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Jensen B, Vardinghus-Nielsen H, Mills EHA, Møller AL, Gnesin F, Zylyftari N, Kragholm K, Folke F, Christensen HC, Blomberg SN, Torp-Pedersen C, Bøggild H. "I think we should wait and see": A qualitative study of call-takers' decision-making in consultations with patients suffering unrecognized myocardial infarction. PATIENT EDUCATION AND COUNSELING 2024; 128:108376. [PMID: 39079431 DOI: 10.1016/j.pec.2024.108376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/04/2024] [Accepted: 07/20/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVES Call-takers face a complex situation when assessing medical problems in emergency medical services calls. Patients with myocardial infarction experiencing atypical symptoms risk misinterpretation. We examined development in call-takers' decision-making process in telephone consultations with patients having imminent myocardial infarction. METHODS Recording of 38 calls among 19 patients (two per patient) who contacted Copenhagen Emergency Medical Services (Denmark) at least twice within one week before myocardial infarction diagnosis. The penultimate and last call were compared using qualitative content analysis. RESULTS Call-takers' assessment of the condition changed from unclear symptom picture and dismissal of heart disease in penultimate call to severe condition, not heart-related, and possible heart disease in last call. Call-takers recommended watchful waiting in the penultimate call. Both calls involved response negotiation, while caution regarding misinterpretation was only seen in the penultimate call. CONCLUSION Call-takers used different decision-making approaches when the caller's symptom descriptions appeared unclear and not corresponding with the medical understanding of severe conditions. Call-takers did not negotiate the condition's assessment but engaged in discussions about the response choice. PRACTICE IMPLICATIONS A protocol to negotiate response choice with callers having unclear clinical conditions should be developed. Clarifying watchful waiting as a recommendation may assist call-takers' decision-making.
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Affiliation(s)
- Britta Jensen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | - Henrik Vardinghus-Nielsen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | | | - Amalie Lykkemark Møller
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Cancer Surveillance and Pharmacoepidemiology, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Filip Gnesin
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Nertila Zylyftari
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Copenhagen Emergency Medical Services, University of Copenhagen, Ballerup, Denmark
| | - Helle Collatz Christensen
- Copenhagen Emergency Medical Services, University of Copenhagen, Ballerup, Denmark; Danish Clinical Quality Program (RKKP), National Clinical Registries, Denmark
| | | | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Henrik Bøggild
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Mills EHA, Møller AL, Engstrøm T, Folke F, Pedersen F, Køber L, Gnesin F, Zylyftari N, Blomberg SNF, Kragholm K, Gislason G, Jensen B, Lippert F, Kragelund C, Christensen HC, Andersen MP, Torp-Pedersen C. Time From Distress Call to Percutaneous Coronary Intervention and Outcomes in Myocardial Infarction. JACC. ADVANCES 2024; 3:101005. [PMID: 39129988 PMCID: PMC11312358 DOI: 10.1016/j.jacadv.2024.101005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 02/07/2024] [Accepted: 03/11/2024] [Indexed: 08/13/2024]
Abstract
Background Early percutaneous coronary intervention (PCI) is recommended for ST-segment elevation myocardial infarction (STEMI) treatment. Delays in time-to-PCI, kept within guideline recommendations, have seldom been investigated. Objectives The purpose of this study was to investigate the consequences of delay, due to system factors or hospital distance, for the time between last patient distress call and PCI. Methods Registry-based cohort study including times of first call to medical services, admission and PCI for patients admitted with STEMI in Copenhagen, Denmark (2014-2018). The main combined outcome included death, recurrent myocardial infarction, or heart failure estimated at 30 days and 1 year from event. Outcomes according to time from call to PCI (system delay) and door-to-balloon time were standardized to the STEMI population using multivariate logistic regression. Results In total, 1,822 STEMI patients (73.5% male, median age 63.3 years [Q1-Q3: 54.6-72.9 years]) called the emergency services ≤72 hours before PCI (1,735, ≤12 hours). The combined endpoint of 1-year cumulative incidence was 13.9% (166/1,196) for patients treated within 120 minutes of the call and 21.2% (89/420) for patients treated later. Standardized 30-day outcomes were 7.33% (95% CI: 5.41%-9.63%) for patients treated <60 minutes, and 11.1% (95% CI: 8.39%-14.2%) for patients treated >120 minutes. Conclusions The risk of recurrent myocardial infarction, death, and heart failure following PCI treatment of STEMI increases rapidly when delay exceeds 1 hour. This indicates a particular advantage of minimizing time from first contact to PCI.
