Path Analysis Modeling Indicates Free Transport Increases Ambulance Use for Minor Indications

Defining a threshold above which an adult can be considered to frequently use ambulance services: a retrospective cross-sectional study of emergency calls to an ambulance service in England

Objective

There is no empirical definition of adult frequent use of ambulance services. This study aimed to define a threshold, and utilise this to explore characteristics of people frequently using services.

Methods

This was a retrospective cross-sectional study in a single ambulance service in England. Routinely collected, pseudo-anonymised call- and patient-level data were collected for two months (January and June 2019). Incidents, defined as independent episodes of care, were analysed using a zero-truncated Poisson regression model to determine a suitable frequent-use threshold, with comparisons subsequently made between frequent and non-frequent users.

Results

A total of 101,356 incidents involving 83,994 patients were included in the analysis. Two potentially appropriate thresholds were identified: five incidents per month (A); and six incidents per month (B). Threshold A produced 3137 incidents from 205 patients, with five patients likely false-positive identifications. Threshold B produced 2217 incidents from 95 patients, with no false-positive identifications but 100 false-negatives compared to threshold A. Regardless of threshold, frequent users compared to non-frequent users had relatively reduced service use between 08:00 and 15:00, were younger and were more likely to receive lower-priority responses (all p < 0.001). We identified several chief complaints indicative of increased frequent use, including chest pain, psychiatric/suicide attempt and abdominal pains/problems.

Conclusions

We suggest a threshold of five incidents per month, with recognition that a small number of patients may be incorrectly identified as using ambulance services frequently. The rationale for this choice is discussed. This threshold may be applicable in wider UK settings and could be used for the routine automated identification of people using ambulance services frequently. The identified characteristics can help inform interventions. Future research should examine applicability of this threshold in other UK ambulance services and countries where patterns and determinants of frequent ambulance use may differ.

Factors Associated with Willingness to Call Emergency Medical Services for Worsening Symptoms of COVID-19 in Addis Ababa, Ethiopia

Background

In response to the COVID-19 pandemic, the Ethiopian Ministry of Health has established ambulances and dispatch centers specifically designed to transport COVID-19 patients to city medical centers. Due to a lack of evidence in this area, it is critical to assess the factors that influence the willingness to call for emergency medical services.

Methods

A community-based cross-sectional study was conducted from June to July 2021 in Addis Ababa. The data were gathered through use of a pretested questionnaire and analyzed using SPSS 25. Logistic regression was used to calculate odds ratios with and without confounding variable controls, and significant associations were declared at (0.05). For the variables that show significant associations in bivariate and multivariate analyses, a 95% confidence interval is provided.

Results

Three-quarters of those surveyed said they would call ambulance if they experienced worsening COVID-19 symptoms. The individual’s language was associated with the willingness to call EMS for worsening COVID-19 symptoms [AOR 0.51(95% CI: 0.28–0.92)].; awareness of the availability of toll-free ambulance services [AOR 3.4(95% CI: 1.92–5.95)]; recalling an EMS number [AOR 4.3(95% CI: 1.71–10.67)]; ambulance crew quality of care perception [AOR 3.6(95% CI: 2.09–6.10)]; ambulance service adequacy and accessibility perception [AOR 0.25(95% CI: 0.11–0.55)].

Conclusion

The study showed significant portion of the Addis Ababa community recognized the need to call EMS due to worsening COVID-19 symptoms. The individual’s language, awareness of toll-free ambulance; ability to recall an ambulance number, perception of the ambulance crew’s quality of care and adequacy and accessibility of service in the city influence the decision to call an ambulance. The finding highlights the significance of addressing problems through various media outlet, for advocacy and public awareness. More research, including qualitative studies, is needed to investigate the factors that encourage people to seek EMS.

Hospital emergency department visits by ambulance for nontraumatic tooth pain in the USA

Objective

This study examined the prevalence of ambulance use for nontraumatic tooth pain (NTP) visit to emergency departments (EDs) and the factors associated with ambulance use for NTP in the USA.

