Initial emergency medical dispatching and prehospital needs assessment: a prospective study of the Swedish ambulance service

The experiences of patients not conveyed after evaluation by emergency medical services in Southwest Finland - A qualitative survey study

BACKGROUND

The amount of non-critical Emergency Medical Services missions has been increasing. After examination and treatment, paramedics can decide, based on guidelines, not to convey the patient to a healthcare facility. This study aimed to investigate patients' experiences in non-conveyance situations in Southwest Finland. Our research questions were: 1) Which patient concerns were not addressed? 2) What key actions improved patient comfort? and 3) What possible enhancements could make the patient experience more positive?

METHODS

This was a qualitative survey study. In March 2023, all the patients who met the inclusion criteria (N = 1017) received a survey via mail. The data from three open-ended questions were analyzed using inductive content analysis.

RESULTS

The response rate was 22.2 % (n = 226). The unaddressed patient concerns were related to inadequate immediate care and guidance and non-clinical factors causing concern. Key actions for improved patient comfort were related to immediate treatment and guidance, as well as non-clinical factors that impact the patient experience. More thorough treatment processes and more attentive encounters would have enhanced the patient experience.

CONCLUSIONS

Predominantly, patients reported having received excellent services. Utilizing paramedics' soft skills and keeping the patient as the central focus is key to improving the non-conveyance process and experience.

The Use of Medical Services for Low-Acuity Emergency Cases in Germany: Protocol for a Multicenter Observational Pilot Study

BACKGROUND

The increasing number of requests for help for acutely ill patients and their management is a major problem in the health systems of many countries, but especially in Germany. Rescue coordination centers and ambulances in Germany are increasingly overloaded. As a result, rides as a part of rescue operations have been increasing in length for years, yet a relevant proportion of these operations represent low-acuity calls (LACs). The basic objective of this pilot study is the quantitative analysis of the potential misuse of requests to the rescue control center. Indications for alternative treatment options and how to handle these treatment options in nonacute, non-life-threatening health conditions, such as minor injuries or minor infectious diseases, will be assessed. The identification of these LACs is vital in order to prevent health care resources in emergency medical care becoming inadequate.

OBJECTIVE

The overarching goal of this study is to determine the percentage of unnecessary rescue missions on site and subsequently to obtain an impression of the paramedics' assessment of alternative treatment options or alternative methods of rescue transportation.

METHODS

This will be an exploratory, noninterventional, cross-sectional study with a quantitative approach. The study is multicentric, with 21 ambulances in 12 different locations. The data for this study were collected via a questionnaire, newly developed for this study, for rescue personnel. Additionally, secondary data from the responsible control center will be linked and processed in an initial descriptive analysis. This descriptive analysis will form the basis for a subsequent variance analysis.

RESULTS

Data collection started as projected on September 18, 2023, and was ongoing until end of November 2023. We expect the documentation of several thousand rescue operations. We expect the following study results: (1) many unnecessary rescue operations, (2) immediate on-site assessment of correct care and treatment, and (3) patients' reasons for calling a rescue coordination center.

CONCLUSIONS

To our knowledge, this is the first observational study in which acute rescue operations are recorded on site. The focus of this study is on the trained paramedics' assessment of whether rescue operations are necessary or not. Additionally, alternative treatments, such as out-of-hours care service or primary care service, are shown for each individual case. The study also intends to cover the question of which factors are relevant and statistically significantly connected to the misuse of ambulances.

TRIAL REGISTRATION

German Register for Clinical Studies (Deutsches Register für Klinische Studien) DRKS00032510; https://drks.de/search/en/trial/DRKS00032510.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54002.

Paramedic management of back pain: a scoping review

BACKGROUND

Research examining paramedic care of back pain is limited.

OBJECTIVE

To describe ambulance service use and usual paramedic care for back pain, the effectiveness and safety of paramedic care of back pain, and the characteristics of people with back pain who seek care from paramedics.

METHODS

We included published peer-reviewed studies of people with back pain who received any type of paramedic care on-scene and/or during transport to hospital. We searched MEDLINE, EMBASE, CINAHL, Web of Science and SciELO from inception to July 2022. Two authors independently screened and selected the studies, performed data extraction, and assessed the methodological quality using the PEDro, AMSTAR 2 and Hawker tools. This review followed the JBI methodological guidance for scoping reviews and PRISMA extension for scoping reviews.

RESULTS

From 1987 articles we included 26 articles (25 unique studies) consisting of 22 observational studies, three randomised controlled trials and one review. Back pain is frequently in the top 3 reasons for calls to an ambulance service with more than two thirds of cases receiving ambulance dispatch. It takes ~ 8 min from time of call to an ambulance being dispatched and 16% of calls for back pain receive transport to hospital. Pharmacological management of back pain includes benzodiazepines, NSAIDs, opioids, nitrous oxide, and paracetamol. Non-pharmacological care is poorly reported and includes referral to alternate health service, counselling and behavioural interventions and self-care advice. Only three trials have evaluated effectiveness of paramedic treatments (TENS, active warming, and administration of opioids) and no studies provided safety or costing data.

CONCLUSION

Paramedics are frequently responding to people with back pain. Use of pain medicines is common but varies according to the type of back pain and setting, while non-pharmacological care is poorly reported. There is a lack of research evaluating the effectiveness and safety of paramedic care for back pain.

A registry-based observational study comparing emergency calls assessed by emergency medical dispatchers with and without support by registered nurses

Background

The requirement concerning formal education for emergency medical dispatcher (EMD) is debated and varies, both nationally and internationally. There are few studies on the outcomes of emergency medical dispatching in relation to professional background. This study aimed to compare calls handled by an EMD with and without support by a registered nurse (RN), with respect to priority level, accuracy, and medical condition.

