients requiring EMS for suspected ACS in the city of Bonn (Germany) during 2018 were investigated. Prehospital and hospital medical records were reviewed regarding medical history, presenting signs and symptoms, as well as final diagnosis.

Results

Out of 740 analyzed patients with prehospital suspected ACS, 283 (38.2%) were ultimately diagnosed with ACS (ACS group). Common diagnoses in the cohort with non-confirmed ACS (nACS group) consisted of unspecific pain syndromes, arrhythmias, hypertensive crises, and heart failure. ST segment elevation (adjusted odds-ratios [adj. OR] 2.70), male sex (adj. OR 1.71), T wave changes (adj. OR 1.27), angina pectoris (adj. OR 1.15) as well as syncope (adj. OR 0.63) were identified among others as informative predictors in a multivariable analysis using the lasso technique for data-driven variable selection.

Conclusions

Misdiagnosed ACS is as common as 61.8% in this cohort and analyses point to a complex of conditions and symptoms (i.e., male sex, electrocardiographic (ECG) changes, AP) for correct ACS diagnosis while neurological symptoms were observed significantly more often in the nACS group (e.g., Glasgow Coma Scale (GCS) < 15, p = 0.03). To ensure adequate and timely therapy for a potentially critical disease as ACS a profound prehospital examination and patient history is indispensable.

Urban-sub-urban-rural variation in the supply and demand of emergency medical services

Background

Emergency medical services (EMSs) are a critical component of health systems, often serving as the first point of contact for patients. Understanding EMS supply and demand is necessary to meet growing demand and improve service quality. Nevertheless, it remains unclear whether the EMS supply matches the demand after the 2016 healthcare reform in China. Our objective was to comprehensively investigate EMS supply-demand matching, particularly among urban vs. sub-urban vs. rural areas.

Methods

Data were extracted from the Tianjin Medical Priority Dispatch System (2017-2021). From supply and demand perspectives, EMS resources and patient characteristics were analyzed. First, we performed a descriptive analysis of characteristics, used Moran's I to explore the spatial layout, and used the Gini coefficient to evaluate the equity of EMS supply and demand. Second, we analyzed urban-sub-urban-rural variation in the characteristics of EMS supply and demand by using the chi-square test. Finally, we examined the association between the EMS health resource density index and the number of patients by using the Spearman correlation and divided supply-demand matching types into four types.

Results

In 2021, the numbers of medical emergency stations and ambulances were 1.602 and 3.270 per 100,000 population in Tianjin, respectively. There were gradients in the health resource density index of the number of emergency stations (0.260 vs. 0.059 vs. 0.036; P = 0.000) in urban, sub-urban, and rural areas. There was no spatial autocorrelation among medical emergency stations, of which the G values by population, geographical distribution, and the health resource density index were 0.132, 0.649, and 0.473, respectively. EMS demand was the highest in urban areas, followed by sub-urban and rural areas (24.671 vs. 15.081 vs. 3.210 per 1,000 population and per year; P = 0.000). The EMS supply met the demand in most districts (r = 0.701, P = 0.003). The high supply-high demand types with stationary demand trends were distributed in urban areas; the low supply-high demand types with significant demand growth trends were distributed in sub-urban areas; and the low supply-low demand types with the highest speed of demand growth were distributed in rural areas.

Conclusion

EMS supply quantity and quality were promoted, and the supply met the demand after the 2016 healthcare reform in Tianjin. There was urban-sub-urban-rural variation in EMS supply and demand patterns.

Characteristics of Emergencies in the Workplace from the Perspective of the Emergency Medical Services: A 4-Year Case-Control Study

INTRODUCTION

Accidents and emergencies in the workplace account for a significant proportion of emergency calls worldwide. The specificity of these events is often associated with hazards at a given workplace. Patients do not always require hospitalization; therefore, the characteristics of events can only be determined from the perspective of emergency medical services teams. The aim of the study was to analyze calls and the course of emergency ambulance interventions to patients at their workplace.

MATERIAL AND METHODS

The study was conducted based on a retrospective analysis of data contained in the medical records of the ambulance service from central Poland from 2015-2018. From all interventions (n = 155,993), 1601 calls to work were selected, and the urgency code, time of day and year, patients' sex, general condition, as well as diagnoses according to the International Classification of Diseases-ICD-10 and the method of ending the call were considered.

RESULTS

The mean age of patients in the study group was 42.4 years (SD ± 13.5). The majority were men (n = 918; 57.3%). The number of calls increased in the autumn (n = 457; 28.5%) and in the morning (n = 609; 38.0%). The main reasons for the intervention were illnesses (ICD-10 group: R-'symptoms') and injuries (ICD-10 group: S, T-'injuries'). Calls at workplaces most often ended with the patient being transported to the hospital (78.8%), and least often with his death (0.8%).

CONCLUSIONS

The patient profile in the workplace indicates middle-aged men who fall ill in the fall, requiring transport to the hospital and further diagnostics.

The General Public Awareness of Emergency Conditions and the Services Provided by Emergency Medical Services

Objective

Considering the growing use of emergency medical services (EMS), we evaluated the level of public awareness of emergency situations in Iran.

Methods

This cross-sectional study was conducted from August 2021 to January 2023 on Iranian residents in Tehran, who were older than 18 years old. The participants were directed to a URL for an online survey link and asked to select their preferred options for the predetermined scenarios. We divided the participants into three groups: abuse, misuse, and non-use. At least 12 correct answers were required to qualify as acceptable knowledge and practice responses (KP score). Then, the relationship between participants' baseline characteristics and their level of awareness was investigated.

Results

Totally, 3864 people participated in the study, of whom 50.5% were men. The participants' ages ranged from 18 to 90 years old, with a mean age of 40.01±11.30 years. In general, the rate of abuse, misuse, and not-use in at least one scenario was 74.5%, 64%, and 70.4%, respectively. The results of the multivariable regression analysis indicated that female sex (OR=1.29), a higher education level (OR=3.36), a higher income level (OR=1.64), and Turkish ethnicity (OR=1.20) were significantly associated with the correct KP score.

