Ambulance use in acute coronary syndrome in Ireland: A cross-sectional study

Analysis of barriers associated with emergency medical service activation in patients with acute stroke and acute myocardial infarction from Zhongjiang County of Sichuan Province in China

OBJECTIVES

The purpose of this study was to investigate the preferred modes of transportation to the hospital among patients with acute stroke and acute myocardial infarction (AMI), as well as to identify the factors that influence the utilization of ambulances.

METHODS

We conducted a cross-sectional study, including patients who were diagnosed with acute stroke and AMI, at the people's hospital of Zhongjiang, from September 30th, 2022 to August 30th, 2023. All patients were divided into emergency medical service (EMS)-activation group and self-transportation group. Chi-square and t-tests were utilized to discern differences between groups at baseline. To screen relevant variables, we employed the Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis using R package glmnet. Subsequently, we performed a logistic regression analysis to identify predictors of EMS activation according the results of LASSO regression.

RESULTS

we collected 929 valid questionnaires. 26.16% of the patients required the services of EMS. 90.9% of individuals have not received any formal first aid education. 42.1% of them reported that they had no understanding of cardiovascular and cerebrovascular diseases. Diagnosed as AMI (OR 0.22, 95%CI 0.06 to 0.88) or acute cerebral infarction (OR 0.26, 0.10 to 0.68), the distance between the patient and the nearest 120 network hospital when the patient had these symptoms (OR 0.97, 0.94 to 0.99), the patient's son or daughter was there when the patient was symptomatic (OR 0.58, 0.37 to 0.94), the patient (OR 0.19, 0.05 to 0.72) and the patient's partner (wife or husband) (OR 0.36, 0.16 to 0.85) had decided that the patient needed further medical help, Among patients who did not seek immediate help after symptom onset, thinking that the symptoms will disappear spontaneously (OR 0.34, 0.13 to 0.92) or not wanting to disturb others (OR 0.06, 0.01 to 0.66) or believing that they are not important symptoms (OR 0.15, 0.05 to 0.42) were factors independently associated with less ambulance use. Age (OR 1.02, 1.00 to 1.04), Stroke patients have experienced symptoms of disturbance of consciousness or convulsions (OR 2.99, 1.72 to 5.2) were independent factors associated with increased ambulance use.

CONCLUSION

There is still ambulance underutilization among patients with acute stroke and AMI in county territory of China. Moreover, it is needed to raise the level of first aid education and awareness about EMS. Additionally, private clinic doctors and the public should gain adequate understanding of the severity of acute stroke and AMI, as well as their common symptoms, the crucial importance of prompt medical intervention. Finally, we propose that all township hospitals should be integrated into the 120 emergency networks and equipped with emergency first aid capabilities, pre-hospital care, and transportation abilities.

Factors related to under-triage of patients with acute coronary syndrome in the emergency department: A retrospective study

INTRODUCTION

This study aimed to provide fundamental data to avoid under-triage in the initial severity classification of patients with suspected acute coronary syndrome (ACS) by analyzing factors associated with patients who visited the emergency department (ED).

METHODS

This retrospective study identified factors related to under-triage by comparing the characteristics of participants diagnosed with ACS and appropriately classified those who were under-triaged.

RESULTS

The probability of under-triage increased 5.402 times in patients who visited the ED immediately than in those who visited the ED through an outpatient clinic. The probability of under-triage decreased in patients who visited the ED by ambulance rather than using their personal vehicle. Furthermore, when patients experienced chest pain, the tendency for under-triage decreased. The under-triage tendency increased 8.315 times in patients with dementia.

CONCLUSIONS

Medical staff training on the classification of non-specific symptoms accompanying diseases is needed. Patients with ACS need to be aware of the symptoms that require visiting the ED and the appropriate route and method. Therefore, it is possible to avoid under-triage for possible ACS during the initial triage, and triage can be performed quickly and accurately.

Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not.

OBJECTIVE

To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay.