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Affiliation(s)
| | | | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Fredrik Folke
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Copenhagen Emergency Medical Services, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Frants Pedersen
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Filip Gnesin
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Nertila Zylyftari
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | | | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Britta Jensen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Freddy Lippert
- Copenhagen Emergency Medical Services, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
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Wilson KH, Johnson RA, Hatzimasoura C, Holman RP, Moore RT, Yokum D. A randomized controlled trial evaluating the effects of nurse-led triage of 911 calls. Nat Hum Behav 2024; 8:1276-1284. [PMID: 38789524 DOI: 10.1038/s41562-024-01889-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 04/16/2024] [Indexed: 05/26/2024]
Abstract
To better connect non-emergent 911 callers to appropriate care, Washington, DC, routed low-acuity callers to nurses. Nurses could provide non-emergent transportation to a health centre, recommend self-care or return callers to the traditional 911 system. Over about one year, 6,053 callers were randomized (1:1) to receive a business-as-usual response (ncontrol = 3,023) or further triage (ntreatment = 3,030). We report on seven of nine outcomes, which were pre-registered ( https://osf.io/xderw ). The proportion of calls resulting in an ambulance dispatch dropped from 97% to 56% (β = -1.216 (-1.324, -1.108), P < 0.001), and those resulting in an ambulance transport dropped from 73% to 45% (β = -3.376 (-3.615, -3.137), P < 0.001). Among those callers who were Medicaid beneficiaries, within 24 hours, the proportion of calls resulting in an emergency department visit for issues classified as non-emergent or primary care physician (PCP) treatable dropped from 29.5% to 25.1% (β = -0.230 (-0.391, -0.069), P < 0.001), and the proportion resulting in the caller visiting a PCP rose from 2.5% to 8.2% (β = 1.252 (0.889, 1.615), P < 0.001). Over the longer time span of six months, we failed to detect evidence of impacts on emergency department visits, PCP visits or Medicaid expenditures. From a safety perspective, 13 callers randomized to treatment were eventually diagnosed with a time-sensitive illness, all of whom were quickly triaged to an ambulance response. These short-term effects suggest that nurse-led triage of non-emergent calls can safely connect callers to more appropriate, timely care.
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Affiliation(s)
| | - Rebecca A Johnson
- The Lab @ DC, Washington, DC, USA
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | | | | | - Ryan T Moore
- The Lab @ DC, Washington, DC, USA
- School of Public Affairs, American University, Washington, DC, USA
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Mills EHA, Møller AL, Gnesin F, Zylyftari N, Jensen B, Christensen HC, Blomberg SN, Kragholm KH, Gislason G, Køber L, Gerds T, Folke F, Lippert F, Torp-Pedersen C, Andersen MP. Association between mortality and phone-line waiting time for non-urgent medical care: a Danish registry-based cohort study. Eur J Emerg Med 2024; 31:127-135. [PMID: 37788126 DOI: 10.1097/mej.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND IMPORTANCE Telephone calls are often patients' first healthcare service contact, outcomes associated with waiting times are unknown. OBJECTIVES Examine the association between waiting time to answer for a medical helpline and 1- and 30-day mortality. DESIGN, SETTING AND PARTICIPANTS Registry-based cohort study using phone calls data (January 2014 to December 2018) to the Capital Region of Denmark's medical helpline. The service refers to hospital assessment/treatment, dispatches ambulances, or suggests self-care guidance. EXPOSURE Waiting time was grouped into the following time intervals in accordance with political service targets for waiting time in the Capital Region: <30 s, 0:30-2:59, 3-9:59, and ≥10 min. OUTCOME MEASURES AND ANALYSIS The association between time intervals and 1- and 30-day mortality per call was calculated using logistic regression with strata defined by age and sex. MAIN RESULTS In total, 1 244 252 callers were included, phoning 3 956 243 times, and 78% of calls waited <10 min. Among callers, 30-day mortality was 1% (16 560 deaths). For calls by females aged 85-110 30-day mortality increased with longer waiting time, particularly within the first minute: 9.6% for waiting time <30 s, 10.8% between 30 s and 1 minute and 9.1% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 11.1%, 12.9% and 11.1%, respectively. Additionally, among calls with a Charlson score of 2 or higher, longer waiting times were likewise associated with increased mortality. For calls by females aged 85-110 30-day mortality was 11.6% for waiting time <30 s, 12.9% between 30 s and 1 minute and 11.2% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 12.7%, 14.1% and 12.6%, respectively. Fewer ambulances were dispatched with longer waiting times (4%/2%) with waiting times <30 s and >10 min. CONCLUSION Longer waiting times for telephone contact to a medical helpline were associated with increased 1- and 30-day mortality within the first minute, especially among elderly or more comorbid callers.