Conclusion

The degree of inappropriate utilization of EMS services in Iran was significant. We found that the proper knowledge regarding the appropriate use of EMS was significantly associated with the participant's level of education, academic field, job, and income.

Diagnoses and mortality among prehospital emergency patients calling 112 with unclear problems: a population-based cohort study from Denmark

BACKGROUND

Patients calling for an emergency ambulance and assessed as presenting with 'unclear problem' account for a considerable part of all emergency calls. Previous studies have demonstrated that these patients are at increased risk for unfavourable outcomes. A deeper insight into the underlying diagnoses and outcomes is essential to improve prehospital treatment. We aimed to investigate which of these diagnoses contributed most to the total burden of diseases in terms of numbers of deaths together with 1- and 30-day mortality.

METHODS

A historic regional population-based observational cohort study from the years 2016 to 2018. Diagnoses were classified according to the World Health Organisation ICD-10 System (International Statistical Classification of Diseases and Related Health Problems, 10th edition). The ICD-10 chapters, R ('symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified)' and Z ('factors influencing health status and contact with health services") were combined and designated "non-specific diagnoses". Poisson regression with robust variance estimation was used to estimate proportions of mortality in percentages with 95% confidence intervals, crude and adjusted for age, sex and comorbidities.

RESULTS

Diagnoses were widespread among the ICD-10 chapters, and the most were 'non-specific diagnoses' (40.4%), 'circulatory diseases' (9.6%), 'injuries and poisonings' (9.4%) and 'respiratory diseases' (6.9%). The diagnoses contributing most to the total burden of deaths (n = 554) within 30 days were 'circulatory diseases' (n = 148, 26%) followed by 'non-specific diagnoses' (n = 88, 16%) 'respiratory diseases' (n = 85, 15%), 'infections' (n = 54, 10%) and 'digestive disease' (n = 39, 7%). Overall mortality was 2.3% (1-day) and 7.1% (30-days). The risk of mortality was highly associated with age.

CONCLUSION

This study found that almost half of the patients brought to the hospital after calling 112 with an 'unclear problem' were discharged with a 'non-specific diagnosis' which might seem trivial but should be explored more as these contributed the second-highest to the total number of deaths after 30 days only exceeded by 'circulatory diseases'.

The potential of new prediction models for emergency medical dispatch prioritisation of patients with chest pain: a cohort study

Objectives

To develop emergency medical dispatch (EMD) centre prediction models with high sensitivity and satisfying specificity to identify high-priority patients and patients suitable for non-emergency care respectively, when assessing patients with chest pain.

Methods

Observational cohort study of 2917 unselected patients with chest pain who contacted an EMD centre in Sweden due to chest pain during 2018. Multivariate logistic regression was applied to develop models predicting low-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge.

Results

Prediction models were developed for the identification of patients suitable for high- and low-priority dispatch, using 11 and 10 variables respectively. The area under the receiver-operating characteristic curve (AUROC) for the high-risk prediction model was 0.79 and for the low-risk model it was 0.74. When applying the high-risk prediction model, 56% of the EMS missions were given highest priority, compared with 65% with the current standard. When applying the low-risk model, 7% were given the lowest priority compared to 1% for the current standard. The new prediction models outperformed today’s dispatch priority accuracy in terms of sensitivity as well as positive and negative predictive value in both high- and low-risk prediction. The low-risk model predicted almost six times as many patients as having low-risk conditions compared with today’s standard. This was done without increasing the number of high-risk patients wrongly assessed as low-risk.

Conclusions

By introducing prediction models, based on logistic regression analyses, using variables obtained by standard EMD-questions on age, sex, medical history and symptomology, EMD prioritisation can be improved compared with using current criteria index-based ones. This will allow a more efficient emergency medical services resource allocation.

Ambulance crew-initiated non-conveyance in the Helsinki EMS system-A retrospective cohort study

Background

Ambulance patients are usually transported to the hospital in the emergency medical service (EMS) system. The aim of this study was to describe the non‐conveyance practice in the Helsinki EMS system and to report mortality following non‐conveyance decisions.

Methods

All prehospital patients ≥16 years attended by the EMS but not transported to a hospital during 2013–2017 were included in the study. EMS mission‐ and patient‐related factors were collected and examined in relation to patient death within 30 days of the EMS non‐conveyance decision.

Results

The EMS performed 324,207 missions with a patient during the study period. The patient was not transported in 95,909 (29.6%) missions; 72,233 missions met the study criteria. The patient mean age (standard deviation) was 59.5 (22.5) years; 55.5% of patients were female. The most common dispatch codes were malaise (15.0%), suspected decline in vital signs (14.0%), and falling over (12.9%). A total of 960 (1.3%) patients died within 30 days after the non‐conveyance decision. Multivariate logistic regression analysis revealed that mortality was associated with the patient's inability to walk (odds ratio 3.19, 95% confidence interval 2.67–3.80), ambulance dispatch due to shortness of breath (2.73, 2.27–3.27), decreased level of consciousness (2.72, 1.75–4.10), decreased blood oxygen saturation (2.64, 2.27–3.06), and abnormal systolic blood pressure (2.48, 1.79–3.37).

Conclusion

One‐third of EMS missions did not result in patient transport to the hospital. Thirty‐day mortality was 1.3%. Abnormalities in multiple respiratory‐related vital signs were associated with an increased likelihood of death within 30 days.

Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings

Background

We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT).

Methods

A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period.

Results

Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or ‘not eligible for intensive care’ (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician.

Conclusion

Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01002-8.

Prehospital Translation of Chest Pain Tools (RESCUE Study): Completion Rate and Inter-rater Reliability

INTRODUCTION

Chest pain is a common reason for ambulance transport. Acute coronary syndrome (ACS) and pulmonary embolism (PE) risk assessments, such as history, electrocardiogram, age, risk factors (HEAR); Emergency Department Assessment of Chest Pain Score (EDACS); Pulmonary Embolism Rule-out Criteria (PERC); and revised Geneva score, are well validated for emergency department (ED) use but have not been translated to the prehospital setting. The objectives of this study were to evaluate the 1) prehospital completion rate and 2) inter-rater reliability of chest pain risk assessments.

