Interrupted transport by the emergency medical service in stroke/transitory ischemic attack: A consequence of changed treatment routines in prehospital emergency care

Video support for prehospital stroke consultation: implications for system design and clinical implementation from prehospital simulations

BACKGROUND

Video consultations between hospital-based neurologists and Emergency Medical Services (EMS) have potential to increase precision of decisions regarding stroke patient assessment, management and transport. In this study we explored the use of real-time video streaming for neurologist-EMS consultation from the ambulance, using highly realistic full-scale prehospital simulations including role-play between on-scene EMS teams, simulated patients (actors), and neurologists specialized in stroke and reperfusion located at the remote regional stroke center.

METHODS

Video streams from three angles were used for collaborative assessment of stroke using the National Institutes of Health Stroke Scale (NIHSS) to assess symptoms affecting patient's legs, arms, language, and facial expressions. The aim of the assessment was to determine appropriate management and transport destination based on the combination of geographical location and severity of stroke symptoms. Two realistic patient scenarios were created, with severe and moderate stroke symptoms, respectively. Each scenario was simulated using a neurologist acting as stroke patient and an ambulance team performing patient assessment. Four ambulance teams with two nurses each all performed both scenarios, for a total of eight cases. All scenarios were video recorded using handheld and fixed cameras. The audio from the video consultations was transcribed. Each team participated in a semi-structured interview, and neurologists and actors were also interviewed. Interviews were audio recorded and transcribed.

RESULTS

Analysis of video-recordings and post-interviews (n = 7) show a more thorough prehospital patient assessment, but longer total on-scene time, compared to a baseline scenario not using video consultation. Both ambulance nurses and neurologists deem that video consultation has potential to provide improved precision of assessment of stroke patients. Interviews verify the system design effectiveness and suggest minor modifications.

CONCLUSIONS

The results indicate potential patient benefit based on a more effective assessment of the patient's condition, which could lead to increased precision in decisions and more patients receiving optimal care. The findings outline requirements for pilot implementation and future clinical tests.

Prehospital assessment of patients with abdominal pain triaged to self-care at home: an observation study

BACKGROUND

Patients who call for emergency medical services (EMS) due to abdominal pain suffer from a broad spectrum of diseases, some of which are time sensitive. As a result of the introduction of the concept of 'optimal level of care', some patients with abdominal pain are triaged to other levels of care than in an emergency department (ED). We hypothesised that it could be challenging in a patient safety perspective.

AIM

This study aims to describe consecutive patients who call for EMS due to abdominal pain and are triaged to self-care by EMS clinicians.

METHODS

This was an observational study performed in an EMS organisation in Western Sweden during 2020. The triage tool Rapid Emergency Triage and Treatment System (RETTS), which included Emergency Signs and Symptom (ESS) codes, was used to find medical records where patients with abdominal pain have been triaged to self-care and 194 patients was included in the study.

RESULTS

Of total 48,311 ambulance missions, A total of 1747 patients were labelled with ESS code six (abdominal pain), including 223 (12.8%) who were given the code for self-care and 194 who were further assessed by the research group. Of these patients, 32 (16.3%) had a return visit within 96 hours due to the same symptoms and 11 (5.6%) were hospitalised. In six of these patients, the EMS triage was evaluated retrospectively and assessed as inappropriate. These patients had a final diagnosis of ruptured abdominal aneurysm (n = 1), acute appendicitis with peritonitis (n = 2) and acute pancreatitis (n = 3). All these patients required extensive evaluation and different treatments, including acute surgery, antibiotics and fluid therapy.

CONCLUSION

Amongst the 1747 patients assessed by EMS due to abdominal pain, 223 (12.8%) were triaged to self-care. Of the 194 patients who were further assessed, 16.3% required a return visit to the ED within 96 hours and 5.6% were hospitalised. Six patients had obvious time-sensitive conditions. Our study highlights the difficulties in the early assessment of abdominal pain and the requirement for an accurate decision support tool.