Methods

A retrospective observational study, performed on registry data from specific regions during 2015. The ambulance personnel’s first assessment of the priority level and medical condition was used as the reference standard. Outcomes were: the proportion of calls dispatched with a priority in concordance with the ambulance personnel’s assessment; over- and undertriage; the proportion of most adverse over- and undertriage; sensitivity, specificity and predictive values for each of the ambulance priorities; proportion of calls dispatched with a medical condition in concordance with the ambulance personnel’s assessment. Proportions were reported with 95% confidence intervals. χ²-test was used for comparisons. P-levels < 0.05 were regarded as significant.

Results

A total of 25,025 calls were included (EMD n = 23,723, EMD + RN n = 1302). Analyses relating to priority and medical condition were performed on 23,503 and 21,881 calls, respectively. A dispatched priority in concordance with the ambulance personnel’s assessment were: EMD n = 11,319 (50.7%) and EMD + RN n = 481 (41.5%) (p < 0.01). The proportion of overtriage was equal for both groups: EMD n = 5904, EMD + RN n = 306, (26.4%) p = 0.25). The proportion of undertriage for each group was: EMD n = 5122 (22.9%) and EMD + RN n = 371 (32.0%) (p < 0.01). Sensitivity for the most urgent priority was 54.6% for EMD, compared to 29.6% for EMD + RN (p < 0.01), and specificity was 67.3% and 84.8% (p < 0.01) respectively. A dispatched medical condition in concordance with the ambulance personnel’s assessment were: EMD n = 13,785 (66.4%) and EMD + RN n = 697 (62.2%) (p = 0.01).

Conclusions

A higher precision of emergency medical dispatching was not observed when the EMD was supported by an RN. How patient safety is affected by the observed divergence in dispatched priorities is an area for future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00987-y.

Live video from bystanders' smartphones to medical dispatchers in real emergencies

Background

Medical dispatchers have limited information to assess the appropriate emergency response when citizens call the emergency number. We explored whether live video from bystanders’ smartphones changed emergency response and was beneficial for the dispatcher and caller.

Methods

From June 2019 to February 2020, all medical dispatchers could add live video to the emergency calls at Copenhagen Emergency Medical Services, Denmark. Live video was established with a text message link sent to the caller’s smartphone using GoodSAM®. To avoid delayed emergency response if the video transmission failed, the medical dispatcher had to determine the emergency response before adding live video to the call. We conducted a cohort study with a historical reference group. Emergency response and cause of the call were registered within the dispatch system. After each video, the dispatcher and caller were given a questionnaire about their experience.

Results

Adding live video succeeded in 838 emergencies (82.2% of attempted video transmissions) and follow-up was possible in 700 emergency calls. The dispatchers’ assessment of the patients’ condition changed in 51.1% of the calls (condition more critical in 12.9% and less critical in 38.2%), resulting in changed emergency response in 27.5% of the cases after receiving the video (OR 1.58, 95% CI: 1.30–1.91) compared to calls without video. Video was added more frequently in cases with sick children or unconscious patients compared with normal emergency calls. The dispatcher recognized other or different disease/trauma in 9.9% and found that patient care, such as the quality of cardiopulmonary resuscitation, obstructed airway or position of the patient, improved in 28.4% of the emergencies. Only 111 callers returned the questionnaire, 97.3% of whom felt that live video should be implemented.

Conclusions

It is technically feasible to add live video to emergency calls. The medical dispatcher’s perception of the patient changed in about half of cases. The odds for changing emergency response were 58% higher when video was added to the call. However, use of live video is challenging with the existing dispatch protocols, and further implementation science is necessary.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00493-5.

Inequalities and short-term outcome among patients assessed as non-urgent in a Swedish ambulance service setting

BACKGROUND

Within the ambulance service, assessment and referral of patients, especially those with non-urgent conditions, is a difficult and complicated task. Studies indicate that 12 to 20 percent of all patients are subjected to non-conveyance and discharged at the scene. There is lack of knowledge of what characterizes conveyed and non-conveyed patients. The aim of this study was to explore non-urgent patients who are conveyed or not conveyed to hospital and the short-term outcome of non-conveyance in a Swedish Ambulance Service setting.

METHODS

This study has a descriptive, cross-sectional design. All patients who were prioritized as non-urgent were eligible for the study and 1,048 patients were followed-up in an administrative data system that stores information about the patients' trajectory in both primary and hospital care.

RESULTS

More women than men were subjected to non-conveyance and most of the non-conveyed patients were left at home out-of-hours. 53% sought care again within 72 h. A large proportion of the non-conveyed patients were assessed as having unspecific symptoms.

CONCLUSIONS

There are prominent gender differences in the context of non-conveyance where unspecific symptoms seem to be the main reason for being left at home. As many of the non-conveyed patients who did not receive any advice about further investigation or intervention sought care again within 72 h, the assessments may be insufficient or inaccurate.

Experience of using video support by prehospital emergency care physician in ambulance care - an interview study with prehospital emergency nurses in Sweden

Introduction

When in need of emergency care and ambulance services, the ambulance nurse is often the first point of contact for the patient with healthcare. This role requires comprehensive knowledge of the ambulance nurse to be able to assign the right level of care and, if necessary, to provide self-care advice for patients with no further conveyance to hospital. Recently, an application was developed for transmitting real-time video to facilitate consultation between ambulance nurses and prehospital physicians in the role of regional medical support (RMS) for ambulance care. The use of video communication as a complement of medical support when referring to self-care is still an unexplored method in a prehospital setting.