METHODS

We conducted a prospective observational cohort study in two emergency medical services (EMS) agencies (April 18, 2018 - January 2, 2019). Adults with acute, non-traumatic chest pain without ST-elevation myocardial infarction or unstable vital signs were accrued. Paramedics were trained to use the HEAR, EDACS, PERC, and revised Geneva score assessments. A subset of patients (a priori goal of N = 250) also had the four risk assessments completed by their treating clinicians in the ED, who were blinded to the EMS risk assessments. Outcomes were 1) risk assessments completion rate and 2) inter-rater reliability between EMS and ED assessments. An a priori goal for completion rate was set as >75%. We computed kappa with corresponding 95% confidence intervals (CI) for each risk assessment as a measure of inter-rater reliability. Acceptable agreement was defined a priori as kappa ≥ 0.60.

RESULTS

During the study period, 837 patients with acute chest pain were accrued. The median age was 54 years, interquartile range 43-66, with 53% female and 51% Black. Completion rates for each risk assessment were above goal: the HEAR score was completed on 95.1% (796/837), EDACS on 92.0% (770/837), PERC on 89.4% (748/837), and revised Geneva score on 90.7% (759/837) of patients. We assessed agreement in a subgroup of 260 patients. The HEAR score had a kappa of 0.51 (95% CI, 0.41-0.61); EDACS was 0.60 (95% CI, 0.49-0.72); PERC was 0.71 (95% CI, 0.61-0.81); and revised Geneva score was 0.51 (95% CI, 0.39-0.62).

CONCLUSION

The completion rate of risk assessments for ACS and PE was high for prehospital field personnel. The PERC and EDACS both demonstrated acceptable agreement between paramedics and clinicians in the ED, although assessments with better agreement are likely needed.

Comparison of the Agreement and Accuracy Between Paramedic and Hospital Diagnosis

OBJECTIVE

Making an accurate clinical diagnosis in the field of prehospital is of great challenge in medical services. This study aimed to determine agreement between prehospital and in-hospital diagnoses.

METHODS

The diagnostic agreement was determined by a comparison of the discharge diagnosis with the prehospital emergency technicians in a period of 6 months at the emergency medical services in northwest Azerbaijan. The diagnostic agreement of discharge diagnoses was compared with the fist diagnosis by the paramedics. The results were analyzed using the kappa agreement coefficient and the chi-square test.

RESULTS

The overall agreement between the diagnosis made by the emergency medical technicians and the hospital's first diagnosis was 67% (95% confidence interval [CI], 61%-77%; k = 0.61; 95% CI, 0.56-0.67), whereas the agreement between the first diagnosis made by the emergency medical technicians and the hospital discharge diagnosis was 58% (95% CI, 49%-65%; k = 0.42; 95% CI, 0.37-0.48).There was a high proportion of diagnostic agreement for pregnancy (100%), poisoning by drugs (88%), essential (primary) hypertension (86%), and ischemic heart diseases (72%). There was a low proportion of diagnostic agreement for weakness (39%), mixed anxiety and depressive disorder (43%), and cerebellar stroke syndrome (59%).

CONCLUSION

Our attention in practice and emergency medical courses should be directed to diseases that have a subjective history, such as weakness and anxiety, due to the high proportion of incorrect diagnoses by the prehospital emergency technician. It should be noted that most of the incorrectly diagnosed cases were overestimated with another coronary syndrome.

A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients

In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50-64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69-0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.

Performance of Prehospital Use of Chest Pain Risk Stratification Tools: The RESCUE Study

BACKGROUND

Emergency medical services (EMS) assesses millions of patients with chest pain each year. However, tools validated to risk stratify patients for acute coronary syndrome (ACS) and pulmonary embolism (PE) have not been translated to the prehospital setting. The objective of this study is to assess the prehospital performance of risk stratification scores for 30-day major adverse cardiac events (MACE) and PE.

METHODS

A prospective observational cohort study of patients ≥21 years of age with acute chest pain who were transported by EMS in two North Carolina (NC) counties was conducted from 18 April 2018-2 January 2019. In this convenience sample, paramedics completed HEAR (history, electrocardiogram, age, risk factor), ED Assessment of Chest Pain Score (EDACS), Revised Geneva Score (RGS), and pulmonary embolism rule-out criteria (PERC) assessments on each patient. MACE (all-cause death, myocardial infarction, and revascularization) and PE at 30 days were determined by hospital records and NC Death Index. The positive (+LR) and negative likelihood ratios (-LR) of the risk scores for 30-day MACE and PE were calculated.

RESULTS

During the study period, 82.1% (687/837) patients had all four risk score assessments. The cohort was 51.1% (351/687) female, 49.5% (340/687) African American, and had a mean age of 55.0 years (SD 16.0). At 30 days, MACE occurred in 7.4% (51/687), PE occurred in 0.9% (6/687), and the combined outcome occurred in 8.2% (56/687). The HEAR score had a - LR of 0.46 (95% CI 0.27-0.78) and + LR of 1.48 (95% CI 1.26-1.74) for 30-day MACE. EDACS had a - LR of 0.61 (95% CI 0.46-0.81) and + LR of 2.53 (95% CI 1.86-3.46) for 30-day MACE. The PERC score had a - LR of 0 (95% CI 0.0-1.4) and a + LR of 1.38 (95% CI 1.32-1.45) for 30-day PE. The RGS score had a - LR of 0 (95% CI 0.0-0.65) and a + LR of 2.36 (95% CI 2.16-2.57) for 30-day PE. The combination of a low-risk HEAR score and negative PERC evaluation had a - LR of 0.25 (95% CI 0.08-0.76) and a + LR of 1.21 (95% CI 1.21-1.30) for 30-day MACE or PE.

CONCLUSION

The combination of a paramedic-obtained HEAR score and PERC evaluation performed best to exclude 30-day MACE and PE but was not sufficient for directing prehospital decision making.