Suboptimal prehospital decision- making for referral to alternative levels of care - frequency, measurement, acceptance rate and room for improvement

Background

The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from “time-sensitive conditions” delaying diagnosis and treatment. Thus, four questions arise:

How often are time-sensitive cases referred to primary care or self-care advice?

How can we measure and define the level of inappropriate clinical decision-making?

What is acceptable?

How to increase patient safety?

Main text

To what extent time-sensitive cases are non-conveyed varies. About 5–25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1–3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%.

The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome.

In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories.

There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another.

Conclusion

A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.

Reasons for bias in ambulance clinicians' assessments of non-conveyed patients: a mixed-methods study

Background

The number of ambulance assignments and the influx of patients to the emergency departments (EDs) in Sweden have increased in recent years. This is one reason the protocol for prehospital emergency care was developed around referring patients for non-conveyance, either through the see-and-convey elsewhere approach or through the see-and-treat approach. However, this protocol has led to challenges in patient assessments.

This study aimed to investigate the underlying causes of patient harm among those referred for the see-and-treat approach by the emergency medical services.

Methods

This three-phase study involved a mixed-methods design. Cases of injuries, internal investigations and incident analyses of referrals for the see-and-treat approach in two regions in south eastern Sweden from 2015 to 2020 were examined using qualitative content analysis. This qualitative analysis was the basis for the quantitative analysis of the ambulance records. After the qualitative analysis was completed, a review protocol was developed; 34 variables were used to review 240 randomly selected ambulance records logged in 2020, wherein patients were referred for the see-and-treat approach. Finally, the review results were synthesised.

Results

The qualitative analysis revealed three common themes: ‘assessment of patients’, ‘guidelines’ and ‘environment and organisation’. These results were confirmed by a medical journal review. Shortcomings were found in the anamnesis and in the number of targeted examinations performed. The checklist for referring patients for the see-and-treat approach and the information sheet to be provided to the patients were not used. In 34% of the ambulance records examined, the EMS clinicians deviated from the current guidelines for a see-and-treat referral.

Conclusions

The results indicated that the low adherence to guidelines and the patient assessment deviating from the protocol put patients at risk of being harmed during a see-and-treat referral.

Measures are needed to guarantee a safe assessment of an increasing number of patients who are referred for the see-and-treat approach, especially the multi-sick elderly patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00630-8.

Difficulties in the prehospital assessment of patients with TIA/stroke

BACKGROUND

In patients with TIA/stroke, early assessment is critical.

AIM

To describe patients who were not directly transported to hospital by ambulance after prehospital assessment.

METHODS

Patients hospitalized with TIA/stroke in Gothenburg, Data were obtained from the EMS and hospital case record system.

RESULTS

There were 7,812 patients with TIA/stroke, of which 4,853 (62%) were candidates for EMS transport. Among them, 176 (3.6%) were not directly transported to hospital by ambulance. In 45% of them, delay from symptom onset to calling for EMS was ≤24 hours. On EMS arrival, common symptom was dizziness (28%), followed by weakness in arm or leg (21%), loss of sensibility (13%), speech disturbances (7%), and facial numbness (4%). The modified National Institute of Health Stroke Score (mNIHSS) was 0 in 80% and >1 in two per cent. The NIHSS at the emergency department was 1-4 in 39% and 5-15 in six per cent. The EMS clinician made the decision not to transport the patient to hospital by the EMS in 84%, the dispatcher in 12% and the patient or relatives in four per cent. Patients were involved in the decision in 51%. Final diagnosis was stroke in 74% and the proportion who were independent in normal daily activities at hospital discharge decreased by 15% compared with before event.

CONCLUSION

About 3%-4% of patients with TIA/stroke were not directly transported to hospital by EMS after prehospital assessment. The most common symptom was dizziness. Decision-support tools for EMS to identify time-sensitive conditions are required.