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Affiliation(s)
| | | | - Filip Gnesin
- Department of Cardiology, Nordsjællands Hospital, Hillerød
| | - Nertila Zylyftari
- Department of Cardiology, Nordsjællands Hospital, Hillerød
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup
| | - Britta Jensen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg
| | - Helle Collatz Christensen
- Copenhagen Emergency Medical Services, Copenhagen and University of Copenhagen
- Danish Clinical Quality Program - National Clinical Registries (RKKP), Righospitalet, Copenhagen
| | | | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup
- The Danish Heart Foundation
| | - Lars Køber
- Department of Cardiology, Rigshospitalet
| | - Thomas Gerds
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup
- Copenhagen Emergency Medical Services, Copenhagen and University of Copenhagen
| | - Freddy Lippert
- Copenhagen Emergency Medical Services, Copenhagen and University of Copenhagen
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg
- Department of Cardiology, Nordsjællands Hospital, Hillerød
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Larsen MB, Blom-Hanssen E, Gnesin F, Kragholm KH, Lass Klitgaard T, Christensen HC, Lippert F, Folke F, Torp-Pedersen C, Ringgren KB. Prodromal complaints and 30-day survival after emergency medical services-witnessed out-of-hospital cardiac arrest. Resuscitation 2024; 197:110155. [PMID: 38423500 DOI: 10.1016/j.resuscitation.2024.110155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a frequent and lethal condition with a yearly incidence of approximately 5000 in Denmark. Thirty-day survival is associated with the patient's prodromal complaints prior to cardiac arrest. This paper examines the odds of 30-day survival dependent on the reported prodromal complaints among OHCAs witnessed by the emergency medical services (EMS). METHODS EMS-witnessed OHCAs in the Capital Region of Denmark from 2016-2018 were included. Calls to the emergency number 1-1-2 and the medical helpline for out-of-hours were analyzed according to the Danish Index; data regarding the OHCA was collected from the Danish Cardiac Arrest Registry. We performed multiple logistic regression to calculate the odds ratio (OR) of 30-day survival with adjustment for sex and age. RESULTS We identified 311 eligible OHCAs of which 79 (25.4%) survived. The most commonly reported complaints were dyspnea (n = 209, OR 0.79 [95% CI 0.46: 1.36]) and 'feeling generally unwell' (n = 185, OR 1.07 [95% CI 0.63: 1.81]). Chest pain (OR 9.16 [95% CI 5.09:16.9]) and heart palpitations (OR 3.15 [95% CI 1.07:9.46]) had the highest ORs, indicating favorable odds for 30-day survival, while unresponsiveness (OR 0.22 [95% CI 0.11:0.43]) and blue skin or lips (OR 0.30, 95% CI 0.09, 0.81) had the lowest, indicating lesser odds of 30-day survival. CONCLUSION Experiencing chest pain or heart palpitations prior to EMS-witnessed OHCA was associated with higher 30-day survival. Conversely, complaints of unresponsiveness or having blue skin or lips implied reduced odds of 30-day survival.
