Emergency physician's dispatch by a paramedic-staffed emergency medical communication centre: sensitivity, specificity and search for a reference standard

Emergency call utilization over a 10-years period: an observational study in Region Zealand, Denmark, 2013-2022

BACKGROUND

Improving prehospital emergency care requires a comprehensive understanding of the efficiency of emergency medical services and demand fluctuations. The medical emergency call is the primary contact between citizens and the emergency medical dispatch center, serving as the gateway to accessing emergency assistance. This study aimed to characterize the emergency call population and analyze the development of emergency call utilization in Region Zealand in Denmark during a 10-years period.

METHODS

This was an observational register-based study of administrative data from the emergency medical dispatch center in Region Zealand. Data was collected from 1 January 2013 to 31 December 2022. All unique emergency calls from residents to the emergency number "1-1-2" were included. Descriptive analyses were used to characterize the study population. Poisson regression models were used to calculate ratio estimates for the association between years and hospital catchment areas, using the incidence rate of emergency calls as outcome measure.

RESULTS

A total of 641,457 emergency calls were included. A significant increase in the total number of emergency calls was found, with an increase from 58,454 annual calls to 80,819 calls over the study period. The incidence rate per 1000 residents per year increased from 71.1 to 95.2, a 35% increase. The southern part of the region had significantly more emergency calls per 1000 residents per year during the study period compared to the eastern part of the region (IRR 1.70). Demographically, males comprised 52.3% of cases, and patients aged 65 and older represented 48.2% of calls. Emergency calls were "Emergency level A" in 45.5% and "Emergency level B" in 39.1%. In 22.3% of cases, the emergency call was categorized as "Unclear problem." The most frequent categories were "chest pain" (12.7%), "impaired consciousness" (9.6%), "breathing difficulties" (8.8%), "accidents" (7.9%), and "minor injuries" (7.6%).

CONCLUSIONS

The study revealed a significant increase in emergency calls, both in absolute numbers and per 1000 residents per year, indicating growing demand for emergency care, along with a surge in activity at the region's dispatch center. Regional disparities underscores the potential necessity for tailored developmental approaches over time.

Appropriately Matching Transport Care Units to Patients in Interhospital Transport Care: Implementation Study

BACKGROUND

In interfacility transport care, a critical challenge exists in accurately matching ambulance response levels to patients' needs, often hindered by limited access to essential patient data at the time of transport requests. Existing systems cannot integrate patient data from sending hospitals' electronic health records (EHRs) into the transfer request process, primarily due to privacy concerns, interoperability challenges, and the sensitive nature of EHR data. We introduce a distributed digital health platform, Interfacility Transport Care (ITC)-InfoChain, designed to solve this problem without compromising EHR security or data privacy.

OBJECTIVE

This study aimed to detail the implementation of ITC-InfoChain, a secure, blockchain-based platform designed to enhance real-time data sharing without compromising data privacy or EHR security.

METHODS

The ITC-InfoChain platform prototype was implemented on Amazon Web Services cloud infrastructure, using Hyperledger Fabric as a permissioned blockchain. Key elements included participant registration, identity management, and patient data collection isolated from the sending hospital's EHR system. The client program submits encrypted patient data to a distributed ledger, accessible to the receiving facility's critical care unit at the time of transport request and emergency medical services (EMS) teams during transport through the PatienTrack web app. Performance was evaluated through key performance indicators such as data transaction times and scalability across transaction loads.

RESULTS

The ITC-InfoChain demonstrated strong performance and scalability. Data transaction times averaged 3.1 seconds for smaller volumes (1-20 transactions) and 6.4 seconds for 100 transactions. Optimized configurations improved processing times to 1.8-1.9 seconds for 400 transactions. These results confirm the platform's capacity to handle high transaction volumes, supporting timely, real-time data access for decision-making during transport requests and patient transfers.

CONCLUSIONS

The ITC-InfoChain platform addresses the challenge of matching appropriate transport units to patient needs by ensuring data privacy, integrity, and real-time data sharing, enhancing the coordination of patient care. The platform's success suggests potential for regional pilots and broader adoption in secure health care systems. Stakeholder resistance due to blockchain unfamiliarity and data privacy concerns remains. Funding has been sought to support a pilot program to address these challenges through targeted education and engagement.

Association between prehospital physician clinical experience and discharge at scene - retrospective cohort study

BACKGROUND

Clinical experience has been shown to affect many patient-related outcomes but its impact in the prehospital setting has been little studied.

