Emergency medical services response time and mortality in an urban setting

Ambulance and helicopter response time. Association with patient outcome and illness severity: Protocol of a systematic literature review and meta-analysis

BACKGROUND

Response time for emergency medical service units is a key performance indicator. Studies have shown reduced response time association with improved outcome for specific critical conditions. To achieve short response time, emergency vehicles utilize lights and sirens, and crews are allowed to be non-compliant with traffic rules, posing a risk for accident. The purpose of the systematic review and meta-analysis is to provide an overview of the current body of evidence regarding the association, if any, between ambulance and helicopter response time and major complications and mortality in patients conveyed by ambulance and/or helicopter. Our secondary aim will be to enhance knowledge in the field of criteria-based dispatch to provide decision makers with evidence to optimize dispatch of limited resources.

RESEARCH QUESTIONS

What is the association between overall emergency medical services unit response time and patient outcomes, major complications, and time-critical conditions? What is the internal and external validity of the included literature?

METHODS

We plan the systematic review and meta-analysis to be in accordance with the Cochrane Handbook and Joanna Briggs Institute Manual for Systematic Reviews. The methodology will include formulating the review questions using a Population, Exposure, and Outcome framework. Every study design is eligible, including qualitative, quantitative, and mixed-methods designs. We will include all articles in English, Scandinavian, German, French and Portuguese in this systematic review.

RESULTS

We will publish results from the systematic review and meta-analysis in a peer-reviewed journal and we will present the results at scientific conferences and meetings. Results will also be available at www.ahrtemis.dk.

CONCLUSION

We will base our conclusions on the findings of the review and meta-analysis.

Ambulance response times and 30-day mortality: a Copenhagen (Denmark) registry study

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.

On Scene Injury Severity Prediction (OSISP) model for trauma developed using the Swedish Trauma Registry

BACKGROUND

Providing optimal care for trauma, the leading cause of death for young adults, remains a challenge e.g., due to field triage limitations in assessing a patient's condition and deciding on transport destination. Data-driven On Scene Injury Severity Prediction (OSISP) models for motor vehicle crashes have shown potential for providing real-time decision support. The objective of this study is therefore to evaluate if an Artificial Intelligence (AI) based clinical decision support system can identify severely injured trauma patients in the prehospital setting.

METHODS

The Swedish Trauma Registry was used to train and validate five models - Logistic Regression, Random Forest, XGBoost, Support Vector Machine and Artificial Neural Network - in a stratified 10-fold cross validation setting and hold-out analysis. The models performed binary classification of the New Injury Severity Score and were evaluated using accuracy metrics, area under the receiver operating characteristic curve (AUC) and Precision-Recall curve (AUCPR), and under- and overtriage rates.

RESULTS

There were 75,602 registrations between 2013-2020 and 47,357 (62.6%) remained after eligibility criteria were applied. Models were based on 21 predictors, including injury location. From the clinical outcome, about 40% of patients were undertriaged and 46% were overtriaged. Models demonstrated potential for improved triaging and yielded AUC between 0.80-0.89 and AUCPR between 0.43-0.62.

CONCLUSIONS

AI based OSISP models have potential to provide support during assessment of injury severity. The findings may be used for developing tools to complement field triage protocols, with potential to improve prehospital trauma care and thereby reduce morbidity and mortality for a large patient population.

Knowledge and willingness of schoolteachers in Jordan to perform CPR: a cross-sectional study

OBJECTIVES

This study aimed to assess the cardiopulmonary resuscitation (CPR) knowledge and willingness of schoolteachers in Jordan.

DESIGN

This was a cross-sectional study conducted using an online questionnaire.

SETTING

For inclusion in this study, schoolteachers must be currently teaching at any level in schools across the country. Responses were collected from 1 April 2021 to 30 April 2021.

PARTICIPANTS

All schoolteachers actively working in public or private schools were included in our study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Continuous variables were summarised as means and SD, whereas categorical variables were reported as frequencies and percentages (%). A χ2 test for independence, independent sample t-tests and analysis of variance were used appropriately. A p-value less than 0.05 was used to determine statistical significance.