Our study aimed to elucidate ambulance nurses’ experience of video consultation with RMS physician during the assessment of patients considered to be triaged to self-care.

Method

We conducted a qualitative design study using semi-structured interviews with open questions. Twelve ambulance nurses were included in the study. To explore the ambulance nurses’ experience of performing video consultation with RMS physician, in cases when a patient was assessed and triaged to self-care, a content analysis was performed.

Results

A main category emerged from the results: “ Video consultation as decision support in the ambulance care promotes increased patient participation and for the ambulance nurses, it creates a feeling of increased patient safety “. The main category was based and formed on the following categories: “ Simultaneous presence of ambulance nurse and a physician increases patient participation during the assessment resulting in a confident care decision “. “Interprofessional collaboration strengthens the medical assessment”. “Video technology promotes accessibility for patients needs in the ambulance care regardless of emergency level”.

Conclusions

Ambulance nurses experienced that the use of video consultation increases patient involvement and confidence in healthcare when both the ambulance nurse and the physician were present when deciding on self-care advice. The live imaging allowed the ambulance nurse and prehospital physician to reach a consensus on the patient’s current medical care needs, which in turn led to a feeling of increased patient safety for the ambulance nurses.

Prediction of a time-sensitive condition among patients with dizziness assessed by the emergency medical services

BACKGROUND

Dizziness is a relatively common symptom among patients who call for the emergency medical services (EMS).

AIM

To identify factors of importance for the early identification of a time-sensitive condition behind the symptom of dizziness among patients assessed by the EMS.

METHODS

All patients assessed by the EMS and triaged using Rapid Emergency Triage and Treatment (RETTS) for adults code 11 (=dizziness) in the 660,000 inhabitants in the Municipality of Gothenburg, Sweden, in 2016, were considered for inclusion. The patients were divided into two groups according to the final diagnosis (a time-sensitive condition, yes or no).

RESULTS

There were 1536 patients who fulfilled the inclusion criteria, of which 96 (6.2%) had a time-sensitive condition. The majority of these had a stroke/transitory ischaemic attack (TIA). Eight predictors of a time-sensitive condition were identified. Three were associated with a reduced risk: 1) the dizziness was of a rotatory type, 2) the dizziness had a sudden onset and 3) increasing body temperature. Five were associated with an increased risk: 1) sudden onset of headache, 2) a history of head trauma, 3) symptoms of nausea or vomiting, 4) on treatment with anticoagulants and 5) increasing systolic blood pressure.

CONCLUSION

Among 1536 patients who were triaged by the EMS for dizziness, 6.2% had a time-sensitive condition. On the arrival of the EMS, eight factors were associated with the risk of having a time-sensitive condition. All these factors were linked to the type of symptoms or to clinical findings on the arrival of the EMS or to the recent clinical history.

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.

Assessing non-conveyed patients in the ambulance service: a phenomenological interview study with Swedish ambulance clinicians

OBJECTIVES

To combat overcrowding in emergency departments, ambulance clinicians (ACs) are being encouraged to make on-site assessments regarding patients' need for conveyance to hospital, and this is creating new and challenging demands for ACs. This study aimed to describe ACs' experiences of assessing non-conveyed patients.

DESIGN

A phenomenological interview study based on a reflective lifeworld research approach.

SETTING

The target area for the study was Stockholm, Sweden, which has a population of approximately 2.3 million inhabitants. In this area, 73 ambulances perform approximately just over 200 000 ambulance assignments annually, and approximately 25 000 patients are non-conveyed each year.

INFORMANTS

11 ACs.

METHODS

In-depth open-ended interviews.

RESULTS

ACs experience uncertainty regarding the accuracy of their assessments of non-conveyed patients. In particular, they fear conducting erroneous assessments that could harm patients. Avoiding hasty decisions is important for conducting safe patient assessments. Several challenging paradoxes were identified that complicate the non-conveyance situation, namely; responsibility, education and feedback paradoxes. The core of the responsibility paradox is that the increased responsibility associated with non-conveyance assessments is not accompanied with appropriate organisational support. Thus, frustration is experienced. The education paradox involves limited and inadequate non-conveyance education. This, in combination with limited support from non-conveyance guidelines, causes the clinical reality to be perceived as challenging and problematic. Finally, the feedback paradox relates to the obstruction of professional development as a result of an absence of learning possibilities after assessments. Additionally, ACs also described loneliness during non-conveyance situations.

CONCLUSIONS

This study suggests that, for ACs, performing non-conveyance assessments means experiencing a paradoxical professional existence. Despite these aggravating paradoxes, however, complex non-conveyance assessments continue to be performed and accompanied with limited organisational support. To create more favourable circumstances and, hopefully, safer assessments, further studies that focus on these paradoxes and non-conveyance are needed.

Ambulance nurses' experiences of deciding a patient does not require ambulance care

AIM

To describe ambulance nurses' experience of deciding a patient does not require ambulance care.

DESIGN

An inductive, empirical study with a qualitative approach.

METHODS

Data collection was conducted through semi-structured interviews, and collected data were analysed with qualitative manifest content analysis. Data were collected during the spring 2017, and eight ambulance nurses participated.

RESULTS

The findings are presented in one main category, which is "Not very ill but a difficult decision" with totally three subcategories. The ambulance nurse's experience of making the assessment when the patient has no need for ambulance care is like walking the balance of slack line. This means that the assessment can be both easy and very difficult but something that definitely requires experience, knowledge and dedication.