A Decision Support Method for Prehospital Emergency Care Based on Ranking the Importance of Physiological Variables

To the on-site nursing staff or field management in prehospital emergency care, it seems baffling to conduct more targeted checklist tests for a specific disease. To address this problem, we proposed a decision support method for prehospital emergency care based on ranking the importance of physiological variables. We used multiple logistic regression models to explore the effects of various physiological variables on diseases based on the area under the curve (AUC) value. We implemented the method on the intensive care database (i.e., the Medical Information Mart for Intensive Care (MIMIC-III) database) and explored the importance of 17 physiological variables for 24 diseases, both chronic and acute. We included 33,798 adult patients, using the full physiological dataset as experiment data. We ranked the importance of the physiological variables related to the diseases according to the experiments’ AUC value. We discussed which physiological variables should be considered more important in adult intensive care units (ICUs) for prehospital emergency care conditions. We also discussed the relationships among the diseases based on ranking the importance of physiological variables. We used large-scale ICU patient data to obtain a cohort of physiological variables related to specific diseases. Ranking a cohort of physiological variables is a cost-effective means of reducing morbidity and mortality under prehospital emergency care conditions.

Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden

Background

There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data.

Methods

A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients’ medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test.

Results

Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women.

Conclusions

Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.

Outcome among patients who call the emergency medical service (EMS) due to dizziness

BACKGROUND

Patient with dizziness are challenging in prehospital care. The aim was to describe final diagnosis among patients assessed by EMS as suffering from dizziness with focus on time-critical conditions.

METHODS

Consecutive patients assessed by an EMS clinician during 12 months in a single large EMS system in Gothenburg, Sweden (660,000 inhabitants), were assessed. The study comprised patients given ESS code 11 dizziness. The main end-point was the final diagnosis (ICD code).

RESULTS

There were 58,575 primary missions, of which 2,048 (3.5%) were assessed as ESS code 11 (dizziness). Of these, 161 (8%) were excluded. Among the remaining 1887 cases, there were 230 different ICD codes and 96 (5%) had a time-critical condition. The majority (88%) had a cerebrovascular disease. The most typical symptoms among time-critical conditions were an acute onset (63%) and nausea, vomiting (61%). When compared with non-time-critical conditions, those with time-critical conditions were older and had a higher median systolic blood pressure at EMS arrival.

CONCLUSION

Among primary missions by the EMS, 3.5% had dizziness. Of these, 5% had a time-critical condition and the majority had a cerebrovascular disease. Instruments to identify time-critical conditions among patients seen by EMS due to dizziness are required.

Patient characteristics, triage utilisation, level of care, and outcomes in an unselected adult patient population seen by the emergency medical services: a prospective observational study

Background

Crowding in the emergency department (ED) is a safety concern, and pathways to bypass the ED have been introduced to reduce the time to definitive care. Conversely, a number of low-acuity patients in the ED could be assessed by the emergency medical services (EMS) as requiring a lower level of care. The limited access to primary care in Sweden leaves the EMS nurse to either assess the patient as requiring the ED or to stay at the scene. This study aimed to assess patient characteristics and evaluate the initial assessment by and utilisation of the ambulance triage system and the appropriateness of non-transport decisions.

Methods

A prospective observational study including 6712 patients aged ≥16 years was conducted. The patient records with 72 h of follow-up for non-transported patients were reviewed. Outcomes of death, time-critical conditions, complications within 48 h and final hospital assessment were evaluated. The Mann-Whitney U test, Fisher’s exact test, and Spearman’s rank correlation were used for statistical analysis.

Results

The median patient age was 66 years, and the most common medical history was a circulatory diagnosis. Males received a higher priority from dispatchers and were more frequently assessed at the scene as requiring hospital care. A total of 1312 patients (19.7%) were non-transported; a history of psychiatric disorders or no medical history was more commonly noted among these patients. Twelve (0.9%) of the 1312 patients not transported were later admitted with time-critical conditions. Full triage was applied in 77.4% of the cases, and older patients were triaged at the scene as an ‘unspecific condition’ more frequently than younger patients. Overall, the 30-day mortality was 4.1% (n = 274).