RESULTS

A total of 385 questionnaires were eligible for analyses. Only 14.5% of the participants received CPR training and overall correct knowledge answers were 18.8% of the total score. Those participants with previous CPR training had higher mean knowledge scores (2.34 vs 1.15, p<0.001). Trained participants were also more likely to provide hands-only CPR to various patient groups than untrained participants (p<0.05). Participants were more willing to provide standard CPR to family members than hands-only CPR (p<0.001), but more willing to provide hands-only CPR to friends (p<0.001), students (75.1% vs 58.2%, p<0.001), neighbour (p<0.001), stranger (p=0.001) and patient from the opposite gender (p<0.001).

CONCLUSIONS

Schoolteachers in Jordan possess limited knowledge of CPR. However, the study participants showed a positive attitude towards performing CPR. The study revealed that they were more inclined to provide hands-only CPR than standard CPR. Policymakers and public health officials can take advantage of these findings to incorporate CPR training programmes for schoolteachers, either as a part of their undergraduate studies or as continuing education programmes with an emphasis on hands-only CPR.

The system-wide effects of dispatch, response and operational performance on emergency medical services during Covid-19

In this paper, we analyze the Fire Department of New York City's pre-hospital emergency medical services dispatch data for the period of March 20, 2019-June 13, 2019, and the corresponding Covid lockdown period of March 20, 2020-June 13, 2020. A fixed effects negative binomial model is used to estimate the heterogeneity effects of average ambulance travel or response times on the daily volume of emergency calls, year, day of the week, dispatcher-assigned medical emergency call type, priority rank, ambulance crew response, borough and an offset for missing calls. We also address the limitations of other non-parametric Covid studies or parametric studies that did not properly account for over-dispersion. When our model is estimated and corrected for clustered standard errors, fixed effects, and over-dispersion, we found that Wednesday was the only day of the week that was most likely to increase travel response time with an odd ratio of 6.91%. All grouped call types that were categorized showed significant declines in average travel time, except for call types designated as allergy and an odds ratio of 21.81%. When compared to Manhattan, Staten Island ambulance response times increased with an odds ratio of 19.05% while the Bronx showed a significant decline with an odds ratio of 31.92% advanced life support (ALS) and BLS ambulances showed the biggest declines in travel time with the exception of BLS assigned ambulance types and emergency priority rank of 6. Surprisingly, in terms of capacity utilization, the dispatch system was not as overwhelmed as previously predicted as emergency call volume declined by 8.83% year over year.

Spatial and neighborhood-level correlates of lay naloxone reversal events and service availability

BACKGROUND

The opioid epidemic in the United States continues to surge, reaching record deaths from opioid and fentanyl overdoses in 2020. This study analyzes spatial and neighborhood correlates of free naloxone distribution sites as well as overdose and naloxone reversal events in Baltimore, Maryland, which has one of the highest overdose rates in the country.

METHODS

Using data from a randomized clinical trial on HIV prevention among people using substances in Baltimore, Maryland, as well as demographic data from the US Census Bureau, we conducted: (1) exploratory spatial visualizations of census tracts' minimum distance to naloxone distribution sites, (2) univariable Wilcoxon rank-sum tests to compare census tracts on demographic metrics, and (3) bivariable and multivariable negative binomial regression models to assess associations between census tract characteristics and naloxone reversal events.

RESULTS

Valid geographic data were provided for 518 overdose events involving either fentanyl or heroin in this study. Of these, 190 (37%) attempted naloxone reversal events were reported. Exploratory spatial visualization techniques suggest that most distribution sites are appropriately located near populations at high risk of overdose, but study findings also identify areas where drug use and overdoses occur that are located farther from distribution sites. In multivariable analyses, naloxone administration was significantly and inversely associated with distance to the nearest distribution site (incidence rate ratio (IRR)=0.72 per 1000m increase, 95% CI 0.59-0.89, p=0.002).

CONCLUSION

Study findings emphasize the correlation between proximity to naloxone sites and utilization of resources, highlighting that physical proximity to harm reduction resources may contribute to uptake. Results further underscore that research on service accessibility and utilization must consider the spatial distribution of health services.