METHODS

This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters.

RESULTS

Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952).

DISCUSSION

Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

Investigating the link between organisational justice, positive organisational behaviour and productivity in emergency nurses

BACKGROUND

Human resource management and employees' performance are fundamental to the success of healthcare organisations. Therefore, it is important to consider the factors that may affect employees' performance.

AIM

To determine the relationship between perceived organisational justice, positive organisational behaviour (POB) and the productivity of emergency nurses.

METHOD

This was a descriptive-analytical study that involved distributing questionnaires to emergency nurses working in hospitals affiliated with Mazandaran University of Medical Sciences in Iran. The researchers used proportionate stratified sampling to calculate the sample size. Three questionnaires were used to collect data on organisational justice, POB and productivity. The data were analysed using the Pearson correlation coefficient and multiple regression tests.

RESULTS

The questionnaires were distributed to 284 emergency nurses and completed by 234 of them. The results demonstrated a significant relationship between the productivity of the emergency nurses and the variables of perceived organisational justice and POB.

CONCLUSION

Higher levels of perceived organisational justice and POB in the ED setting are likely to lead to increased productivity among emergency nurses, and as a result the quality of patient care is likely to improve. Therefore, healthcare organisations should pay particular attention to the application of organisational justice, with the aim of promoting POB among nurses and increasing their productivity.

Prehospital emergency medical service utilization and associated factors among critically ill COVID-19 patients treated at centers in Addis Ababa, Ethiopia

The majority of populations in developing countries are living in areas of no access or limited access to prehospital emergency medical services (EMS). In Addis Ababa, the reported prehospital EMS utilization were ranging from zero to thirty-eight percent. However, there is limited research on reasons for the low utilization of prehospital resources in Ethiopia. This study aimed to assess factors associated with prehospital EMS utilization among critically ill COVID-19 patients in Addis Ababa, Ethiopia. A hospital-based cross-sectional study was conducted to collect primary data from 421 COVID-19 patients in Addis Ababa between May and July 2021. Logistic regression was used to identify factors associated with prehospital service utilization. Andersen's Behavioral Model was implemented to address independent variables, including predisposing, enabling, need, and health behaviors-related variables. The level of prehospital care utilization was 87.6%. Being married [AOR 2.6(95%; CI:1.24-5.58)], belief that self-transport is quicker than the ambulance [AOR 0.13(95%; CI: 0.05-0.34)], and perceptions that ambulance provides transportation service only [AOR 0.14(95%; CI:0.04-0.45)] were predisposing factors associated with prehospital service utilization while the source of referrals [AOR 6.9(95%; CI: 2.78-17.30)], and prior knowledge on the availability of toll-free ambulance calling numbers [AOR 0.14(95%; CI: 0.04-0.45)] were identified as enabling factors. Substantial proportions of critically ill COVID-19 patients used prehospital services to access treatment centers. Prehospital EMS utilization in this study varies by predisposing and enabling factors, particularly: marital status, source of referral, prior knowledge on the availability of toll-free ambulances, belief that self-transport is quicker than ambulances, and perceptions that ambulance provides transportation service only. Our findings call for further actions to be taken by policymakers including physical and media campaigns focusing on the identified factors.

Barriers associated with emergency medical service activation in patients with ST-segment elevation acute coronary syndromes

Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. A prospective, single-center, survey administered to all patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 01/06/2018 to 31/05/2020. The questionnaire was filled out by 293 patients. Of these, 191 (65.2%) activated the EMS after symptoms onset. The main reasons for failing to contact EMS were the perception that the symptoms were unrelated to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.

Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome

Objective

Between 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian’s awareness of acute coronary syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia.

Methods

The Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and (1) EMS arrival and (2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics.