A deep learning-based system capable of detecting pneumothorax via electrocardiogram

PURPOSE

To determine if an electrocardiogram-based artificial intelligence system can identify pneumothorax prior to radiological examination.

METHODS

This is a single-center, retrospective, electrocardiogram-based artificial intelligence (AI) system study that included 107 ECGs from 98 pneumothorax patients. Seven patients received needle decompression due to tension pneumothorax, and the others received thoracostomy due to instability (respiratory rate ≥ 24 breaths/min; heart rate, < 60 beats/min or > 120 beats/min; hypotension; room air O₂ saturation, < 90%; and patient could not speak in whole sentences between breaths). Traumatic pneumothorax and bilateral pneumothorax were excluded. The ECGs of 132,127 patients presenting to the emergency department without pneumothorax were used as the control group. The development cohort included approximately 80% of the ECGs for training the deep learning model (DLM), and the other 20% of ECGs were used to validate the performance. A human-machine competition involving three physicians was conducted to assess the model performance.

RESULTS

The areas under the receiver operating characteristic (ROC) curves (AUCs) of the DLM in the validation cohort and competition set were 0.947 and 0.957, respectively. The sensitivity and specificity of our DLM were 94.7% and 88.1% in the validation cohort, respectively, which were significantly higher than those of all physicians. Our DLM could also recognize the location of pneumothorax with 100% accuracy. Lead-specific analysis showed that lead I ECG made a major contribution, achieving an AUC of 0.930 (94.7% sensitivity, 86.0% specificity). The inclusion of the patient characteristics allowed our AI system to achieve an AUC of 0.994.

CONCLUSION

The present AI system may assist the medical system in the early identification of pneumothorax through 12-lead ECG, and it performs as well with lead I ECG alone as with 12-lead ECG.

Prehospital time for patients with acute cardiac complaints: A rural health disparity

OBJECTIVE

Delays in care for patients with acute cardiac complaints are associated with increased morbidity and mortality. The objective of this study was to quantify rural and urban differences in prehospital time intervals for patients with cardiac complaints.

METHODS

The ESO Data Collaborative dataset consisting of records from 1332 EMS agencies was queried for 9-1-1 encounters with acute cardiac problems among adults (age ≥ 18) from 1/1/2013-6/1/2018. Location was classified as rural or urban using the 2010 United States Census. The primary outcome was total prehospital time. Generalized estimating equations evaluated differences in the average times between rural and urban encounters while controlling for age, sex, race, transport mode, loaded mileage, and patient stability.

RESULTS

Among 428,054 encounters, the median age was 62 (IQR 50-75) years with 50.7% female, 75.3% white, and 10.3% rural. The median total prehospital, response, scene, and transport times were 37.0 (IQR 29.0-48.0), 6.0 (IQR 4.0-9.0), 16.0 (IQR 12.0-21.0), and 13.0 (IQR 8.0-21.0) minutes. Rural patients had an average total prehospital time that was 16.76 min (95%CI 15.15-18.38) longer than urban patients. After adjusting for covariates, average total time was 5.08 (95%CI 4.37-5.78) minutes longer for rural patients. Average response and transport time were 4.36 (95%CI 3.83-4.89) and 0.62 (95%CI 0.33-0.90) minutes longer for rural patients. Scene time was similar in rural and urban patients (0.09 min, 95%CI -0.15-0.33).

CONCLUSION

Rural patients with acute cardiac complaints experienced longer prehospital time than urban patients, even after accounting for other key variables, such as loaded mileage.

2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force

Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

PURPOSE

Swiss and German (pre-)hospital systems, distribution and organization of trauma centres differ from each other. It is unclear if outcome in trauma patients differs as well. Therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both German-speaking countries.

METHODS

The TraumaRegister DGU® (TR-DGU) was used. Patients with Injury Severity Score ≥ 9 admitted to a level 1 trauma centre between 01/2009 and 12/2017 were included if they required ICU care or died. Trauma pattern, pre-hospital procedures and outcome were compared between Swiss (CH, n = 4768) and German (DE, n = 66,908) groups.

RESULTS

Swiss patients were older than German patients (53 vs. 50 years). ISS did not differ between groups (CH 23.8 vs. DE 23.0 points). There were more low falls < 3 m (34% vs. 21%) at the expense of less traffic accidents (37% vs. 52%) in the Swiss population. In Switzerland 30% of allocations were done without physician involvement, whereas this occurred in 4% of German cases. Despite a comparable number of patients with a GCS ≤ 8 (CH 29.6%; DE 26.4%), differences in pre-hospital intubation rates occurred (CH 31% vs. DE 40%). Severe traumatic brain injuries were diagnosed most frequently in Switzerland (CH 62% vs. DE 49%). Admission vital signs were similar, and standardized mortality ratios were close to one in both countries.

CONCLUSION

This study demonstrates that patients' age, trauma patterns and pre-hospital care differ between Germany and Switzerland. However, adjusted mortality was almost similar. Further benchmarking studies are indicated to optimize trauma care in both German-speaking countries.

Identification of new demands regarding prehospital care based on 35,188 missions in 2018

BACKGROUND

Population ageing and increased prevalence of chronic diseases result in the emergence of new demands in prehospital care. The prehospital system is facing an increase of cases without acute threat to life (so-called "non-urgent"), which generates tension due to a higher number of admissions to emergency departments and a greater use of prehospital resources. Our aim is to understand this transition in prehospital activities and to delineate the primary missions performed by paramedics in 2018 with a focus on the population concerned, the severity of cases encountered and the typology of health issues.

METHOD

The study is retrospective, and descriptive, using a statistical description of 35,188 primary missions realized in 2018 in the State of Vaud (Switzerland). The characteristics taken into consideration are the age and gender of patients, as well as the health issue, the severity of cases based on National Advisory Committee for Aeronautics score (NACA score), and the time and place of intervention.

RESULTS

The results describe the primary missions in the State of Vaud in 2018 and show that 87% of missions concern "non-urgent" situations (without acute threat to life). Over half of patients are 65 or older, the highest proportion of health issues, 49%, are medical and only 23% of missions are for traumas. Mission related to mental health issues reach 7% and those for intoxication 6%. Most missions take place between 7:00 am and 6:00 pm (67%), and around 12% of missions lead to the non-transport of the patient.