Materials and methods

Data from the National Hospital Ambulatory Medical Care survey conducted in the USA from 2003 to 2012 were analyzed. Descriptive statistics were obtained, and multivariable logistic regression was used to determine associations with ambulance use for NTP.

Results

The total proportion of ED visits due to NTP by ambulance was 1.1%, lowest in 2008 (0.43%) and highest in 2011 (2.28%). The proportion of ED visits due to NTP by ambulance was highest among public insurance enrollees (1.9%), Hispanics (2.3%) and those aged 45-64 years (2.7%). In the multivariable analysis, those aged 45-64 years had approximately four times higher odds of an ED visit for NTP by ambulance compared to those aged 25-44 years.

Conclusion

This study demonstrates that transport to EDs by ambulance for NTP does occur at a measurable rate and adults aged 45-64 years had significantly higher odds of ED visits for NTP by ambulance.

Age distribution of emergency department presentations in Victoria

OBJECTIVES

To describe patterns of ED utilisation over time, by patient age group and triage classification.

METHODS

Secondary analysis of data from all patients presenting to EDs in Victoria utilising the Victorian Emergency Minimum Dataset (VEMD) for the years 2002-2013. The VEMD includes all hospitals in Victoria with 24 h EDs.

RESULTS

The absolute number of presentations to EDs in Victoria has grown by over 52% in the last 11 years. The triage categories of highest urgency (1-3) grew by 89% whereas the categories of lowest urgency (4-5) grew by 33%. Over this period, the 5 year age band with the greatest number of ED presentations has consistently been, by far, children 0-4 years of age. This age group has seen an increase of 29% in ED presentations overall with a >55% increase in Triage 1-3, and an increase of 16% in triage 4-5. For all age groups, there has been little change in the number of triage category 4-5 presentations since 2007/2008. However, for triage categories 1-3, there have been consistent increases in presentations across all age groups.

CONCLUSION

The age range with the greatest absolute number of ED presentations in Victoria is children 0-4 years of age. This finding is consistent over time and across all triage classifications. The age range with the second highest absolute number of ED presentations is comprised of those 20-24 years of age. This is in contrast to the frequent public attention placed on the volume of ED presentations by the elderly.

Physiological-social scores in predicting outcomes of prehospital internal patients

The physiological-social modified early warning score system is a newly developed instrument for the identification of patients at risk. The aim of this study was to investigate the feasibility of using the physiological-social modified early warning score system for the identification of patients that needed prehospital emergency care. This prospective cohort study was conducted with 2157 patients. This instrument was used as a measure to detect critical illness in patients hospitalised in internal wards. Judgment by an emergency medicine specialist was used as a measure of standard. Data were analyzed by using receiver operating characteristics curves and the area under the curve with 95% confidence interval. The mean score of the physiological-social modified early warning score system was 2.71 ± 3.55. Moreover, 97.6% patients with the score ≥ 4 needed prehospital emergency services. The area under receiver operating characteristic curve was 0.738 (95% CI = 0.708-0.767). Emergency medical staffs can use PMEWS ≥ 4 to identify those patients hospitalised in the internal ward as at risk patients. The physiological-social modified early warning score system is suggested to be used for decision-making of emergency staff about internal patients' wards in EMS situations.

Exploring Factors Affecting Emergency Medical Services Staffs' Decision about Transporting Medical Patients to Medical Facilities

Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs' decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed using a content analysis approach. The data analysis revealed the following theme: "degree of perceived risk in EMS staffs and their patients." This theme consisted of two main categories: (1) patient's condition' and (2) the context of the EMS mission'. The patent's condition category emerged from "physical health statuses," "socioeconomic statuses," and "cultural background" subcategories. The context of the EMS mission also emerged from two subcategories of "characteristics of the mission" and EMS staffs characteristics'. EMS system managers can consider adequate technical, informational, financial, educational, and emotional supports to facilitate the decision making of their staffs. Also, development of an effective and user-friendly checklist and scoring system was recommended for quick and easy recognition of patients' needs for transportation in a prehospital situation.