Results

Between 2003 and 2015, there were 124 632 eligible ED presentations with ACS and 536 148 with U-CP. In patients with ACS, the campaign period was associated with an increase in ED presentations (incidence rate ratio: 1.11; 95% CI 1.07 to 1.15), a decrease in presentations via a GP (adjusted OR (AOR): 0.77; 95% CI 0.70 to 0.86) and an increase in EMS use (AOR: 1.10; 95% CI 1.05 to 1.17). Similar, but smaller associations were seen in U-CP.

Conclusions

The Warning Signs Campaign was associated with improvements in treatment seeking in patients with ACS—including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education needs to focus on improving EMS use in ACS patient groups where use remains low.

Analysis of the Adequacy of Prehospital Emergency Medical Services Use of Patients Who Visited Emergency Departments in Korea from 2016 to 2018: Data from the National Emergency Department Information System

Introduction

Proper ambulance use is important not only due to the patient's transport quality but also because of the need for efficient use of limited resources allotted by the system. Therefore, this study was conducted to check for overuse or underuse of the ambulance system by patients who visited the emergency department (ED).

Methods

In this study, a secondary data analysis was conducted using the existing database of the National Emergency Department Information System with all patients who visited EDs over the three-year study period from 2016 to 2018. The study subjects were classified into the following groups: (1) appropriate Emergency Medical Services (EMS) usage; (2) appropriate no EMS usage; (3) underuse; and (4) overuse groups.

Results

Of 18,298,535 patients, 11,668,581 (63.77%) were classified under the appropriate usage group, while 6,629,954 (36.23%) were classified under the inappropriate usage group. In the appropriate EMS usage group, there were 2,408,845 (13.16%) patients. In the appropriate no EMS usage group, there were 9,259,706 (50.60%) patients. As for the inappropriate usage group, there were 5,147,352 (28.13%) patients categorized under the underuse group. On the other hand, there were 1,482,602 (8.10%) patients under the overuse group.

Conclusion

There are many patients who use ambulances appropriately, but there are still many overuse and underuse. Guidelines on ambulance use are necessary for the efficient use of emergency medical resources and for the safety of patients.

The application of optimisation modelling and geospatial analysis to propose a coronary care network model for patients with ST-elevation myocardial infarction

Background

The incidence of myocardial infarction is increasing in South Africa. Prompt treatment is indicated to reduce mortality. One way of expediting treatment is to set up regional referral recommendations that can guide prehospital providers on the best reperfusion strategy for a particular patient. A coronary care network model for patients who present with ST-elevation myocardial infarction is proposed, using the North West province, of South Africa as a case study.

Methods

Geospatial analysis with network optimisation modelling was applied, to determine which strategy (prehospital thrombolysis, in-hospital thrombolysis or percutaneous coronary intervention) was most appropriate for patients presenting within each of the municipal wards of the North West province.

Results

An efficient and swift recommendation for the optimal reperfusion strategy is obtained using the current model, even in the instance of a large amount of ward data with additional constraints. For most municipal wards (204, 53%) percutaneous coronary intervention is the preferred reperfusion strategy based on proximity. For the remainder of the wards prehospital (138, 36%) or in-hospital (44, 11%) thrombolysis is recommended.

Conclusion

A scalable and efficient method of determining the optimal reperfusion strategy for a patient presenting with ST-elevation myocardial infarction in the North West province, is presented. This approach can serve as a model which can be applied to other settings and can form the basis of regional coronary care network development priorities and resource allocations.

Health-Seeking Behavior of Patients with Acute Coronary Syndrome and Their Family Caregivers

IntroductionAcute Coronary Syndrome (ACS) is a life-threatening condition. Immediate and proper treatment will decrease mortality rate. Patient awareness on ACS is still lacking and as the consequence, ACS patients do not seek immediate help.ProblemThe patients' efforts to get rid of ACS symptoms.

METHODS

The study was a descriptive, qualitative study in which a semi-structured, in-depth interview became the instrument. The respondents were 34 participants (including 17 ACS patients and 17 family caregivers). Data analysis was done by triangulation of data sources.