CONCLUSION

The prehospital sector is confronted with a major transition in terms of patient care. An increase of non-urgent cases is observed, associated with the care of persons aged 65 or more. Our results question the adequacy between the needs in terms of prehospital care and the paramedic profession as it is currently defined, as well as the place of this profession within the health network. Reflecting upon the role of paramedics with respect to the socio-demographic evolution of populations appears necessary, to analyse the adequacy of the paramedics' skills to respond to the current needs.

Which symptoms pose the highest risk in patients calling for an ambulance? A population-based cohort study from Denmark

BACKGROUND

Emergency medical service patients are a vulnerable population and the risk of mortality is considerable. In Denmark, healthcare professionals receive 112-emergency calls and assess the main reason for calling. The main aim was to investigate which of these reasons, i.e. which symptoms or mechanism of injury, contributed to short-term risk of death. Secondary aim was to study 1-30 day-mortality for each symptom/ injury.

METHODS

Historic population-based cohort study of emergency medical service patients calling 112 in the North Denmark Region between 01.01.2016-31.12.2018. We defined 1-day mortality as death on the same or the following day. The frequency of each symptom and cumulative number of deaths on day 1 and 30 together with 1- and 30-day mortality for each symptom/mechanism of injury is presented in proportions. Poisson regression with robust variance estimation was used to estimate incident rates (IR) of mortality with 95% confidence intervals (CI), crude and age and sex adjusted, mortality rates on day 1 per 100,000 person-year in the population.

RESULTS

The five most frequent reasons for calling 112 were "chest pain" (15.9%), "unclear problem" (11.9%), "accidents" (11.2%), "possible stroke" (10.9%), and "breathing difficulties" (8.3%). Four of these contributed to the highest numbers of deaths: "breathing difficulties" (17.2%), "unclear problem" (13.2%), "possible stroke" (8.7%), and "chest pain" (4.7%), all exceeded by "unconscious adult - possible cardiac arrest" (25.3%). Age and sex adjusted IR of mortality per 100,000 person-year was 3.65 (CI 3.01-4.44) for "unconscious adult - possible cardiac arrest" followed by "breathing difficulties" (0.45, CI 0.37-0.54), "unclear problem"(0.30, CI 0.11-0.17), "possible stroke"(0.13, CI 0.11-0.17) and "chest pain"(0.07, CI 0.05-0.09).

CONCLUSION

In terms of risk of death on the same day and the day after the 112-call, "unconscious adult/possible cardiac arrest" was the most deadly symptom, about eight times more deadly than "breathing difficulties", 12 times more deadly than "unclear problem", 28 times more deadly than "possible stroke", and 52 times more deadly than "chest pain". "Breathing difficulties" and "unclear problem" as presented when calling 112 are among the top three contributing to short term deaths when calling 112, exceeding both stroke symptoms and chest pain.

Medical dispatchers' perception of the interaction with the caller during emergency calls - a qualitative study

BACKGROUND

Medical dispatching is a highly complex procedure and has an impact upon patient outcome. It includes call-taking and triage, prioritization of resources and the provision of guidance and instructions to callers. Whilst emergency medical dispatchers play a key role in the process, their perception of the process is rarely reported. We explored medical dispatchers' perception of the interaction with the caller during emergency calls. Secondly, we aimed to develop a model for emergency call handling based on these findings.

METHODS

To provide an in-depth understanding of the dispatching process, an explorative qualitative interview study was designed. A grounded theory design and thematic analysis were applied.

RESULTS

A total of 5 paramedics and 6 registered nurses were interviewed. The emerging themes derived from dispatchers' perception of the emergency call process were related to both the callers and the medical dispatchers themselves, from which four and three themes were identified, respectively. Dispatchers reported that for callers, the motive for calling, the situation, the perception and presentation of the problem was influencing factors. For the dispatchers the expertise, teamwork and organization influenced the process. Based on the medical dispatchers´ perception, a model of the workflow and interaction between the caller and the dispatcher was developed based on themes related to the caller and the dispatcher.

CONCLUSIONS

According to medical dispatchers, the callers seem to lack knowledge about best utilization of the emergency number and the medical dispatching process, which can be improved by public awareness campaigns and incorporating information into first aid courses. For medical dispatchers the most potent modifiable factors were based upon the continuous professional development of the medical dispatchers and the system that supports them. The model of call handling underlines the complexity of medical dispatching that embraces the context of the call beyond clinical presentation of the problem.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

BACKGROUND

The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.

METHODS

This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).

RESULTS

53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (ORON 3.6, 95% CI 3.21-3.30; OROFF 3.18, 95% CI 3.04-3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9-47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6-79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.

CONCLUSIONS

This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

Trends and Characteristics of Emergency Medical Services in Italy: A 5-Years Population-Based Registry Analysis

Background: Emergency Medical Services (EMS) plays a fundamental role in providing good quality healthcare services to citizens, as they are the first responders in distressing situations. Few studies have used available EMS data to investigate EMS call characteristics and subsequent responses. Methods: Data were extracted from the emergency registry for the period 2013–2017. This included call and rescue vehicle dispatch information. All relationships in analyses and differences in events proportion between 2013 and 2017 were tested against the Pearson’s Chi-Square with a 99% level of confidence. Results: Among the 2,120,838 emergency calls, operators dispatched at least one rescue vehicle for 1,494,855. There was an estimated overall incidence of 96 emergency calls and 75 rescue vehicles dispatched per 1000 inhabitants per year. Most calls were made by private citizens, during the daytime, and were made from home (63.8%); 31% of rescue vehicle dispatches were advanced emergency medical vehicles. The highest number of rescue vehicle dispatches ended at the emergency department (74.7%). Conclusions: Our data showed that, with some exception due to environmental differences, the highest proportion of incoming emergency calls is not acute or urgent and could be more effectively managed in other settings than in an Emergency Departments (ED). Better management of dispatch can reduce crowding and save hospital emergency departments time, personnel, and health system costs.