Route less travelled? Ambulance use for children with high-acuity acute illness

AIM

Ambulance transportation offers important supportive care and treatment en route to definitive treatment. However, children may be at risk of under-utilising ambulance transportation, where private vehicle is possible. This study aims to determine how many of the sickest children present to hospitals in Auckland via ambulance and whether certain population groups are lower users of ambulance services.

METHODS

Transportation, demographic and outcome data were collected and analysed for children presenting to Starship Children's Health (Starship) from 1 January to 31 December 2011), who were 'self referrals' to hospital, less than 15 years of age, and assigned triage category 1 and 2 on presentation.

RESULTS

There were 1047 presentations to Starship identified that met inclusion criteria. Of these, 256 of the 341 triage one presentations (75.1%) and 217 of the 706 triage two presentations (30.7%) were transported by ambulance.Ambulance use was higher among older children (P < 0.001). Severity of illness or injury, as estimated by admission rates (56.7% vs. 43.3%, P = 0.21) and length of hospital stay (median = 1 day, P = 0.92), did not differ significantly by mode of transportation. There was no observed relationship with gender, ethnicity or area deprivation index score.

CONCLUSION

A significant proportion of acutely unwell children presenting to hospital were not transported by ambulance, particularly those aged less than 1 year. This has the potential to result in worse health outcomes. There were no identified associations with patient demographics, and further research is required to better understand this problem and develop solutions.

Universal access to ambulance does not increase overall demand for ambulance services in Queensland, Australia

OBJECTIVE

To determine the impact of the introduction of universal access to ambulance services via the implementation of the Community Ambulance Cover (CAC) program in Queensland in 2003-04.

METHOD

The study involved a 10-year (2000-01 to 2009-10) retrospective analysis of routinely collected data reported by the Queensland Ambulance Service (QAS) and by the Council of Ambulance Authorities. The data were analysed for the impact of policy changes that resulted in universal access to ambulance services in Queensland.

RESULTS

QAS is a statewide, publically funded ambulance service. In Queensland, ambulance utilisation rate (AUR) per 1000 persons grew by 41% over the decade or 3.9% per annum (10-year mean=149.8, 95% CI: 137.3-162.3). The AUR mean after CAC was significantly higher for urgent incidents than for non-urgent ones. However projection modelling demonstrates that URs after the introduction of CAC were significantly lower than the projected utilisation for the same period.

CONCLUSIONS

The introduction of universal access under the Community Ambulance Cover program in Queensland has not had any significant independent long-term impact on demand overall. There has been a reduction in the long-term growth rate, which may have been contributed to by an 'appropriate use' public awareness program.

Ambulance use is associated with higher self-rated illness seriousness: user attitudes and perceptions

OBJECTIVES

The objective was to study the role and effect of patients' perceptions on reasons for using ambulance services in Queensland, Australia.

METHODS

A cross-sectional survey was conducted of patients (n = 911) presenting via ambulance or self-transport at eight public hospital emergency departments (EDs). The survey included perceived illness severity, attitudes toward ambulance, and reasons for using ambulance. A theoretical framework was developed to inform this study.

RESULTS

Ambulance users had significantly higher self-rated perceived seriousness, urgency, and pain than self-transports. They were also more likely to agree that ambulance services are for everyone to use, regardless of the severity of their conditions. In compared to self-transports, likelihood of using an ambulance increased by 26% for every unit increase in perceived seriousness; and patients who had not used an ambulance in the 6 months prior to the survey were 66% less likely to arrive by ambulance. Patients who had presented via ambulance stated they considered the urgency (87%) or severity (84%) of their conditions as reasons for calling the ambulance. Other reasons included requiring special care (76%), getting higher priority at the ED (34%), not having a car (34%), and financial concerns (17%).