RESULTS

Three themes were obtained, namely: (1) prefer traditional and self-treatment, for example (a) traditional medicine, (b) taking non-prescription drugs to overcome ACS symptoms, and (c) spontaneous action; (2) using available health resources and facilities that consisted of (a) getting initial treatment at home by nurses, (b) visiting a health center to take care of the symptoms, and (c) using non-ambulance service to visit the health centers; and (3) expectations on health care services to patients composed by sub-themes such as (a) the expectation to get information that supports the healing, and (b) the caring attitude of the heath professional.

CONCLUSIONS

The results showed that in the prehospital setting when experiencing ACS symptoms, the patients try to overcome the symptoms independently. However, as the symptoms get worse, they utilize health facilities in different ways. At the time of obtaining health services, patients are satisfied with health professionals who show caring attitudes, explain the results of the examination, and provide health education on health care efforts. Thus, to prevent mortality and morbidity, it is important for a health professional to educate the public about ACS, including topics about ACS healthy lifestyles and potential threats if it is too late to get treatment. Furthermore, it is also important for the government to implement prehospital emergency services nation-wide. KumboyonoK, RefialdinataJ, WihastutiTA, RachmawatiSD, AzizAN. Health-seeking behavior of patients with Acute Coronary Syndrome and their family caregivers. Prehosp Disaster Med. 2018;33(6):614-620.

Barriers to the use of emergency medical services for ST-elevation myocardial infarction: Determining why many patients opt for self-transport

RATIONALE, AIMS, AND OBJECTIVES

Access to timely ST-elevation myocardial infarction (STEMI) care is facilitated by paramedics and emergency medical services (EMS). However, a large proportion of STEMI patients do not access care through EMS. This study sought to identify patient-reported factors for their decision to use (or not use) EMS.

METHODS

Semi-structured interviews were conducted with a sample of STEMI patients admitted to a large tertiary care centre between November 2011 and January 2012. Participants were grouped according to mode of transportation to hospital at time of index event (EMS vs self-transport). Participant responses were classified using a published framework (modified for a STEMI population) as barriers or facilitators to EMS use, and compared between groups.

RESULTS

Data were collected on 61 patients (32 EMS, 29 self-transport). Mean age was 60.3 (SD 11.5), and 23% were female. EMS users were more likely to have a Killip Class >1 (25% vs 4%; P = 0.03). Self-transport patients were more likely to perceive EMS as slower (48% vs 0%) and express concerns over resources misuse (34% vs 3%; P = 0.002), when compared to EMS patients. Patients who accessed EMS were more likely to acknowledge the benefits of EMS (44% vs 7%; P = 0.001) and were more likely to have been encouraged by a family member to call EMS (34% vs 4%; P = 0.003).

CONCLUSIONS

STEMI patient perceptions are a key factor in determining EMS use. Health care stakeholders should target the identified barriers to improve utilization of EMS, and develop strategies to optimize care for patients who do not access EMS.

Usage of ambulance transport and influencing factors in acute coronary syndrome: a cross-sectional study at a tertiary centre in China

OBJECTIVES

The aim of this study was to explore the choice of transportation mode to hospital in patients with acute coronary syndrome (ACS) and to determine the factors influencing the use of ambulance.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study was conducted in a tertiary and teaching hospital in China. The study was carried out between 24 August 2015 and 24 July 2016. A total of 828 patients with ACS presented at the emergency department (ED) were included. The study population was dichotomised according to their primary mode of transport (ambulance or self-transport) to hospital. Social demographics, cardiovascular history, risk factors, prehospital medications, clinical characteristics and symptom characteristics were collected. Multivariable logistic regression was used to examine the factors associated with ambulance use.