Social factors in frequent callers: a description of isolation, poverty and quality of life in those calling emergency medical services frequently

Background

Frequent users of emergency medical services (EMS) comprise a disproportionate percentage of emergency department (ED) visits. EDs are becoming increasingly overwhelmed and a portion of use by frequent callers of EMS is potentially avoidable. Social factors contribute to frequent use however few studies have examined their prevalence. This study aims to describe social isolation/loneliness, poverty, and quality of life in a sample of frequent callers of EMS in the Hamilton region, a southern Ontario mid-sized Canadian city.

Study design

Cross-sectional quantitative study.

Methods

We surveyed people who called EMS five or more times within 12 months. A mailed self-administered survey with validated tools, and focused on four major measures: demographic information, social isolation, poverty, and quality of life.

Results

Sixty-seven frequent EMS callers revealed that 37–49% were lonely, 14% had gone hungry in the preceding month, and 43% had difficulties making ends meet at the end of the month. For quality of life, 78% had mobility problems, 55% had difficulty with self-care, 78% had difficulty with usual activities, 87% experienced pain/discomfort, and 67% had anxiety/depression. Overall quality adjusted life years value was 0.53 on a scale of 0 to 1. The response rate was 41.1%.

Conclusions

Loneliness in our participants was more common than Hamilton and Canadian rates. Frequent EMS callers had higher rates of poverty and food insecurity than average Ontario citizens, which may also act as a barrier to accessing preventative health services. Lower quality of life may indicate chronic illness, and users who cannot access ambulatory care services consistently may call EMS more frequently. Frequent callers of EMS had high rates of social loneliness and poverty, and low quality of life, indicating a need for health service optimization for this vulnerable population.

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.

The ambulance nurse experiences of non-conveying patients

Aims and objectives

To explore ambulance nurses' (ANs) experiences of non‐conveying patients to alternate levels of care.

Background

Increases in ambulance utilisation and in the number of patients seeking ambulance care who do not require medical supervision or treatment during transport have led to increased nonconveyance (NC) and referral to other levels of care.

Design

A qualitative interview study was conducted using an inductive research approach.

Methods

The study was conducted in a region in the middle of Sweden during 2016–2017. Twenty nurses were recruited from the ambulance departments in the region. A conventional content analysis was used to analyse the interviews. The study followed the COREQ checklist.

Results

The ANs experienced NC as a complex and difficult task that carried a large amount of responsibility. They wanted to be professional, spend time with the patient and find the best solution for him or her. These needs conflicted with the ANs' desire to be available for assignments with a higher priority. The ANs could feel frustrated when they perceived that ambulance resources were being misused and when it was difficult to follow the NC guidelines.

Conclusion

If ANs are expected to nonconvey patients seeking ambulance care, they need a formal mandate, knowledge and access to primary health care.

Relevance to clinical practice

This study provides new knowledge regarding the work situation of ANs in relation to NC. These findings can guide future research and can be used by policymakers and ambulance organisations to highlight areas that need to evolve to improve patient care.

Inter-disciplinary cooperation in a physician-staffed emergency medical system

BACKGROUND

On-scene management of pre-hospital emergencies is often inter-disciplinary, involving ground-emergency medical services (EMS), police- and fire services, and in Norway general practitioners on-call. This can also be supplemented by physician-staffed EMS (P-EMS), utilizing helicopters or rapid response vehicles. We hypothesized that P-EMS cooperates extensively with other emergency services, and therefore the primary aim of this study was to investigate the fraction of inter-disciplinary cooperation between P-EMS and other emergency services.

METHODS

Retrospective, observational study of primary pre-hospital missions with patient contact performed at a Norwegian P-EMS base from 01.01.06 to 31.12.15. Descriptive statistics, comparisons using Student`s t-test, and chi-squared test for trend were applied.

RESULTS

Inter-disciplinary cooperation occurred in 94.3% of the 8580 missions, of which physician-staffed EMS cooperated with ground EMS in 92.4%, general practitioner 32.9%, police service 11.6% and fire service 11.8%. Trauma constituted 34.4 and cardiac arrest 14.1% of missions. The mean National Advisory Committee for Aeronautics score was 4.21 (95% Confidence Interval 4.18-4.24). There was an overall decrease in cooperation with general practitioners and the police service (P < 0.001). During helicopter missions, we reported a decrease in general practitioner cooperation compared to an increase during rapid response car missions (P < 0.001). In cardiac arrest cases, cooperation with both general practitioners and the fire service increased (P < 0.001).

CONCLUSION

Physician-staffed EMS cooperates extensively with other professional emergency services, especially ground-EMS. On-scene cooperation with general practitioners decreased, whereas there was an increased cooperation with the fire service in a "first-responder" role during cardiac arrest missions.

A comparison of two emergency medical dispatch protocols with respect to accuracy

Background

Emergency medical dispatching should be as accurate as possible in order to ensure patient safety and optimize the use of ambulance resources. This study aimed to compare the accuracy, measured as priority level, between two Swedish dispatch protocols – the three-graded priority protocol Medical Index and a newly developed prototype, the four-graded priority protocol, RETTS-A.

Methods

A simulation study was carried out at the Emergency Medical Communication Centre (EMCC) in Stockholm, Sweden, between October and March 2016. Fifty-three voluntary telecommunicators working at SOS Alarm were recruited nationally. Each telecommunicator handled 26 emergency medical calls, simulated by experienced standard patients. Manuscripts for the scenarios were based on recorded real-life calls, representing the six most common complaints. A cross-over design with 13 + 13 calls was used. Priority level and medical condition for each scenario was set through expert consensus and used as gold standard in the study.