OBJECTIVES

To determine whether rates of discharge at scene, handover to paramedics and supervision are associated with clinical experience.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective study, performed on all prehospital interventions carried out by physicians working in a mobile medical unit ("service mobile d'urgence et de réanimationˮ [SMUR]) at Geneva University Hospitals between 1 January 2010 and 31 December 2019. The main exclusion criteria were phone consultations and major incidents with multiple casualties.

EXPOSURE

The exposure was the clinical experience of the prehospital physician at the time of the intervention, in number of years since graduation.

OUTCOME MEASURES AND ANALYSIS

The main outcome was the rate of discharge at scene. Secondary outcomes were the rate of handover to paramedics and the need for senior supervision. Outcomes were tabulated and multilevel logistic regression was performed to take into account the cluster effect of physicians.

RESULTS

In total, 48,368 adult patients were included in the analysis. The interventions were performed by 219 different physicians, most of whom were male (53.9%) and had graduated in Switzerland (82.7%). At the time of intervention, mean (standard deviation [SD]) level of experience was 5.2 (3.3) years and the median was 4.6 (interquartile range [IQR]: 3.4-6.0). The overall discharge at scene rate was 7.8% with no association between clinical experience and discharge at scene rate. Greater experience was associated with a higher rate of handover to paramedics (adjusted odds ratio [aOR]: 1.17, 95% confidence interval [CI]: 1.13-1.21) and less supervision (aOR: 0.85, 95% CI: 0.82-0.88).

CONCLUSION

In this retrospective study, there was no association between level of experience and overall rate of discharge at scene. However, greater clinical experience was associated with higher rates of handover to paramedics and less supervision.

Can video communication in the emergency medical communication centre improve dispatch precision? A before-after study in Norwegian helicopter emergency medical services

OBJECTIVES

Dispatching helicopter emergency medical services (HEMS) to the patients with the greatest medical or logistical benefit remains challenging. The introduction of video calls (VC) in the emergency medical communication centres (EMCC) could provide additional information for EMCC operators and HEMS physicians when assessing the need for HEMS dispatch. The aim of this study was to evaluate the impact from VC in the EMCC on HEMS dispatch precision.

DESIGN

An observational before-after study.

SETTING

The regional EMCC and one HEMS base in Mid-Norway.

PARTICIPANTS

EMCC operators and HEMS physicians at the EMCC and HEMS base in Trondheim, Norway.

INTERVENTION

In January 2022, VC became available in emergency calls in Trondheim EMCC. Data were collected from 2020 2021 (pre-intervention) and 2022 (post-intervention).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of seriously ill or injured HEMS patients, defined as a National Advisory Committee for Aeronautics (NACA) score between 4 and 7. The secondary outcome was the proportion of inappropriate dispatches, defined as missions with neither provision of additional competence nor any logistical contribution based on quality indicators for physician-staffed emergency medical services.

RESULTS

811 and 402 HEMS missions with patient contact were included in the pre- and post-intervention group, respectively. The proportion of missions with NACA 4-7 was not significantly changed after the intervention (OR 1.21, 95% CI 0.92 to 1.61, p=0.17). There was no significant change in HEMS alarm times between the pre- and post-intervention groups (7.6 min vs 6.4 min, p=0.15). The proportion of missions with neither medical nor logistical benefit was significantly lower in the post-intervention group (28.4% vs 40.3%, p=0.007).

CONCLUSION

The results from this study indicate that VC is a promising, feasible and safe tool for EMCC operators in the complex HEMS dispatch process.

Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study

BACKGROUND

Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS).

METHODS

This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level.

RESULTS

A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience.

CONCLUSION

The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes.

REGISTRATION

This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).

The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study

BACKGROUND

Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies.

METHODS

This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI).

RESULTS

Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group.

CONCLUSION

Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.

Differences between the dispatch priority assessments of emergency medical dispatchers and emergency medical services: a prospective register-based study in Finland

BACKGROUND

Responsive and efficient emergency medical services (EMS) require accurate telephone triage. In Finland, such services are provided by Emergency Response Centre Agency (ERC Agency). In 2018, a new Finnish computer-assisted emergency dispatch system was introduced: the Emergency Response Integrated Common Authorities (ERICA). After the introduction of ERICA, the appropriateness of EMS dispatch has not been investigated yet. The study´s objective is to determine the consistency between the priority triage of the emergency medical dispatcher (EMD) and the on-scene priority assessment of the EMS, and whether the priority assessment consistency varied among the dispatch categories.

METHODS

This was a prospective register-based study. All EMS dispatches registered in the Tampere University Hospital area from 1 August 2021 to 31 August 2021 were analysed. The EMD's mission priority triaged during the emergency call was compared with the on-scene EMS's assessment of the priority, derived from the pre-set criteria. The test performance levels were measured from the crosstabulation of true or false positive and negative values of the priority assessment. Statistical significance was analysed using the chi-square test and the Kruskal-Wallis H test, and p-values < 0.05 were considered significant.