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Affiliation(s)
- Mia Bang Larsen
- Department of Clinical Medicine, Aalborg University, Denmark.
| | | | - Filip Gnesin
- Department of Cardiology, Nordsjaellands Hospital, Denmark
| | - Kristian Hay Kragholm
- Department of Clinical Medicine, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Denmark
| | | | | | - Freddy Lippert
- Falck, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Fredrik Folke
- Department of Clinical Medicine, University of Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Denmark; Copenhagen Emergency Medical Services, University of Copenhagen, Denmark
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Mills AAM, Mills EHA, Blomberg SNF, Christensen HC, Møller AL, Gislason G, Køber L, Kragholm KH, Lippert F, Folke F, Andersen MP, Torp-Pedersen C. Ambulance response times and 30-day mortality: a Copenhagen (Denmark) registry study. Eur J Emerg Med 2024; 31:59-67. [PMID: 37788140 DOI: 10.1097/mej.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND IMPORTANCE Ensuring prompt ambulance responses is complicated and costly. It is a general conception that short response times save lives, but the actual knowledge is limited. OBJECTIVE To examine the association between the response times of ambulances with lights and sirens and 30-day mortality. DESIGN A registry-based cohort study using data collected from 2014-2018. SETTINGS AND PARTICIPANTS This study included 182 895 individuals who, during 2014-2018, were dispatched 266 265 ambulances in the Capital Region of Denmark. OUTCOME MEASURES AND ANALYSIS The primary outcome was 30-day mortality. Subgroup analyses were performed on out-of-hospital cardiac arrests, ambulance response priority subtypes, and caller-reported symptoms of chest pain, dyspnoea, unconsciousness, and traffic accidents. The relation between variables and 30-day mortality was examined with logistic regression. RESULTS Unadjusted, short response times were associated with higher 30-day mortality rates across unadjusted response time quartiles (0-6.39 min: 9%; 6.40-8.60 min: 7.5%, 8.61-11.80 min: 6.6%, >11.80 min: 5.5%). This inverse relationship was consistent across subgroups, including chest pain, dyspnoea, unconsciousness, and response priority subtypes. For traffic accidents, no significant results were found. In the case of out-of-hospital cardiac arrests, longer response times of up to 10 min correlated with increased 30-day mortality rates (0-6.39 min: 84.1%; 6.40-8.60 min: 86.7%, 8.61-11.8 min: 87.7%, >11.80 min: 85.5%). Multivariable-adjusted logistic regression analysis showed that age, sex, Charlson comorbidity score, and call-related symptoms were associated with 30-day mortality, but response time was not (OR: 1.00 (95% CI [0.99-1.00])). CONCLUSION Longer ambulance response times were not associated with increased mortality, except for out-of-hospital cardiac arrests.
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Affiliation(s)
| | | | | | - Helle Collatz Christensen
- Copenhagen Emergency Medical Services, Copenhagen and University of Copenhagen
- Danish Clinical Quality Program (RKKP), Rigshospitalet
| | - Amalie Lykkemark Møller
- Cancer Surveillance and Pharmacoepidemiology, Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen
- Department of Cardiology, Nordsjællands Hospital, Hillerød
- Department of Public Health, University of Copenhagen
| | - Gunnar Gislason
- The Danish Heart Foundation, Copenhagen
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup
- Department of Clinical Medicine, University of Copenhagen
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg
| | - Freddy Lippert
- Copenhagen Emergency Medical Services, Copenhagen and University of Copenhagen
| | - Frederik Folke
- Copenhagen Emergency Medical Services, Copenhagen and University of Copenhagen
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Hellerup
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Hillerød
- Department of Public Health, University of Copenhagen
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Wenstrup J, Havtorn JD, Borgholt L, Blomberg SN, Maaloe L, Sayre MR, Christensen H, Kruuse C, Christensen HC. A retrospective study on machine learning-assisted stroke recognition for medical helpline calls. NPJ Digit Med 2023; 6:235. [PMID: 38114611 PMCID: PMC10730829 DOI: 10.1038/s41746-023-00980-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Advanced stroke treatment is time-dependent and, therefore, relies on recognition by call-takers at prehospital telehealth services to ensure fast hospitalisation. This study aims to develop and assess the potential of machine learning in improving prehospital stroke recognition during medical helpline calls. We used calls from 1 January 2015 to 31 December 2020 in Copenhagen to develop a machine learning-based classification pipeline. Calls from 2021 are used for testing. Calls are first transcribed using an automatic speech recognition model and then categorised as stroke or non-stroke using a text classification model. Call-takers achieve a sensitivity of 52.7% (95% confidence interval 49.2-56.4%) with a positive predictive value (PPV) of 17.1% (15.5-18.6%). The machine learning framework performs significantly better (p < 0.0001) with a sensitivity of 63.0% (62.0-64.1%) and a PPV of 24.9% (24.3-25.5%). Thus, a machine learning framework for recognising stroke in prehospital medical helpline calls may become a supportive tool for call-takers, aiding in early and accurate stroke recognition.