Results

A total of 1293 calls were included in the analysis. For priority level, n = 349 (54.0%) of the calls were assessed correctly with Medical Index and n = 309 (48.0%) with RETTS-A (p = 0.012). Sensitivity for the highest priority level was 82.6% (95% confidence interval: 76.6–87.3%) in the Medical Index and 54.0% (44.3–63.4%) in RETTS-A. Overtriage was 37.9% (34.2–41.7%) in the Medical Index and 28.6% (25.2–32.2%) in RETTS-A. The corresponding proportion of undertriage was 6.3% (4.7–8.5%) and 23.4% (20.3–26.9%) respectively.

Conclusion

In this simulation study we demonstrate that Medical Index had a higher accuracy for priority level and less undertriage than the new prototype RETTS-A. The overall accuracy of both protocols is to be considered as low. Overtriage challenges resource utilization while undertriage threatens patient safety. The results suggest that in order to improve patient safety both protocols need revisions in order to guarantee safe emergency medical dispatching.

Trust in the early chain of healthcare: lifeworld hermeneutics from the patient's perspective

PURPOSE

Patients must be able to feel as much trust for caregivers and the healthcare system at the healthcare centre as at the emergency department. The aim of this study is to explain and understand the phenomenon of trust in the early chain of healthcare, when a patient has called an ambulance for a non-urgent condition and been referred to the healthcare centre.

METHOD

A lifeworld hermeneutic approach from the perspective of caring science was used. Ten patients participated: seven female and three male. The setting is the early chain of healthcare in south-western Sweden.

RESULTS

The findings show that the phenomenon of trust does not automatically involve medical care. However, attention to the patient's lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the "voice of the lifeworld" enables the patient to feel trust.

CONCLUSION

Trust in the early chain of healthcare entails caregivers' ability to pay attention to both medical and existential issues in compliance with the patient's information and questions. Thus, the patient must be invited to participate in assessments and decisions concerning his or her own healthcare, in a credible manner and using everyday language.

Patients with head trauma: A study on initial prehospital assessment and care

BACKGROUND

Best evidence guidelines are intended to standardise assessment and treatment of patients with head trauma and improve outcomes for TBI patients. The primary aim was to explore pre-hospital emergency care nurses' (PECNs') documented assessment and care of patients with head trauma and the secondary aim to study gender differences in the documented care and interventions given by the PECNs.

METHODS

A retrospective observational study was conducted by evaluating 2750 prehospital medical records.

RESULTS

The results showed that 25.2% of the patients were assessed according to all four core-elements in the guidelines and 78.6% of the patients underwent at least one intervention by the PECNs. Male patients were to a higher extent assessed according to guidelines and were given higher transport priority while females were more often assessed for vital parameters and received significantly more analgesics. The assessment documented by the PECNs was not optimal concerning documentation using the Glasgow Coma Scale, but the documented assessment of circulation and, especially, respiratory rate was high (77.2%) compared to previous studies.

CONCLUSION

The findings of this study showed a low degree of documented assessment of parameters related to head trauma and might also indicate some gender differences in the assessment and management.

Comparison of prehospital triage and five-level triage system at the emergency department

OBJECTIVE

There is lack of scientific evidence regarding the effectiveness of prehospital triage systems. This study compared the two-level Taiwan Prehospital Triage System (TPTS) with the five-level Taiwan Triage and Acuity Scale (TTAS) at ED arrival regarding the prediction of patient outcomes and the utilisation of medical resources.

DESIGN

This was a retrospective cohort study. Adult patients transported via the emergency medical service (EMS), who arrived at the ED of a medical centre in northern Taiwan during the study period were enrolled. TTAS acuity levels 1-2 were considered comparable to the designation of 'emergent' by the prehospital TPTS system. The outcomes were analysed by comparing TPTS and TTAS by acuity levels.

RESULTS

Among 4430 enrolled patients, 25.2% and 74.8% were classified as emergent and non-emergent by TPTS; 44.1% and 55.9% were classified as levels 1-2 and levels 3-5 by TTAS. Of the TPTS emergent patients, 15.2% were classified as TTAS levels 3-5, whereas 30.4% of TPTS non-emergent transports were classified as TTAS levels 1-2 at the ED. TTAS levels 1-2 showed better predictability than TPTS emergent level for hospitalisation rate with a sensitivity of 70.3% (95% CI 68.3% to 72.2%) versus 41.1% (95% CI 39.0% to 43.2%), and a negative predictive value of 74.8% (95% CI 73.4% to 76.0%) versus 62.6% (95% CI 61.7% to 63.5%).

CONCLUSION

The current prehospital triage system is insufficient and inappropriate in classifying patients transported to the ED. The present study offers supporting evidence for the introduction of a five-level triage system to prehospital EMS systems.

Early prehospital assessment of non-urgent patients and outcomes at the appropriate level of care: A prospective exploratory study

INTRODUCTION

The Ambulance Organization of Sweden provides qualified medical assessment and treatment by ambulance nurses based on patient needs regarding appropriate levels of care. A new model for patients with non-urgent medical conditions has been introduced. The main objective of this study was to examine early prehospital assessment of non-urgent patients, and its impact on the choice of the appropriate level of care.

METHODS

The study design was a 1-year, prospective study, involving an ambulance district in southwestern Sweden with a population of 78,000. Eligible patients were from18years of age, assessed as priority GREEN by Rapid Emergency Triage and Treatment System (RETTS). Ambulance nurses contacted primary care physicians on decisions on whether a patient should be transported to a primary healthcare unit or an A&E. Data was collected from electronic health records from April 2014 to July 2015. A comparison was made with a retrospective control group without consulting a physician concerning the appropriate level of care.