Conclusions

Age, sex, medical history, and presentation all appear to influence the initial assessment. A number of patients transported to ED could be managed at a lower level of care. A small proportion of the non-transported patients were later diagnosed with a time-critical condition, warranting improved assessment tools at the scene and education of the personnel focusing on the elderly population. These results may be useful in addressing resource allocation issues aiming at increasing patient safety.

Towards definitions of time-sensitive conditions in prehospital care

Background

Prehospital care has changed in recent decades. Advanced assessments and decisions are made early in the care chain. Patient assessments form the basis of a decision relating to prehospital treatment and the level of care. This development imposes heavy demands on the ability of emergency medical service (EMS) clinicians properly to assess the patient. EMS clinicians have a number of assessment instruments and triage systems available to support their decisions. Many of these instruments are based on vital signs and can sometimes miss time-sensitive conditions. With this commentary, we would like to start a discussion to agree on definitions of temporal states in the prehospital setting and ways of recognising patients with time-sensitive conditions in the most optimal way.

Main body

There are several articles discussing the identification and management of time-sensitive conditions. In these articles, neither definitions nor terminology have been uniform. There are a number of problems associated with the definition of time-sensitive conditions. For example, intoxication can be minor but also life threatening, depending on the type of poison and dose. Similarly, diseases like stroke and myocardial infarction can differ markedly in terms of severity and the risk of life-threatening complications. Another problem is how to support EMS clinicians in the early recognition of these conditions. It is well known that many of them can present without a deviation from normal in vital signs. It will most probably be impossible to introduce specific decision support tools for every individual time-sensitive condition. However, there may be information in the type and intensity of the symptoms patients present. In future, biochemical markers and machine learning support tools may help to identify patients with time-sensitive conditions and predict mortality at an earlier stage.

Conclusion

It may be of great value for prehospital clinicians to be able to describe time-sensitive conditions. Today, neither definitions nor terminology are uniform. Our hope is that this commentary will initiate a discussion on the issue aiming at definitions of time-sensitive conditions in prehospital care and how they should be recognised in the most optimal fashion.

Interrupted transport by the emergency medical service in stroke/transitory ischemic attack: A consequence of changed treatment routines in prehospital emergency care

BACKGROUND

The discovery that not all patients who call for the emergency medical service (EMS) require transport to hospital has changed the structure of prehospital emergency care. Today, the EMS clinician at the scene already distinguishes patients with a time-critical condition such as stroke/transitory ischemic attack (TIA) from patients without. This highlights the importance of the early identification of stroke/TIA.

AIM

To describe patients with a final diagnosis of stroke/TIA whose transport to hospital was interrupted either due to a lack of suspicion of the disease by the EMS crew or due to refusal by the patient or a relative/friend.

METHODS

Data were obtained from a register in Gothenburg, covering patients hospitalised due to a final diagnosis of stroke/TIA. The inclusion criterion was that patients were assessed by the EMS but were not directly transported to hospital by the EMS.

RESULTS

Among all the patients who were assessed by the EMS nurse and subsequently diagnosed with stroke or TIA in 2015, the transport of 34 of 1,310 patients (2.6%) was interrupted. Twenty-five of these patients, of whom 20 had a stroke and five had a TIA, are described in terms of initial symptoms and outcome. The majority had residual symptoms at discharge from hospital. Initial symptoms were vertigo/disturbed balance in 11 of 25 cases. Another three had symptoms perceived as a change in personality and three had a headache.

CONCLUSION

From this pilot study, we hypothesise that a fraction of patients with stroke/TIA who call for the EMS have their direct transport to hospital interrupted due to a lack of suspicion of the disease by the EMS nurse at the scene. These patients appear to have more vague symptoms including vertigo and disturbed balance. Instruments to identify these patients at the scene are warranted.