Road user perceptions of appropriateness of ambulance lights and sirens use in developing countries

INTRODUCTION

Ambulance lights and sirens use has traditionally been an important strategy to shorten ambulance travel times. This study explored road users' perceptions toward the importance and risks of lights and sirens use by ambulances in Jordan.

METHODS

A cross-sectional survey was used on a sample of 1700 adult road users in Northern Jordan. The questionnaire included 19 items addressing demographics, driving-related characteristics, and perception statements toward lights and sirens use. Continuous variables were summarized as means and standard deviation and categorical variables were reported as frequencies and percentages. Chi-square test was used to assess differences between categorical variable.

RESULTS

A total of 1634 participants completed the questionnaire. The mean age was 32.4 (SD ± 11.4) years, and 65.4% were males. Most participants agreed on the importance of using lights and sirens for emergency medical services to function effectively (96.5%), and penalizing those who do not yield to emergency ambulances (90.2%). However, around half of the participants perceive that lights and sirens could be over-used by ambulance personnel (48.1%), provoke distraction (48.7%) and create stress (50.3%) for road users. These negative perceptions were reported more often among males, taxi/bus drivers, and novice drivers.

CONCLUSIONS

Although the majority of road users, in our region, acknowledge the importance of ambulance lights and sirens use, about half of them perceive that ambulance lights and sirens put them under stress, distraction, and unacceptable risk. Policy-related and educational interventions might be necessary to monitor the use of ambulance lights and sirens and reduce negative road users' perceptions.

Does Every Minute Really Count? Road Time as an Indicator for the Economic Value of Emergency Medical Services

OBJECTIVES

This article builds on the literature regarding the association between emergency medical service (EMS) response times and patient outcomes (death and severe injury). Three issues are addressed in this article with respect to the empirical estimation of this relationship: the endogeneity of response time (systematically quicker response for higher degrees of urgency), the nonlinearity of this relationship, and the variation between such estimations for different patient outcomes.

METHODS

Binomial and multinomial logistic regression models are used to estimate the impact of response time on the probabilities of death and severe injury using data from French Fire and Rescue Services. These models are developed with response time as an explanatory variable and then with road time (dispatch to arrival) hypothesized as representing the exogenous variation within response time. Both models are also applied to data subsets based on response time intervals.

RESULTS

The results show that road time yields a higher estimate for the impact of response time on patient outcomes than (total) response time. The impact of road time on patient outcomes is also shown to be nonlinear. These results are of both statistical significance (model coefficients are significant at the 95% confidence level) and economical significance (when taking into account the number of annual interventions performed).

CONCLUSIONS

When using heterogeneous data on EMS interventions where endogeneity is a clear issue, road time is a more reliable indicator to estimate the impact of EMS response time on patient outcomes than (total) response time.

The Casualty Stabilization–Transportation Problem in a Large-Scale Disaster

We address the problem of picking up, stabilizing, and transporting casualties in response to mass-injury disasters. Our proposed methodology establishes the itinerary for collecting, on-site stabilization, and transporting victims considering capacitated vehicles and medical care centers. Unlike previous works, we minimize the time required to achieve on-site stabilization of each victim according to his age and level of severity of the injuries for their subsequent transfer to specialized medical centers. Thus, more critical patients will be the first to be stabilized, maximizing their chances of survival. In our methodology, the victims’ age, the injuries’ severity level, and their deterioration over time are considered critical factors in prioritizing care for each victim. We tested our approach using simulated earthquake scenarios in the city of Iquique, Chile, with multiple injuries. The results show that explicitly considering the on-site stabilization of the vital functions of the prioritized victims as an objective, before their transfer to a specialized medical center, allows treating and stabilizing patients earlier than with traditional objectives.