RESULTS

394 patients were included, 184 in the intervention group, and 210 in the control group. There were statistically significant differences in favor of the study group (p<0.001) regarding no transport, or transport and admission to an A&E. The groups did not differ significantly regarding transport to a primary care unit.

CONCLUSION

This prehospital assessment model indicates a decrease in ambulance transports to an A&E and admissions to a hospital ward. Collaboration between ambulance nurses and primary physicians affects the decision for the appropriate level of care for patients with a non-urgent condition.

Possible effects of a course in cardiovascular nursing on prehospital care of patients experiencing suspected acute coronary syndrome: a cluster randomised controlled trial

BACKGROUND

Current research suggests that nurses can influence the outcome for patients with acute coronary syndrome (ACS). The aim of this study has been to evaluate whether a course in cardiovascular nursing (CVN) can improve ambulance nurses' (ANs') prehospital care of patients experiencing suspected ACS, related to pain intensity.

METHODS

This is a cluster randomised controlled trial that was conducted in the ambulance services. Patients were allocated to one of two groups: in the first group, patients were treated by ANs who had attended the CVN course and in the second group patients were treated by ANs without this qualification. Inclusion criteria were: 1/pain raising suspicion of ACS, and 2/pain score ≥4 on a visual analogue scale (VAS). The primary outcome was the estimated intensity of pain or discomfort according to VAS 15 min after randomisation. Secondary outcomes were estimated intensity of pain or discomfort on admission to hospital and further requirement of pain treatment, as well as symptoms such as paleness and/or cold sweat; nausea and/or vomiting; anxiety, dyspnea, degree of alertness, respiratory depression and aggressiveness. A further secondary outcome measured was survival to 30 days. Lastly, a final diagnosis was made. A total of 38 ANs attended the CVN course. There were 1,747 patients who fulfilled the inclusion criteria.

RESULTS

The pain score did not differ significantly between the two groups fifteen minutes after randomisation (median value of VAS was 4.0 in both groups). On admission to hospital the pain score was significantly lower for patients treated by an AN who had attended the CVN course (n = 332) compared with those treated by an AN who had not attended the course (n = 1,415) (median 2.5 and 3.0 respectively, p = 0.001). The ANs who had attended the course used higher doses of morphine.

CONCLUSIONS

An educational intervention with a CVN course did not relate significantly to more efficient pain relief in suspected ACS during the first 15 min. However, this intervention was associated with more effective pain relief later on in the prehospital setting. Thus, a CVN course for ANs appears to be associated with reduced pain intensity among patients experiencing suspected ACS. This result needs however to be confirmed in further trials.

TRIAL REGISTRATION

The ClinicalTrials.gov Protocol Registration System (registration number NCT00792181).

Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain

In the treatment of acute coronary syndromes, reduction of sympathetic stress and catecholamine release is an important therapeutic goal. One method used to achieve this goal is pain reduction through the systemic administration of analgesia. Historically, morphine has been the analgesic of choice in ischemic cardiac pain. This randomized double-blind controlled trial seeks to prove the utility of fentanyl as an alternate first-line analgesic for ischemic-type chest pain in the prehospital setting. Successive patients who were treated for suspected ischemic chest pain in the emergency medical services system were considered eligible. Once chest pain was confirmed, patients received oxygen, aspirin, and nitroglycerin therapy. If the ischemic-type chest pain continued the patient was randomized in a double-blinded fashion to treatment with either morphine or fentanyl. Pain scale scores, necessity for additional dosing, and rate of adverse events between the groups were assessed every 5 minutes and were compared using t-testing, Fisher's Exact test, or Analysis of Variance (ANOVA) where appropriate. The primary outcome of the study was incidence of hypotension and the secondary outcome was pain reduction as measured by the visual analog score and numeric rating score. A total of 207 patients were randomized with 187 patients included in the final analysis. Of the 187 patients, 99 were in the morphine group and 88 in the fentanyl group. No statistically significant difference between the two groups with respect to hypotension was found (morphine 5.1% vs. fentanyl 0%, p = 0.06). Baseline characteristics, necessity for additional dosing, and other adverse events between the two groups were not statistically different. There were no significant differences between the changes in visual analog scores and numeric rating scale scores for pain between the two groups (p = 0.16 and p = 0.15, respectively). This study supports that fentanyl and morphine are comparable in providing analgesia for ischemic-type chest pain. Fentanyl appears to be a safe and effective alternative to morphine for the management of chest pain in the prehospital setting.

Non-specific complaints in the ambulance; predisposing structural factors

BACKGROUND

The pre-hospital assessment non-specific complaint (NSC) often applies to patients whose diagnosis does not match any other specific assessment correlating to particular symptoms or diseases, though some previous studies have found them to be related to serious underlying conditions. The aim was to identify whether the structural factors such as urgency according to the dispatch priority of the Emergency Medical Communication Centre (EMCC) or work load in the Emergency Medical Services (EMS) are predisposing factors for the assessment of NSC instead of a specific assessment.

METHODS

All patients with assessed condition NSCs by the EMS to Södersjukhuset during 2011 (n = 493) were compared with gender- and age-matched controls (n = 493), which were randomly drawn from all patients with specific conditions in the EMS, regarding day of week, time of day and priority set by EMCC with chi-squared tests and multivariate logistic regression models.

RESULTS

Among patients with NSCs, more were females (58 %) and the median age was 82. Almost all patients were categorized with NSCs during the daytime (8 a.m. to 9 p.m.), i.e. 450 (91 %) as compared to 373 (75 %) of those with specific conditions (p < 0.01). The risk of having an EMS dispatched as low priority by the EMCC was almost doubled among patients with NSCs compared to controls (OR 1.97, 95 % CI 1.38-2.79).