CONCLUSIONS

Understanding patients' perceptions is essential in explaining their actions and developing safe and effective health promotion programs. Individuals use ambulances for various reasons and justifications according to their beliefs, attitudes, and sociodemographic conditions. Policies to reduce and manage demand for such services need to address both general opinions and specific attitudes toward emergency health services to be effective.

Impact of a government triple zero awareness campaign on emergency department patient characteristics

OBJECTIVE

To evaluate the impact of a government triple zero community awareness campaign on the characteristics of patients attending an ED.

METHODS

A study using Emergency Department Information System data was conducted in an adult metropolitan tertiary-referral teaching hospital in Brisbane. The three outcomes measured in the 3 month post-campaign period were arrival mode, Australasian Triage Scale and departure status. These measures reflect ambulance usage, clinical urgency and illness severity, respectively. They were compared with those in the 3 month pre-campaign period. Multivariate logistic regression models were used to investigate the impacts of the campaign on each of the three outcome measures after controlling for age, sex, day and time of arrival, and daily minimum temperature.

RESULTS

There were 17,920 visits in the pre- and 17,793 visits in the post-campaign period. After the campaign, fewer patients arrived at the ED by road ambulance (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.80-1.00), although the impact of the campaign on the arrival mode was only close to statistical significance (Wald χ(2) -test, P= 0.055); and patients were significantly less likely to have higher clinical urgency (OR 0.86, 95% CI 0.79-0.94), while more likely to be admitted (OR 1.68, 95% CI 1.38-2.05) or complete treatment in the ED (OR 1.46, 95% CI 1.23-1.73) instead of leaving without waiting to be seen.

CONCLUSIONS

The campaign had no significant impact on the arrival mode of the patients. After the campaign, the illness acuity of the patients decreased, whereas the illness severity of the patients increased.

Increasing utilisation of emergency ambulances

BACKGROUND

Increased ambulance utilisation is closely linked with Emergency Department (ED) attendances. Pressures on hospital systems are widely acknowledged with ED overcrowding reported regularly in the media and peer-reviewed literature. Strains on ambulance services are less well-documented or studied.

AIMS

To review the literature to determine the trends in utilisation of emergency ambulances throughout the developed world and to discuss the major underlying drivers perceived as contributing to this increase.

METHOD

A search of online databases, search engines, peer-reviewed journals and audit reports was undertaken.

FINDINGS

Ambulance utilisation has increased in many developed countries over the past 20 years. Annual growth rates throughout Australia and the United Kingdom are similar. Population ageing, changes in social support, accessibility and pricing, and increasing community health awareness have been proposed as associated factors. As the extent of their contribution has not yet been established these factors were reviewed.

CONCLUSION

The continued rise in utilisation of emergency ambulances is placing increasing demands on ambulance services and the wider health system, potentially compromising access, quality, safety and outcomes. A variety of factors may contribute to this increase and targeted strategies to reduce utilisation will require an accurate identification of the major drivers of demand.

Factors influencing women's quality of life in the later half of life

BACKGROUND

Among older women in East Asia, and Taiwan in particular, there is little research on quality of life and the health care they receive to address the symptoms of menopause. This study evaluated factors which influence quality of life among post middle-age women in Taiwan.

METHODS

This cross-sectional study recruited 1250 women between 43 and 77 years of age during the year 2002. The factors investigated were demographics, menstruation status, menopausal symptoms, osteoporosis status, and use of hormone replacement therapy (HRT). SF-36 was used to assess the health-related quality of life of these women. Correlation, multiple regression and path analysis were used to test for direct and indirect relationships among the variables.

RESULTS

There are statistical significances between menopause symptoms and quality of life across different age groups. Path analysis shows a direct positive effect of HRT and a direct negative effect of climacteric symptoms on both physical and mental components of quality of life. Age, marital status, education and osteoporosis also have direct and indirect effects, some positive and others negative, on the components of quality of life.

CONCLUSIONS

When developing programs to enhance health in post middle-age women, consideration should be given to symptom relief as well as quality of life.