RESULTS

We found that only 179 (21.6%) patients with ACS chose taking ambulance to hospital. Factors associated with ambulance use were single (OR 1.66, 95% CI 1.07 to 2.57), taking Suxiaojiuxin pills (OR 1.91, 1.31 to 2.80) or nitrates (OR 2.91, 1.70 to 4.99) before going to hospital, diagnosed as ST-elevation myocardial infarction (STEMI) (OR 2.43, 1.45 to 4.05), with persistent symptoms (OR 1.95, 1.33 to 2.86) and symptoms accompanied with vomiting (OR 2.35, 1.19 to 4.62). The patients who had symptoms precipitated or aggravated by exercise (OR 0.37, 0.14 to 0.98) tended to choose self-transport.

CONCLUSION

The usage of ambulance in patients with ACS presenting to the ED was low in China. Factors like single, taking Suxiaojiuxin pills or nitrates before going to hospital, diagnosed as STEMI, accompanied with vomiting and persistent symptoms were independently associated with ambulance use. Future education programmes should focus on these factors and increase people's knowledge on ACS and the benefits of ambulance use.

Factors influencing choice of pre-hospital transportation of patients with potential acute coronary syndrome: An observational study

OBJECTIVE

To determine factors associated with ambulance use in patients with confirmed and potential acute coronary syndrome presenting to the ED.

METHODS

A convenience sample of patients (n = 247) presenting to the ED from April 2014 to January 2015 with suspected acute coronary syndrome were included in the study. Data on mode of transport and patient demographics were collected from the Emergency Department Information System database. Clinical data were collected from chart records and information systems. A questionnaire assessed reasons for using a chosen method of transport, symptom timing and characteristics, acute coronary syndrome knowledge, and awareness of the National Heart Foundation Early Warning Symptoms campaign.

RESULTS

Approximately half the patients (49.4%) assessed with symptoms of potential acute coronary syndrome used ambulance transport to the ED. Patients who arrived by ambulance were older than those not arriving by ambulance (mean 56.7 years vs 51.7 years, P = 0.01). Risk factors were not associated with ambulance use. Dizziness (P < 0.01), sweating (P = 0.03), nausea (P = 0.03) and vomiting (P = 0.04) were associated with increased ambulance use. Mean systolic blood pressure was lower in the ambulance group (136 mmHg, standard deviation [SD] = 19.8) than in the non-ambulance group (143 mmHg, SD = 25.9). Awareness of the National Heart Foundation Heart Attack Warning Signs campaign was not associated with ambulance use.

CONCLUSIONS

Patients with possible ischaemic symptoms who are at a high risk of cardiac disease do not utilise ambulance services more than low risk patients. In general, transport to hospital using ambulance services by patients with symptoms of possible acute coronary syndrome is low despite community campaigns.

Facilitators of and barriers to emergency medical service use by acute ischemic stroke patients: A retrospective survey

OBJECTIVE

The objective of the study was to identify facilitators and barriers to emergency medical service use among acute ischemic stroke patients in Korea.

METHODS

This paper presents a secondary analysis of a retrospective survey that collected data from questionnaires and medical records. Among 233 acute ischemic stroke patients enrolled in a large-scale study, 160 patients who had arrived at a hospital within 72 h after symptom onset were included in the data analysis.

RESULTS

Users of emergency medical services needed a shorter time than non-users to arrive at hospital (140 min vs. 625 min., p = 0.001) and were more likely to arrive at hospital within 3 h of symptom onset (51.9% vs. 31.5%, p = 0.013). For those who first contacted emergency medical service, the facilitators of emergency medical service use were the presence of hemiparesis (p = 0.003), bilateral paralysis (p = 0.040), and loss of balance (p = 0.021). The predominant barrier was the failure to recognize the urgency of symptoms (p = 0.006).

CONCLUSIONS

The use of emergency medical services reduced prehospital delay and increased the likelihood of patient arrival at hospital within 3 h. Given that experiencing typical stroke symptoms was a facilitator of emergency medical service use yet failure to recognize the urgency of symptoms was a barrier, public awareness should be raised as regards stroke symptoms and the benefits of using emergency medical services.

Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population

Background

In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥ 2 h.

Methods

A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

Results

The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

Conclusions

Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0271-x) contains supplementary material, which is available to authorized users.