CONCLUSIONS

Since patients with NSCs appear most frequently during the hours with most transportations for the EMS, i.e. 10 a.m. to 2 p.m., and the risk of having the assessment NSC was doubled if the EMCC dispatched EMS as low priority, structural factors might be predisposing factors for the assessment.

Barriers and opportunities in assessing calls to emergency medical communication centre--a qualitative study

INTRODUCTION

Previous studies have described the difficulties and the complexity of assessing an emergency call, and assessment protocols intended to support the emergency medical dispatcher's (EMD) assessment have been developed and evaluated in recent years. At present, the EMD identifies about 50-70 % of patients suffering from cardiac arrest, acute myocardial infarction or stroke. The previous research has primarily been focused on specific conditions, and it is still unclear whether there are any overall factors that may influence the assessment of the call to the emergency medical communication centre (EMCC).

AIM

The aim of the study was to identify overall factors influencing the registered nurses' (RNs) assessment of calls to the EMCC.

METHOD

A qualitative study design was used; a purposeful selection of calls to the EMCC was analysed by content analysis.

RESULTS

One hundred calls to the EMCC were analysed. Barriers and opportunities related to the RN or the caller were identified as the main factors influencing the RN's assessment of calls to the EMCC. The opportunities appeared in the callers' symptom description and the communication strategies used by the RN. The barriers appeared in callers' descriptions of unclear symptoms, paradoxes and the RN's lack of communication strategies during the call.

CONCLUSION

Barriers in assessing the call to the EMCC were associated with contradictory information, the absence of a primary problem, or the structure of the call. Opportunities were associated with a clear symptom description that was also repeated, and the RN's use of different communication strategies such as closed loop communication.

ECG signs of acute myocardial ischemia in the prehospital setting of a suspected acute coronary syndrome and its association with outcomes

AIMS

The aims of this study were (a) to determine the prehospital prevalence of electrocardiographic (ECG) signs of acute myocardial ischemia in patients with suspected acute coronary syndrome and (b) to describe the relationships between the various ECG patterns and the diagnosis of acute myocardial infarction (AMI) and outcomes.

METHODS

Prospective cohort study using data from an interventional trial in acute chest pain patients transported by the emergency medical services. These patients were classified into 3 groups: patients with ECG showing signs of acute myocardial ischemia, patients with ECG showing other abnormal changes (bundle-branch block, pacemaker rhythm, Q-wave or T-wave inversion) and patients without significant pathologic findings. All P values are age-adjusted.

RESULTS

Among 1546 patients, 312 (20%) had ECG signs of acute myocardial ischemia. Of them, 57% had a final diagnosis of AMI versus 26% of those with other abnormal ECGs and 12% of those with ECG without significant pathologic findings (P<.0001). In all, 53% of all AMI cases involved patients without ECG signs of acute myocardial ischemia. Although ECG signs of acute myocardial ischemia predicted heart failure and ventricular tachyarrhythmias both prior to and after hospital admission, there was no significant difference in 30-day mortality between the 3 patient groups (4.3%, 3.7%, and 1.2%, respectively, P=.11).

CONCLUSION

Among patients with a clinical suspicion of AMI in the prehospital setting, the prevalence of ECG signs suggesting AMI was low, as was the ability to identify AMI patients using ECG findings only. We therefore need better instruments in the prehospital triage of patients with acute chest pain.

The public's perception of prehospital emergency care in the County of Skane, southern Sweden

INTRODUCTION

The prehospital emergency care has had a rapid progress in Sweden in terms of technology, treatments and personnel education demands. In the County of Skane there is at least one specialized nurse in every ambulance. Possible misuses of the resources by the public have been acknowledged.

AIM

To investigate the public's use, knowledge and expectations of the prehospital emergency care in Skane, southern Sweden.

METHOD

A cross sectional descriptive survey, using a stratified sampling. Inclusion criteria were: 18 year or older and currently living in Skane.

RESULTS

Of 735 people who were asked 54.4% (n=400) chose to participate in the study. 44.0% of the respondents had been transported with ambulance. 34.5% of the respondents believed that the lowest educated personnel responsible for the patient was the paramedic. The results show that the respondents trust the personnel's knowledge and work skills. Older informants expected faster treatment by a physician when arriving by ambulance to the hospital, regardless of medical condition.

CONCLUSION

The public had confidence in the ambulance personnel's knowledge, ability to make assessment and give treatment despite not being updated on the current competence of the personnel. A positive experience of contact with the ambulance service was distinct.

The Prehospital assessment of severe trauma patients` performed by the specialist ambulance nurse in Sweden - a phenomenographic study

Background

A common feature of prehospital emergency care is the short and fragmentary patient encounters with increased demands for efficient and rapid treatment. Crucial decisions are often made and the premise is the specialist ambulance nurse’s ability to capture the situation instantaneously. The assessment is therefore a pre-requisite for decisions about appropriate actions. However, the low exposure to severe trauma cases in Sweden leads to vulnerability for the specialist ambulance nurse, which makes the assessment more difficult. Our objective was to describe specialist ambulance nurses’ perceptions of assessing patients exposed to severe trauma.

Methods

This study had a phenomenographic approach and was performed in 2011 as an interview study. 15 specialist ambulance nurses with a minimum of 2.5 years of experience from praxis were included. The analysis of data was performed using phenomenography according to Marton.

Results

The perceptions of assessing patients exposed to severe trauma were divided into: To be prepared for emergency situations, Confidence in one’s own leadership and Developing professional knowledge.