Chest pain management: use of troponins in internal medicine wards

OBJECTIVES

To probe the reference biomarkers used to manage chest pain (CP) by Italian internists.

METHODS

Two hundred and fifty-seven doctors registered as members of the Federation of Associations of Hospital Doctors on Internal Medicine of the Campania Region (FADOI-Campania) were surveyed by means of Google Forms platform. Each participant was asked to report his/her sex, age, and location and hospital size (beds in hospital) in which he/she worked. Furthermore, they were asked to indicate the reference biomarker he/she usually employed in the management of patients with CP, choosing from four possible answers. In line with national and international guidelines, cardiac troponins are the gold standard biomarkers.

RESULTS

Eighty-two internists (30 females) completed the survey. Interestingly, only 30.5% of participants indicated the cardiac troponins as reference biomarker. Moreover, internists working in medium-sized hospitals appeared to prefer the simultaneous measurement of cardiac troponins and Creatine Kinase MB Isoenzyme.

CONCLUSIONS

Given the economic impact of performing inappropriate examinations and the frequency of the CP symptom and associated diseases, rethinking pathways in a multidisciplinary and shared fashion can promote optimization and appropriateness, and therefore stop wastefulness.

Characteristics and outcomes of patients with dyspnoea as the main symptom, assessed by prehospital emergency nurses- a retrospective observational study

Background

Dyspnoea (breathing difficulty) is among the most commonly cited reasons for contacting emergency medical services (EMSs). Dyspnoea is caused by several serious underlying medical conditions and, based on patients individual needs and complex illnesses or injuries, ambulance staff are independently responsible for advanced care provision. Few large-scale prehospital studies have reviewed patients with dyspnoea. This study aimed to describe the characteristics and final outcomes of patients whose main symptom was classified as dyspnoea by the prehospital emergency nurse (PEN).

Methods

This retrospective observational study included patients aged > 16 years whose main symptom was dyspnoea. All the enrolled patients were assessed in the south-western part of Sweden by PENs during January and December, 2017. Of 7260 assignments (9% of all primary missions), 6354 fulfilled the inclusion criteria. Analysis was performed using descriptive statistics, and the tests used were odds ratios and Kaplan-Meier analysis.

Results

The patients mean age was 73 years, and approximately 56% were women. More than 400 different final diagnostic codes (International Statistical Classification of Diseases and Related Health Problems [ICD]-10th edition) were observed, and 11% of the ICD-10 codes denoted time-critical conditions. The three most commonly observed aetiologies were chronic obstructive pulmonary disease (20.4%), pulmonary infection (17.1%), and heart failure (15%). The comorbidity values were high, with 84.4% having previously experienced dyspnoea. The overall 30-day mortality was 11.1%. More than half called EMSs more than 50 h after symptom onset.

Conclusions

Among patients assessed by PENs due to dyspnoea as the main symptom there were more than 400 different final diagnoses, of which 11% were regarded as time-critical. These patients had a severe comorbidity and 11% died within the first 30 days.

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.

[System and skill utilization in an Austrian emergency physician system: retrospective study]

BACKGROUND

The continuous rise in calls for emergency physicians and the low proportion of indicated missions has led to a loss of job attractiveness, which in turn renders services in some areas unable to sufficiently staff units. This retrospective analysis evaluated the frequency of emergency and general medical interventions in a ground-based emergency physician response system.

METHODS

A retrospective analysis of anonymized data from the electronic documentation system of the emergency physician response unit at the Medical University of Graz was carried out. Calls answered by emergency physicians between 2010 and 2018 were extracted, measures carried out were evaluated and categorized into three groups: specific emergency interventions (category I), general medical interventions (category II) and no medical activity (category III). The frequency of occurrence of these categories was compared and incidences of individual measures per 100,000 inhabitants were calculated.

RESULTS

A total of 15,409 primary responses and 322 secondary transports were extracted and analyzed. The annual rate of system activation rose almost continuously from 1442 calls in 2010 to 2301 calls in 2018. The 3687 (23.4%) cancellations resulted in 12,044 patient contacts. Of these, 2842 (18%) calls were coded as category I, 7372 (47%) as category II and 5518 (35%) as category III. The frequency of specific emergency measures and general medical interventions was estimated at 157/100,000 and 409/100,000 inhabitants, respectively.

CONCLUSIONS

No specific emergency physician interventions were required in the majority of call-outs. The current model of preclinical care does not appear to be patient-oriented and efficient. Furthermore, the low proportion of critically ill and injured patients already leads to a reduction in attractiveness for emergency physicians and may introduce the threat of quality issues due to insufficient routine experience and lack of training.

Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care

INTRODUCTION

We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California.

METHODS

We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations.

RESULTS

PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol.

CONCLUSION

Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.

Drivers of Increasing Emergency Ambulance Demand

Objectives: Although the factors driving emergency department demand have been extensively investigated, a comparatively minimal amount is known about the factors that are driving an increase in emergency ambulance demand. Methods: We conducted a retrospective observational study of consecutive cases attended by Ambulance Victoria in Melbourne, Australia from 2008 to 2015. Incidence rates were calculated, and adjusted time series regression analyses were performed to assess the driving factors of ambulance demand. Results: A total of 2,443,952 consecutive cases were included. Demand grew by 29.2% over the 8-year period. The age-specific incidence increased significantly over time for patients aged < 60 years, but not for patients aged ≥ 60 years. After adjustment for seasonality and population growth, demand increased by 1.4% per annum (incident rate ratio [IRR] = 1.014 [1.011-1.017]). The largest annual growth in demand was observed in patients with a history of mental health issues (IRR = 1.058 [1.054-1.062]), alcohol/drug abuse (IRR = 1.061 [1.056-1.066]), or a Charlson Comorbidity Index [CCI] score ≥ 4 (IRR = 1.045 [1.039-1.051]). Cases involving patients of relative socio-economic/educational disadvantage, younger age, or with no preexisting health conditions according to the CCI also grew faster than the overall patient population. Cases requiring transport to hospital increased by 1.2% annually (IRR = 1.012 [1.009-1.016]), although patients not requiring medical intervention from paramedics increased by 6.7% annually (IRR = 1.067 [1.063-1.072]). Conclusions: Increases in ambulance demand exceeded population growth. Emergency ambulances were increasingly utilized for transport of patients who did not require medical intervention from paramedics. Identifying the characteristics of patients driving ambulance demand will enable targeted demand management strategies.