Linkage of Emergency Medical Services and Hospital Data: A Necessary Precursor to Improve Understanding of Outcomes of Prehospital Care

Objective: Linking emergency medical services (EMS) data to hospital outcomes is important for quality assurance and research initiatives. However, non-linkage due to missing or incomplete patient information may increase the risk of bias and distort findings. The purpose of this study was to explore if an optimization strategy, in addition to an existing linkage process, improved the linkage rate and reduced selection and information bias.Methods: 4,150 transported patients in a metropolitan EMS system in Alberta, Canada from 2016/17 were linked to two Emergency Department (ED) databases by a standard strategy using a unique health care number, date/time of ED arrival, and hospital name. An optimized strategy added additional linkage steps incorporating last name, year of birth, and a manual search. The strategies were compared to assess the rate of linkage, and to describe event and patient-level characteristics of unlinked records.Results: The standard strategy resulted in 3,650 out of 4,150 (88.0%) linked records (95% CI 86.9%-88.9%). Of the 500 non-linked records, an additional 381 were linked by the optimized strategy (n = 4,031/4,150 [97.1%; 95% CI: 96.6%-97.6%]). There were no false positive linkages. The highest linkage failure was in 25 to 34 year-old patients (n = 93/478, 19.5%), males (n = 236/1975, 12.0%), Echo level events (n = 15/77, 19.5%), and emergency transport (45/231, 19.5%). The optimized strategy improved linkage in these groups by 68.8% (64/93), 79.2% (187/236), 40.0% (6/15), and 51.1% (23/45) respectively. For dispatch card, the highest linkage failure occurred in Card 24-Pregnancy/Childbirth/Miscarriage (n = 30/44, 68.2%), Card 27-Stab/Gunshot/Penetrating Trauma (n = 6/17, 35.3%), and Card 9-Cardiac/Respiratory Arrest/Death (n = 12/46, 26.1%). The optimized strategy improved linkage by 10.0% (3/30), 83.3% (5/6), and 41.7% (5/12) respectively. For the 119 unlinked records, 71 (59.7%) had sufficient information for linkage, but no appropriately matching records could be found.Conclusion: An optimized sequential deterministic strategy linking EMS data to ED outcomes improved the linkage rate without increasing the number of false positive links, and reduced the potential for bias. Even with adequate information, some records were not linked to their ED visit. This study underscores the importance of understanding how data are linked to hospital outcomes in EMS research and the potential for bias.

Spatial Accessibility Assessment of Prehospital EMS with a Focus on the Elderly Population: A Case Study in Ningbo, China

The spatial accessibility of prehospital EMS is particularly important for the elderly population’s physiological functions. Due to the recent expansion of aging populations all over the globe, elderly people’s spatial accessibility to prehospital EMS presents a serious challenge. An efficient strategy to address this issue involves using geographic information systems (GIS)-based tools to evaluate the spatial accessibility in conjunction with the spatial distribution of aging people, available road networks, and prehospital EMS facilities. This study employed gravity model and empirical Bayesian Kriging (EBK) interpolation analysis to evaluate the elderly’s spatial access to prehospital EMS in Ningbo, China. In our study, we aimed to solve the following specific research questions: In the study area, “what are the characteristics of the prehospital EMS demand of the elderly?” “Do the elderly have equal and convenient spatial access to prehospital EMS?” and “How can we satisfy the prehospital EMS demand of an aging population, improve their spatial access to prehospital EMS, and then ensure their quality of life?” The results showed that 37.44% of patients admitted to prehospital EMS in 2020 were 65 years and older. The rate of utilization of ambulance services by the elderly was 27.39 per 1000 elderly residents. Ambulance use by the elderly was the highest in the winter months and the lowest in the spring months (25.90% vs. 22.38%). As for the disease spectrum, the main disease was found to be trauma and intoxication (23.70%). The mean accessibility score was only 1.43 and nearly 70% of demand points had scored lower than 1. The elderly’s spatial accessibility to prehospital EMS had a central-outward gradient decreasing trend from the central region to the southeast and southwest of the study area. Our proposed methodology and its spatial equilibrium results could be taken as a benchmark of prehospital care capacity and help inform authorities’ efforts to develop efficient, aging-focused spatial accessibility plans.