Conclusions

This study reveals that the specialist ambulance nurse, on the scene of accident, finds the task of assessment of severe trauma patients difficult and complicated. In some cases, even exceeding what they feel competent to accomplish. The specialist ambulance nurses feel that no trauma scenarios are alike and that more practical skills, more training, exercise and feedback are needed.

Reliability of a Swedish pre-hospital dispatch system in prioritizing patients

The need of emergency help often begins with a call to a dispatch center. The operator uses a medical index to prioritize dispatches. Since the resources of ambulances are limited, it is important that the priority grading decided by the operator at the dispatch center is as adequate as possible. In the county of Jamtland in Sweden, a system for triage named METTS-A (Medical Emergency Triage and Treatment System-A) has been in use since 2009, when the patient is coded according to priority level. The aim of this study was to analyse the sensitivity and specificity of the priority grading made by the dispatch center in comparison with the METTS-A priority assessed by the ambulance nurse. Statistics from a data-base in northern Sweden were analyzed. The material covered every ambulance that was dispatched, 6986 times during the period of data collecting. The results show a high sensitivity but low specificity in the dispatch system. The results also indicate that over prioritization exists since most of the patients with a high acute need of an ambulance are correctly identified, while many patients without that need are also given a high priority ambulance service. Therefore the conclusions were that both over- and under prioritizations were made.

To handle the unexpected - the meaning of caring in pre-hospital emergency care

The patient's voice has not been present to the same degree as the professional perspective in caring research in a pre-hospital context. In order to further develop and improve pre-hospital care, it is therefore important to explore patients' situations not only in life threatening but also in non-traumatic situations. This is especially important as these patients might be defined as inappropriate attendees of ambulance services. The aim of this study was to interpret and explain experiences of caring in pre-hospital care situations that are not defined as traumatic or life threatening. Twenty informants aged between 34 and 82 years were interviewed. The design of the study was exploratory, and it used an interpretative approach in order to understand the meaning of pre-hospital caring. The findings show that pre-hospital caring can be understood and explained as a matter of interplay between carer(s) and patient with potentials for positive as well as negative outcomes. Our conclusion is that the initial meeting is of vital importance in how patients experience pre-hospital care. It is suggested that general public information on the development of Swedish pre-hospital care received in turn may facilitate the first encounter between patient and carer(s).

Is pre-hospital treatment of chest pain optimal in acute coronary syndrome? The relief of both pain and anxiety is needed

BACKGROUND

Many patients who suffer from acute chest pain are transported by ambulance. It is not known how often treatment prior to hospital admission is optimal and how optimal pain-relieving treatment is defined. It is often difficult to delineate pain from anxiety.

AIM

To describe various aspects of chest pain in the pre-hospital setting with the emphasis on a) treatment and b) presumed acute coronary syndrome.

METHODS

In the literature search, we used PubMed and the appropriate key words. We included randomised clinical trials and observational studies.

RESULTS

Four types of drug appear to be preferred: 1) narcotic analgesics, 2) nitrates, 3) beta-blockers and 4) benzodiazepines. Among narcotic analgesics, morphine has been associated with the relief of pain at the expense of side-effects. Alfentanil was reported to produce more rapid pain relief. Nitrates have been associated with the relief of pain with few side-effects. Beta-blockers have been reported to increase the relief of pain when added to morphine. The combination of beta-blockers and morphine has been reported to be as effective as beta-blockers alone in pain relief, but this combination therapy was associated with more side-effects. Experience from anxiety-relieving drugs such as benzodiazepines is limited. It is not known how these 4 drugs should be combined. The results indicate that various pain-relieving treatments might modify the disease.

CONCLUSION

Our knowledge of the optimal treatment of chest pain and associated anxiety in the pre-hospital setting is insufficient. Recommendations from existing guidelines are limited. Large randomised clinical trials are warranted.

Geographic-Time Distribution of Ambulance Calls in Singapore: Utility of Geographic Information System in Ambulance Deployment (CARE 3)

Introduction: Pre-hospital ambulance calls are not random events, but occur in patterns and trends that are related to movement patterns of people, as well as the geographical epidemiology of the population. This study describes the geographic-time epidemiology of ambulance calls in a large urban city and conducts a time demand analysis. This will facilitate a Systems Status Plan for the deployment of ambulances based on the most cost-effective deployment strategy. Materials and Methods: An observational prospective study looking at the geographic-time epidemiology of all ambulance calls in Singapore. Locations of ambulance calls were spot-mapped using Geographic Information Systems (GIS) technology. Ambulance response times were mapped and a demand analysis conducted by postal districts. Results: Between 1 January 2006 and 31 May 2006, 31,896 patients were enrolled into the study. Mean age of patients was 51.6 years (S.D. 23.0) with 60.0% male. Race distribution was 62.5% Chinese, 19.4% Malay, 12.9% Indian and 5.2% others. Trauma consisted 31.2% of calls and medical 68.8%. 9.7% of cases were priority 1 (most severe) and 70.1% priority 2 (moderate severity). Mean call receipt to arrival at scene was 8.0 min (S.D. 4.8). Call volumes in the day were almost twice those at night, with the most calls on Mondays. We found a definite geographical distribution pattern with heavier call volumes in the suburban town centres in the Eastern and Southern part of the country. We characterised the top 35 districts with the highest call volumes by time periods, which will form the basis for ambulance deployment plans. Conclusion: We found a definite geographical distribution pattern of ambulance calls. This study demonstrates the utility of GIS with despatch demand analysis and has implications for maximising the effectiveness of ambulance deployment. Keywords: Demand analysis, Despatch, Emergency Medical Services