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Affiliation(s)
- Jonathan Wenstrup
- Department of Neurology, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Copenhagen Emergency Medical Services, Telegrafvej 5, 2750, Ballerup, Denmark
| | - Jakob Drachmann Havtorn
- Corti, Store Strandstræde 21, 1255, Copenhagen, Denmark
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, 321, 223, 2800 Kgs, Lyngby, Denmark
| | - Lasse Borgholt
- Corti, Store Strandstræde 21, 1255, Copenhagen, Denmark
- Department of Electronic Systems, Aalborg University, Fredrik Bajers Vej 7K, 9220, Aalborg Ø, Denmark
- Pioneer Centre for Artificial Intelligence, Øster Voldgade 3, 1350, Copenhagen, Denmark
| | | | - Lars Maaloe
- Corti, Store Strandstræde 21, 1255, Copenhagen, Denmark
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, 321, 223, 2800 Kgs, Lyngby, Denmark
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, 325 9th Ave, Box 359727, Seattle, WA, 98104, USA
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
- University of Copenhagen, Department of Clinical Medicine, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- University of Copenhagen, Department of Clinical Medicine, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Helle Collatz Christensen
- Prehospital Centre Region Zealand, Ringstedgade 61, 4700, Næstved, Denmark.
- University of Copenhagen, Department of Clinical Medicine, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
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8
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Tuffley RH, Folke F, Ersbøll AK, Blomberg SNF, Linderoth G. Is dispatcher-assisted cardiopulmonary resuscitation affected by a bystander's emotional stress state in out-of-hospital cardiac arrest? Scand J Trauma Resusc Emerg Med 2023; 31:82. [PMID: 37978562 PMCID: PMC10656878 DOI: 10.1186/s13049-023-01117-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/06/2023] [Indexed: 11/19/2023] Open
Abstract
AIM The study aimed to investigate whether a bystander's emotional stress state affects dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) in out-of-hospital cardiac arrest (OHCA). The primary outcome was initiation of chest compressions (Yes/No). Secondarily we analysed time until chest compressions were initiated and assessed how dispatchers instructed CPR. METHOD The study was a retrospective, observational study of OHCA emergency calls from the Capital Region of Denmark. Recorded calls were evaluated by five observers using a pre-defined code catalogue regarding the variables wished investigated. RESULTS Included were 655 OHCA emergency calls, of which 211 callers were defined as emotionally stressed. When cardiac arrest was recognized, chest compressions were initiated in, respectively, 76.8% of cases with an emotionally stressed caller and 73.9% in cases with a not emotionally stressed caller (2.18 (0.80-7.64)). Cases with an emotionally stressed caller had a longer time until chest compressions were initiated compared to cases with a not emotionally stressed caller, however non-significant (164 s. vs. 146 s.; P = 0.145). The dispatchers were significantly more likely to be encouraging and motivating, and to instruct on speed and depth of chest compressions in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.64 (1.07-2.56); 1.78 (1.13-2.88)). Barriers to CPR were significantly more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.83 (1.32-2.56)). CONCLUSION There was no significant difference in initiation of chest compressions or in time until initiation of chest compressions in the two groups. However, the dispatchers were overall more encouraging and motivating, and likely to instruct on speed and depth of chest compressions when the caller was emotionally stressed. Furthermore, barriers to CPR were more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller. TRIAL REGISTRATION We applied for ethical approval from The Danish National Committee on Health Research Ethics, but formal approval was waived. We received permission for storage of data and to use these for research of OHCAs in the Capital Region of Denmark by Danish Data Protection Agency (P-2021-670) and Danish Health Authorities (R-2,005,114). The study is registered at ClinicalTrials (NTC05113706).