RESULTS

Of the 6416 EMS dispatches analysed in this study, 36% (2341) were urgent according to the EMD's dispatch priority, and of these, only 29% (688) were urgent according to the EMS criteria. On the other hand, 64% (4075) of the dispatches were non-urgent according to the EMD's dispatch priority, of which 97% (3949) were non-urgent according to the EMS criteria. Moreover, there were differences between the EMD and EMS priority assessments among the dispatch categories (p < 0.001). The overall efficiency was 72%, sensitivity 85%, specificity 71%, positive predictive value 29%, and negative predictive value 97%.

CONCLUSION

While the EMD recognised the non-urgent dispatches with high consistency with the EMS criteria, most of the EMD's urgent dispatches were not urgent according to the same criteria. This may diminish the availability of the EMS for more urgent missions. Thus, measures are needed to ensure more accurate and therefore, more efficient use of EMS resources in the future.

Introduction of Telemedicine in a Prehospital Emergency Care Setting: A Pilot Study

Background

Advances in information and communication technology have led to telemedicine applications that could support paramedics in the prehospital field. In an effort to optimise the available resources like prehospital emergency physicians (PHP), the State Health Services of a Swiss state decided to launch a pilot study on the feasibility of using telemedicine in the prehospital emergency setting.

Objective

The primary objective was to measure the number of missions completed without technical problems with remote PHP support through telemedicine (tele-PHP). The secondary objectives were to evaluate the safety of this protocol and to describe the actions and decisions that clinicians can make by using tele-PHP.

Methods

This was a prospective observational pilot study on all missions involving the dispatch of ground PHP or tele-PHP. The severity score, dispatch criteria, actions, and decisions made by ground PHP and tele-PHP were collected.

Results

PHP were dispatched simultaneously with an ambulance on 478 occasions, including 68 (14%) situations that started directly with tele-PHP. Among those situations, three had to be transformed into on-site PHP missions after the on-site evaluation by paramedics. Fifteen missions were cancelled by paramedics once they were on site, and six missions encountered a connection issue. Forty-four PHP missions that were dispatched simultaneously with paramedics were completed by tele-PHP only without any connection problems. Paramedics and PHP estimated that actions or decisions were provided by PHP in 66% of the on-site PHP missions and 34% of the tele-PHP missions.

Conclusions

This is the first experience of tele-PHP regarding PHP dispatch in Switzerland. Despite the small number of missions carried out, tele-PHP could be used for well-selected situations to reduce the need for a PHP on site.

Paramedic Clinical Consults with a Paramedic or Nurse in an EMS Communications Center Compared to Traditional Online Physician Consults

OBJECTIVES

In many emergency medical services (EMS) systems, a direct medical oversight physician is available to paramedics for mandatory and/or elective consultations. At the time of this study, a clinical support desk (CSD) was being implemented within the medical communications center of a provincial EMS system in addition to the physician resource. The CSD was initially staffed with a registered nurse or an advanced care paramedic. The objective of the current study was to compare CSD "peer to peer" consults versus physician consults with regards to consultation patterns, transport dispositions, and patient safety measures.

METHODS

This retrospective cohort study analyzed 2 months before (September 1 to October 31, 2012) and 2 months after (September 1 to October 31, 2013) implementation of the CSD. In the before period, all clinical consults were fielded by the direct medical oversight physician. In the after period, consults were fielded by the physician, CSD or both. EMS databases were queried, and manual chart review and abstraction of audio recordings were done. Relapses back to EMS within 48 hours of non-transport were measured.

RESULTS

1621 consults were included, with 764 consults in the before period and 857 after (p = 0.02). The number of physician consults decreased from 764 before to 464 after (39.2%, p < 0.001), with the CSD taking 325 (37.9%) consults. The CSD was consulted more for police custody and trip destination. The physician was consulted more for cease resuscitation and clinical consults prior to medication administration. Overall non-transport rates were 595/764 before (77.9%), and 646/857 after (75.4%) (p = 0.2). Non-transports were 233/325 (71.7%) via the CSD, 364/464 (78.4%) via the physician, and 49/68 (72.1%) when both were involved (p = 0.07). Rate of relapse to EMS was similar before (25/524, 4.8%) and after (26/568, 4.6%) (p = 0.76), and between CSD (12/216, 5.5%) and physician consults (13/325, 4.0%) in the after period (p = 0.41).

CONCLUSION

The introduction of a novel "peer-to-peer" consult program was associated with an increased total number of consults made and reduced call volume for direct medical oversight physicians. There was no change in the patient safety measure studied.