Patient experience of severe acute dyspnoea and relief during treatment in ambulances: a prospective observational study

Background

Acute dyspnoea is common among ambulance patients, but little is known of the patients’ experience of symptom. We aimed to investigate ambulance patients initial perceived intensity of acute dyspnoea, and whether they experienced relief during prehospital treatment. Furthermore, to investigate the validity and feasibility of using a subjective dyspnoea score in the ambulance, and its association with objectively measured vital signs.

Methods

We performed a prospective observational study in the North Denmark Region from 1. July 2017 to 30. March 2019. We studied patients over the age of 18 to whom an ambulance was dispatched. Patients with acute dyspnoea assessed either at the emergency call or by ambulance professionals on scene were included. Patients were asked to assess dyspnoea on a 0 to 10 verbal numeric rating scale at the primary contact with the ambulance personnel and immediately before release at the scene or arrival at the hospital. Patients received usual prehospital medical treatment. We used visual inspection and Wilcoxon matched-pairs signed-ranks test, to assess dyspnoea scores and change hereof. Scatterplots and linear regression analyses were used to assess associations between the dyspnoea score and vital signs.

Results

We included 3199 patients with at least one dyspnoea score. Of these, 2219 (69%) had two registered dyspnoea scores. The initial median dyspnoea score for all patients was median 8 (interquartile range 6–10). In 1676 (76%) of patients with two scores, the first score decreased from 8 (6–9) to 4 (2–5) during prehospital treatment. The score was unchanged for 370 (17%) and increased for 51 (2%) patients. Higher respiratory rate, blood pressure, and heart rate was seen with higher dyspnoea scores whereas blood oxygen saturation lowered.

Conclusions

We found that acute dyspnoea scored by ambulance patients, was high on a verbal numerical rating scale but decreased before arrival at hospital, suggesting relief of symptoms. The acute dyspnoea score was statistically associated with vital signs, but of limited clinical relevance; this stresses the importance of patients’ experience of symptoms. To this end, the dyspnoea scale appears feasible in the prehospital setting.

Mobile Intensive Care Unit versus Hospital walk-in patients, in the treatment of first episode ST- elevation myocardial infarction

OBJECTIVE

To determine the impact of the attention given by emergency medical services teams working in mobile intensive care units (MICU) versus patients arriving at the hospital under their own means with ST-elevation myocardial infarction (STEMI) event in terms of time to reperfusion (TR), mortality at 30 days and six months.

METHODS

We retrospectively studied 634 consecutive patients with STEMI who underwent primary a percutaneous coronary intervention from January 1st 2015 to December 31st 2018 in a single centre. Depending on the first medical contact patients were classified into two groups, MICU versus walk-in patients. We extracted data on patients' characteristics, symptoms, treatments, times to reperfusion and mortality.

RESULTS

In our study 634 patients were included, of whom 59.0% were initially attended by the MICU. Differences were seen between the two groups in time delays to the first medical contact (120.0 vs 63.0 min; p < 0.001) and TR (208.0 Vs 150.0 min; p < 0.001). Patients attended by the MICUs presented a shorter ICU and hospital stay. The lowest 30-day mortality rate was observed in MICU group: 9.0% in contrast with 4.5%, p = 0.03; remaining after 6 months. The multivariable analysis showed that the initial attention given by MICU to STEMI patients was a protective agent against mortality [OR: 0.32 (0.11-0.90); p = 0.03].

CONCLUSION

Initial attention of the patients with STEMI by doctor-on-board-MICU and available 24 h a day 7 days a week as part of a regional network (CORECAM), was associated with a decrease in the ischemia time, hospital stay and mortality of these patients in our environment.

Evaluation of the discriminative performance of the prehospital National Advisory Committee for Aeronautics score regarding 48-h mortality

OBJECTIVE

The National Advisory Committee for Aeronautics (NACA) score is used by many emergency medical services to assess the severity of prehospital patients. Little is known about its discriminative performance regarding short-term mortality.

PARTICIPANTS AND METHODS

We retrospectively included adult missions between 2008 and 2014 in a Swiss ground and air-based emergency medical services. We excluded uninjured or dead-on-scene patients. Primary outcome was assessment of the discriminative performance of the NACA score to classify the 48-h vital status of patients. Overall discrimination was quantified using the area under receiver operating characteristic curve (AUC). We also explored the influence of epidemiological characteristics (age and sex), mechanism (trauma or nontrauma) and clinical parameters (respiratory rate, oxygen saturation, heart rate, systolic blood pressure, capillary refill time, and Glasgow Coma Scale) on its discriminative performance. We then assessed the incremental value of these variables in the classification accuracy of a rule based on these variables in addition to the NACA score.

RESULTS

We included 11 567 patients out of 11 639 (72 exclusions for missing data). Overall AUC was 0.86. The score was more discriminant for trauma (AUC = 0.95 vs. 0.83), and for younger patients (AUC = 0.91 for 16-59 vs. 0.78 for 84-104 years). Adding age, sex, mechanism, and clinical parameters resulted in a classification rule with higher discriminative performance than NACA score alone (AUC of 0.92 vs. 0.86; P < 0.001).

CONCLUSION

The NACA score is an efficient way to discriminate victims regarding short-term mortality. Its performance can be enhanced by also integrating epidemiological and clinical parameters into an extended classification rule.

Temporal Trends and Future Predictions of Regional EMS System Utilization Using Statistical Modeling

Introduction:

Trends in utilization of Emergency Medical Services (EMS) systems can be used to extrapolate future use of an EMS system, which will be valuable for the budgeting and planning of finances and resources. The best model for incorporation of seasonal and regional fluctuations in utilization to predict future utilization is unknown.