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Affiliation(s)
- Rebecca Hvidt Tuffley
- Copenhagen Emergency Medical Services, University of Copenhagen, Telegrafvej 5, Ballerup, 2750, Denmark.
| | - Fredrik Folke
- Copenhagen Emergency Medical Services, University of Copenhagen, Telegrafvej 5, Ballerup, 2750, Denmark
- Dept. of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, Herlev, 2730, Denmark
- Dept. of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, 2200, Denmark
| | - Annette Kjær Ersbøll
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, Copenhagen, 1455, Denmark
| | | | - Gitte Linderoth
- Copenhagen Emergency Medical Services, University of Copenhagen, Telegrafvej 5, Ballerup, 2750, Denmark
- Dept. of Anesthesiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark
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Borch-Johnsen L, Gren C, Lund S, Folke F, Schrøder M, Frederiksen MS, Lippert F, Ersbøll AK, Greisen G, Cortes D. Video Tutorials to Empower Caregivers of Ill Children and Reduce Health Care Utilization: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2336836. [PMID: 37824145 PMCID: PMC10570874 DOI: 10.1001/jamanetworkopen.2023.36836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/18/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Young children often fall ill, leading to concern among their caregivers and urgent contact with health care services. Objective To assess the effectiveness and safety of video tutorials to empower caregivers in caring for acutely ill children. Design, Setting, and Participants Caregivers calling the out-of-hours Medical Helpline 1813 (MH1813), Emergency Medical Services Capital Region, Denmark, and their children aged 0.5 to 11.9 years were randomized to video tutorials (intervention) or telephone triage by a nurse or physician (control) from October 2020 to December 2021 and followed up for 72 hours blinded to the intervention. Data were analyzed from March to July 2022. Intervention The intervention group had the call disconnected before telephone triage and received video tutorials on managing common symptoms in acutely ill children and when to seek medical help. Caregivers could subsequently call MH1813 for telephone triage. Main outcomes and measures The primary outcome was caregivers' self-efficacy, reported in an electronic survey the following day. Secondary outcomes were satisfaction, child status, assessment by a general practitioner or physician at the hospital, telephone triage, and adverse events during the 72-hour follow-up period. Results In total, 4686 caregivers and children were randomized to intervention (2307 participants) or control (2379 participants), with a median (IQR) child age of 2.3 (1.3-5.1) years and 53% male distribution in both groups (2493 participants). Significantly more caregivers in the intervention group reported high self-efficacy (80% vs 76%; crude odds ratio [OR], 1.30; 95% CI, 1.01-1.67; P = .04). The intervention group received fewer telephone triages during follow-up (887 vs 2374 in the control group). Intention-to-treat analysis showed no difference in secondary outcomes, but per-protocol subanalysis showed fewer hospital assessments when caregivers watched video tutorials (27% vs 35%; adjusted OR, 0.67; 95% CI, 0.55-0.82). Randomization to video tutorials did not increase adverse outcomes. Conclusions and relevance In this randomized clinical trial, offering caregivers video tutorials significantly and safely increased self-efficacy and reduced use of telephone triage. Children had fewer hospital assessments when caregivers watched videos. This suggests a future potential of health care information to empower caregivers and reduce health care utilization. Trial Registration ClinicalTrials.gov Identifier: NCT04301206.
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Affiliation(s)
- Liv Borch-Johnsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital—Amager and Hvidovre, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Caroline Gren
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital—Amager and Hvidovre, Copenhagen, Denmark
| | - Stine Lund
- Hans Christian Andersens Childrens Hospital, Odense University Hospital, Odense, Denmark
- Department of Neonatology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Fredrik Folke
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Emergency Medical Services Capital Region, Denmark
- Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, Copenhagen, Denmark
| | - Morten Schrøder
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Marianne Sjølin Frederiksen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital—Herlev and Gentofte, Copenhagen, Denmark
| | | | - Annette Kjær Ersbøll
- Emergency Medical Services Capital Region, Denmark
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Gorm Greisen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neonatology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Dina Cortes
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital—Amager and Hvidovre, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Berg KP, Sørensen VFI, Blomberg SNF, Christensen HC, Kruuse C. Recognition of visual symptoms in stroke: a challenge to patients, bystanders, and Emergency Medical Services. BMC Emerg Med 2023; 23:96. [PMID: 37626329 PMCID: PMC10463357 DOI: 10.1186/s12873-023-00870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Identification of visual symptoms as a sign of acute stroke can be challenging for both first line healthcare professionals and lay persons. Failed recognition of visual symptoms by medical dispatchers at the Emergency Medical Dispatch Center (EMDC-112) or personnel at the Out-of-Hours Health Service (OOHS) may delay stroke revascularization. We aimed to identify correct system response to visual symptoms in emergency calls. METHODS Phone calls from patient or bystander to the EMDC-112 or OOHS, which included visual symptoms on patients later verified with stroke/Transient ischemic attack (TIA) diagnosis, were analyzed. Data were stratified according to hospitalization within and after 4.5 h from symptom onset. Descriptive and multiple logistic regression analysis were performed. RESULTS Of 517 calls identified, 290 calls fulfilled inclusion criteria. Only 30% of the patients received correct visitation by the medical dispatchers and referral to the hospital by a high-priority ambulance. Correct visitation was associated with early contact (adjusted OR: 2.37, 95% CI: 1.11, 5.03), contact to the EMDC-112 (adjusted OR: 3.18, 95% CI: 1.80, 5.62), and when the medical dispatcher asked additional questions on typical stroke symptoms (adjusted OR: 6.36, 95% CI: 3.01, 13.43). No specific visual symptom was associated with stroke recognition and fast hospitalization. CONCLUSIONS First line healthcare professionals had significant problems in identifying visual symptoms as a sign of acute stroke and eliciting correct response. This highlights an urgent need to improve knowledge of visual symptoms in acute stroke and emphasize correct response to stroke symptoms in general.