Smart Glasses: A New Tool for Assessing the Number of Patients in Mass-Casualty Incidents

INTRODUCTION

Mass-casualty incidents (MCIs) are events in which many people are injured during the same period of time. This has major implications in regards to practical concerns and planning for both personnel and medical equipment. Smart glasses are modern tools that could help Emergency Medical Services (EMS) in the estimation of the number of potential patients in an MCI. However, currently there is no study regarding the advantage of employing the use of smart glasses in MCIs in Thailand.

STUDY OBJECTIVE

This study aims to compare the overall accuracy and amount of time used with smart glasses and comparing it to manual counting to assess the number of casualties from the scene.

METHODS

This study was a randomized controlled trial, field exercise experimental study in the EMS unit of Srinagarind Hospital, Thailand. The participants were divided into two groups (those with smart glasses and those doing manual counting). On the days of the simulation (February 25 and 26, 2022), the participants in the smart glasses group received a 30-minute training session on the use of the smart glasses. After that, both groups of participants counted the number of casualties on the simulation field independently.

RESULTS

Sixty-eight participants were examined, and in the smart glasses group, a total of 58.8% (N = 20) of the participants were male. The mean age in this group was 39.4 years old. The most experienced in the EMS smart glasses group had worked in this position for four-to-six years (44.1%). The participants in the smart glasses group had the highest scores in accurately assessing the number of casualties being between 21-30 (98.0%) compared with the manual counting group (89.2%). Additionally, the time used for assessing the number of casualties in the smart glasses group was shorter than the manual counting group in tallying the number of casualties between 11-20 (6.3 versus 11.2 seconds; P = .04) and between 21-30 (22.1 versus 44.5 seconds; P = .02).

CONCLUSION

The use of smart glasses to assess the number of casualties in MCIs when the number of patients is between 11 and 30 is useful in terms of greater accuracy and less time being spent than with manual counting.

Pre-hospital emergency anaesthesia in trauma patients: An observational study from a state-wide Australian pre-hospital and retrieval service

OBJECTIVE

To assess the performance of an Australian pre-hospital and retrieval medicine (PHRM) service against the National Institute for Health and Care Excellence (NICE) standard which recommends that pre-hospital emergency anaesthesia (PHEA) in trauma patients should be conducted within 45-min of first contact with emergency services.

METHODS

Retrospective observational study of all adult trauma patients in which PHEA was conducted by the PHRM service covering a 5-year period from January 2015 to December 2019.

RESULTS

Over the 5-year study period, 1509 (22%) of the PHRM service workload comprised primary retrievals from scene. Most 1346 (89%) of these cases had a primary diagnosis of trauma. Of these we have complete data for 328 of the 337 cases requiring a PHEA and 121 (37%) patients received this within the recommended 45-min time frame. The service attended in rapid response vehicles (n = 160, 49%), rotary wing (n = 151, 46%) and fixed wing (n = 17, 5%) transport modalities. For a service covering 983 482 km² , the median distance travelled to patients was 35 (16-71) km and the median time to PHEA was 54 (38-80) min.

CONCLUSIONS

In a cohort of 337 patients treated by a dedicated PHRM service in South Australia, the median time to PHEA was 54 (38-80) min with only 37% of patients receiving PHEA within 45 min from the activation of the team. Despite differing patient demographics, the percentage of patients receiving PHEA within the recommended time frame was greater than a similar cohort from the UK. However, both data sets still fall short of recommended targets.

Multiple Sclerosis Recognition by Biorthogonal Wavelet Features and Fitness-Scaled Adaptive Genetic Algorithm

Aim: Multiple sclerosis (MS) is a disease, which can affect the brain and/or spinal cord, leading to a wide range of potential symptoms. This method aims to propose a novel MS recognition method. Methods: First, the bior4.4 wavelet is used to extract multiscale coefficients. Second, three types of biorthogonal wavelet features are proposed and calculated. Third, fitness-scaled adaptive genetic algorithm (FAGA)-a combination of standard genetic algorithm, adaptive mechanism, and power-rank fitness scaling-is harnessed as the optimization algorithm. Fourth, multiple-way data augmentation is utilized on the training set under the setting of 10 runs of 10-fold cross-validation. Our method is abbreviated as BWF-FAGA. Results: Our method achieves a sensitivity of 98.00 ± 0.95%, a specificity of 97.78 ± 0.95%, and an accuracy of 97.89 ± 0.94%. The area under the curve of our method is 0.9876. Conclusion: The results show that the proposed BWF-FAGA method is better than 10 state-of-the-art MS recognition methods, including eight artificial intelligence-based methods, and two deep learning-based methods.

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP’s decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age > 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP’s decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.