Problem:

Authors aimed to trend patterns of utilization in a regional EMS system to identify the needs of a growing population and to allow for a better understanding of how the EMS system is used on a basis of call volume and frequency of EMS transportation. The authors then used a best-fitting prediction model approach to show how the studied EMS system will be used in future years.

Methods:

Systems data were retrospectively extracted by using the electronic medical records of the studied EMS system and its computer-assisted dispatch (CAD) database from 2010 through 2017. All EMS dispatches entering the system’s 9-1-1 public service access point were captured. Annual utilization data were available from 2010 through 2017, while quarterly data were available only from 2013 through 2017. The 9-1-1 utilization per capita, Advanced Life Support (ALS) utilization per capita, and ALS cancel rates were calculated and trended over the study period. The methods of prediction were assessed through a best-fitting model approach, which statistically suggested that Additive Winter’s approach (SAS) was the best fit to determine future utilization and ALS cancel rates.

Results:

Total 9-1-1 call volume per capita increased by 32.46% between 2010 and 2017, with an average quarterly increase of 0.78% between 2013 and 2017. Total ALS call volume per capita increased by 1.93% between 2010 and 2017. Percent ALS cancellations (cancelled en route to scene) increased by eight percent between 2010 and 2017, with an average quarterly increase of 0.42% (2013–2017). Predictions to end of 2019 using Additive Winter’s approach demonstrated increasing trends in 9-1-1 call volume per capita (R2 = 0.47), increasing trends of ALS utilization per capita (R2 = 0.71), and increasing percent ALS cancellation (R2 = 0.93). Each prediction showed increasing future trends with a 95% confidence interval.

Conclusions:

The authors demonstrate paramount per capita increases of 9-1-1 call volume in the studied ALS system. There are concomitant increases of ALS cancellations prior to arrival, which suggests a potential burden on this regional ALS response system.

An Autonomous Wireless Health Monitoring System Based on Heartbeat and Accelerometer Sensors

Falls are a main cause of injury for patients with certain diseases. Patients who wear health monitoring systems can go about daily activities without limitations, thereby enhancing their quality of life. In this paper, patient falls and heart rate were accurately detected and measured using two proposed algorithms. The first algorithm, abnormal heart rate detection (AHRD), improves patient heart rate measurement accuracy and distinguishes between normal and abnormal heart rate functions. The second algorithm, TB-AIC, combines an acceleration threshold and monitoring of patient activity/inactivity functions to accurately detect patient falls. The two algorithms were practically implemented in a proposed autonomous wireless health monitoring system (AWHMS). The AWHMS was implemented based on a GSM module, GPS, microcontroller, heartbeat and accelerometer sensors, and a smartphone. The measurement accuracy of the recorded heart rate was evaluated based on the mean absolute error, Bland–Altman plots, and correlation coefficients. Fourteen types of patient activities were considered (seven types of falling and seven types of daily activities) to determine the fall detection accuracy. The results indicate that the proposed AWHMS succeeded in monitoring the patient’s vital signs, with heart rate measurement and fall detection accuracies of 98.75% and 99.11%, respectively. In addition, the sensitivity and specificity of the fall detection algorithm (both 99.12%) were explored.

An Advanced First Aid System Based on an Unmanned Aerial Vehicles and a Wireless Body Area Sensor Network for Elderly Persons in Outdoor Environments

For elderly persons, a fall can cause serious injuries such as a hip fracture or head injury. Here, an advanced first aid system is proposed for monitoring elderly patients with heart conditions that puts them at risk of falling and for providing first aid supplies using an unmanned aerial vehicle. A hybridized fall detection algorithm (FDB-HRT) is proposed based on a combination of acceleration and a heart rate threshold. Five volunteers were invited to evaluate the performance of the heartbeat sensor relative to a benchmark device, and the extracted data was validated using statistical analysis. In addition, the accuracy of fall detections and the recorded locations of fall incidents were validated. The proposed FDB-HRT algorithm was 99.16% and 99.2% accurate with regard to heart rate measurement and fall detection, respectively. In addition, the geolocation error of patient fall incidents based on a GPS module was evaluated by mean absolute error analysis for 17 different locations in three cities in Iraq. Mean absolute error was 1.08 × 10-5° and 2.01 × 10-5° for latitude and longitude data relative to data from the GPS Benchmark system. In addition, the results revealed that in urban areas, the UAV succeeded in all missions and arrived at the patient's locations before the ambulance, with an average time savings of 105 s. Moreover, a time saving of 31.81% was achieved when using the UAV to transport a first aid kit to the patient compared to an ambulance. As a result, we can conclude that when compared to delivering first aid via ambulance, our design greatly reduces delivery time. The proposed advanced first aid system outperformed previous systems presented in the literature in terms of accuracy of heart rate measurement, fall detection, and information messages and UAV arrival time.

Videotelephony-assisted medical direction to improve emergency medical service

INTRODUCTION

In South Korea, on-line medical direction using voice calls has been implemented to improve the quality of the emergency medical system. However, in the same, short time span, video will be able to convey more information than by voice. The purpose of this study is to find out if videotelephony-assisted medical direction (VAMD) can change the intervention of the emergency medical technician compared to using conventional voice calls.

METHODS

We conducted a prospective study of 312 patients with online medical direction from November 2017 to November 2018. We assisted patients with direct medical direction using conventional voice calls from October to November 2017, and then VAMD was implemented from October to November 2018.

RESULTS

From the total number of conventional voice calls, 131 were used for this study, and of the total number of VAMD interventions, 181 were included. There were differences between conventional voice call and VAMD interventions in such types of medical direction as hospital selection (7.6% vs. 36.6%), ECG interpretation (0% vs. 3.4%), and advice on medical techniques (0% vs. 25.1%). The effectiveness of VAMD by survey is greater compared to conventional direct medical direction using voice calls (median value, 3.0 vs. 1.5).

CONCLUSIONS

The number of instances of medical direction for some interventions, such as interpretation of ECG and advice on medical techniques that did not perform well in conventional voice calls, increased in VAMD. VAMD may play an important role in the prehospital emergency care.