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Affiliation(s)
- Kristina Parsberg Berg
- Department of Neurology, Copenhagen University Hospital - Herlev Gentofte, Copenhagen, Denmark
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Copenhagen, Denmark
| | - Viktor Frederik Idin Sørensen
- Department of Neurology, Copenhagen University Hospital - Herlev Gentofte, Copenhagen, Denmark
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Copenhagen, Denmark
| | | | - Helle Collatz Christensen
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Copenhagen, Denmark.
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark.
- Emergency Medical Services Region Zealand, Naestved, Denmark.
| | - Christina Kruuse
- Department of Neurology, Copenhagen University Hospital - Herlev Gentofte, Copenhagen, Denmark
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Jensen B, Vardinghus-Nielsen H, Mills EHA, Møller AL, Gnesin F, Zylyftari N, Kragholm K, Folke F, Christensen HC, Blomberg SN, Torp-Pedersen C, Bøggild H. "I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction. PATIENT EDUCATION AND COUNSELING 2023; 109:107643. [PMID: 36716564 DOI: 10.1016/j.pec.2023.107643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers. METHODS Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied. RESULTS Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see". CONCLUSION Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response. PRACTICE IMPLICATIONS Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.
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Affiliation(s)
- Britta Jensen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | - Henrik Vardinghus-Nielsen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | | | | | - Filip Gnesin
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Nertila Zylyftari
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Kristian Kragholm
- Unit of Clinical Biostatistics and Epidemiology, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Copenhagen Emergency Medical Services, University of Copenhagen, Ballerup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Helle Collatz Christensen
- Copenhagen Emergency Medical Services, University of Copenhagen, Ballerup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Danish Clinical Quality Program (RKKP), National Clinical Registries, Denmark
| | | | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Bøggild
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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12
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Nikolaj Blomberg S, Jensen TW, Porsborg Andersen M, Folke F, Kjær Ersbøll A, Torp-Petersen C, Lippert F, Collatz Christensen H. When the machine is wrong. Characteristics of true and false predictions of Out-of-Hospital Cardiac arrests in emergency calls using a machine-learning model. Resuscitation 2023; 183:109689. [PMID: 36634755 DOI: 10.1016/j.resuscitation.2023.109689] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/29/2022] [Accepted: 01/02/2023] [Indexed: 01/10/2023]
Abstract
BACKGROUND A machine-learning model trained to recognize emergency calls regarding Out-of-Hospital Cardiac Arrest (OHCA) was tested in clinical practice at Copenhagen Emergency Medical Services (EMS) from September 2018 to December 2019. We aimed to investigate emergency call characteristics where the machine-learning model failed to recognize OHCA or misinterpreted a call as being OHCA. METHODS All emergency calls were linked to the dispatch database and verified OHCAs were identified by linkage to the Danish Cardiac Arrest Registry. Calls with either false negative or false positive predictions of OHCA were evaluated by trained auditors. Descriptive analyses were performed with absolute numbers and percentages reported. RESULTS The machine-learning model processed 169,236 calls to Copenhagen EMS and suspected 5,811 (3.4%) of the calls as OHCA, resulting in 84.5% sensitivity and 97.1% specificity. Among OHCAs not recognised by machine-learning model, a condition completely different from OHCA was presented by caller in 31% of the cases. In 28% of unrecognised calls, patient was reported breathing normally, and language barriers were identified in 23% of the cases. Among falsely suspected OHCA, the patient was reported unconscious in 28% of the cases, and in 13% of the false positive cases the machine-learning model interpreted calls regarding dead patients with irreversible signs of death as OHCA. CONCLUSION Continuous optimization of the language model is needed to improve the prediction of OHCA and thereby improve sensitivity and specificity of the machine-learning model on recognising OHCA in emergency telephone calls.
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Affiliation(s)
- Stig Nikolaj Blomberg
- Copenhagen Emergency Medical Services, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Theo W Jensen
- Copenhagen Emergency Medical Services, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | | | - Fredrik Folke
- Copenhagen Emergency Medical Services, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Cardiology, Herlev Gentofte University Hospital, Copenhagen, Denmark
| | - Annette Kjær Ersbøll
- Copenhagen Emergency Medical Services, Denmark; National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Christian Torp-Petersen
- Department of Cardiology, Nordsjællands Hospital, Denmark; Department of Public Health, University of Copenhagen, Denmark
| | - Freddy Lippert
- Copenhagen Emergency Medical Services, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Falck, Denmark
| | - Helle Collatz Christensen
- Copenhagen Emergency Medical Services, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Danish Clinical Quality Program (RKKP), National Clinical Registries, Denmark
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13
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Gnesin F, Mills EHA, Jensen B, Møller AL, Zylyftari N, Bøggild H, Ringgren KB, Kragholm K, Blomberg SNF, Christensen HC, Lippert F, Køber L, Folke F, Torp-Pedersen C. Symptoms reported in calls to emergency medical services within 24 hours prior to out-of-hospital cardiac arrest. Resuscitation 2022; 181:86-96. [PMID: 36334842 DOI: 10.1016/j.resuscitation.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
AIM There is limited evidence regarding prodromal symptoms of out-of-hospital cardiac arrest (OHCA). We aimed to describe patient characteristics, prodromal symptoms, and prognosis of patients contacting emergency medical services (EMS) within 24 hours before OHCA. METHODS We identified all OHCA treated by Copenhagen EMS from 2016 through 2018 using the Danish Cardiac Arrest Registry and linked them to emergency calls. We included all pre-arrest calls by patients or bystanders if they were performed 1) within 24 hours before the OHCA call or 2) during the OHCA event for EMS-witnessed OHCA. Calls were reviewed by healthcare professionals using a survey guide. RESULTS Among 4,071 patients, 481 patients (12 %) had 539 calls within 24 hours prior to OHCA (60 % male, median age 74 years of age). The patient spoke on the phone in 25 % of calls. The most common symptoms were breathing problems (59 %), confusion (23 %), unconsciousness (20 %), chest pain (20 %), and paleness (19 %). Patients with breathing problems compared to chest pain were more likely to be ≤ 75 years of age (55 % versus 35 %), less likely to be male (52 % versus 73 %), have shockable rhythm (10 % versus 38 %), receive bystander defibrillation (6 % versus 19 %) or EMS defibrillation (15 % versus 65 %), achieve return of spontaneous circulation (37 % versus 68 %) and survive 30 days following OHCA (10 % versus 50 %). CONCLUSION More than 10% of patients with OHCA had a call to EMS within 24 hours before OHCA. The most common symptom was breathing problems which compared to chest pain had lower 30-day survival.
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Affiliation(s)
- Filip Gnesin
- Department of Cardiology, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.
| | | | - Britta Jensen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Niels Jernes Vej 14, 9220 Aalborg E, Denmark
| | | | - Nertila Zylyftari
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 2900 Hellerup, Denmark
| | - Henrik Bøggild
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Niels Jernes Vej 14, 9220 Aalborg E, Denmark
| | | | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | | | - Helle Collatz Christensen
- Copenhagen Emergency Medical Services, University of Copenhagen, Telegrafvej 5, 2750 Ballerup, Denmark; Danish Clinical Quality Program (RKKP), National Clinical Registries, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
| | - Freddy Lippert
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Lars Køber
- Department of Cardiology, Heart Center, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 2900 Hellerup, Denmark; Copenhagen Emergency Medical Services, University of Copenhagen, Telegrafvej 5, 2750 Ballerup, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark; Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353 København K, Denmark
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