Correction of the travel time estimation for ambulances of the red cross Tijuana using machine learning

This paper addresses the problem of estimating the response time to a medical emergency, specifically from the Red Cross of Tijuana (RCT), which provides most of the emergency medical services (EMS) in the city of Tijuana, Mexico. For institutions with low funding, such as the RCT, relying on free or open source mapping systems to estimate travel times is necessary but also error prone because these systems are not tuned for ambulance movements within a city. Therefore, this work formulates a supervised machine learning problem where the goal is to predict the difference in travel time between the ground truth travel time provided by a GPS and the approximation offered by two mapping systems, Google Maps (GM) and Open Source Routing Machine (OSRM). To this end, this work develops a new dataset based on the EMS logs of the RCT, considering calls from January 2017 to April 2017. The posed learning problem is solved under different scenarios, including using an off-the-shelf default configuration of a Random Forest classifier, applying a hyper-parameter optimization process and using an Auto Machine Learning (AutoML) system. Considering all of the dataset for GM, test accuracy was 69.6% for the first two learning approaches and 71.6% using AutoML. For OSRM, performance was 64.6%, 65.2% and 66.4% for each of the learning approaches, respectively. Results show that it is possible to predict the level by which a mapping system over or under estimates the true travel time of an ambulance. Finally, the impact of the model is demonstrated by using it to solve the ambulance location problem, with notable differences in ambulance deployments and percentage of double coverage achieved relative to using the standard mapping system. Results show that without correcting the travel time the percentage of double coverage is 83.90%; on the other hand, double coverage reaches 100% when applying travel time correction.

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar

Aims: There are very few studies comparing epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in different ethnic groups. Previous ethnicity studies have mostly determined OHCA differences between African American and Caucasian populations. The aim of this study was to compare epidemiology, clinical presentation, and outcomes of OHCA between the local Middle Eastern Gulf Cooperation Council (GCC) Arab and the migrant North African populations living in Qatar.Methods: This was a retrospective cohort study of Middle Eastern GCC Arabs and migrant North African patients with presumed cardiac origin OHCA resuscitated by Emergency Medical Services (EMS) in Qatar, between June 2012 and May 2015.Results: There were 285 Middle Eastern GCC Arabs and 112 North African OHCA patients enrolled during the study period. Compared with the local GCC Arabs, univariate analysis showed that the migrant North African OHCA patients were younger and had higher odds of initial shockable rhythm, pre-hospital interventions (defibrillation and amioderone), pre-hospital scene time, and decreased odds of risk factors (hypertension, respiratory disease, and diabetes) and pre-hospital response time. The survival to hospital discharge had greater odds for North African OHCA patients which did not persist after adjustment. Multivariable logistic regression showed that North Africans were associated with lower odds of diabetes (OR 0.48, 95% CI 0.25-0.91, p = 0.03), and higher odds of initial shockable rhythm (OR 2.86, 95% CI 1.30-6.33, p = 0.01) and greater scene time (OR 1.02 95% CI 1.0-1.04, p = 0.02).Conclusions: North African migrant OHCA patients were younger, had decreased risk factors and favourable OHCA rhythm and received greater ACLS interventions with shorter pre-hospital response times and longer scene times leading to better survival.

Comparison of pre-hospital emergency services time intervals in patients with heart attack in Arak, Iran

Background:

After cardiac arrest, the possibility of death or irreversible complications will highly increase in the absence of cardiac resuscitation within 4 to 6 minutes. Accordingly, measuring the pre-hospital services time intervals is important for better management of emergency medical services delivery. The purpose of this study then was to investigate pre-hospital time intervals for patients with heart attack in Arak city, based on locations and time variables.

Methods:

This is a retrospective descriptive cross-sectional study, which was conducted at the Arak Emergency Medical Services (EMS) during 2017-2018. Data were analyzed by SPSS version 13.

Results:

The total number of heart attack patients registered in Arak emergency medical services was 2,659 of which 51% of patients were males. Six percent of patients were under 25 and about 49 percent were between 46 and 65 years old. The average of activation, response, on-scene, transportation, recovery and total time intervals were 3:30, 7:56, 15:15, 13:34, 11:07, 12:11, and 41:25, respectively. In the city area, the shortest and longest average response time intervals were in spring and winter, respectively. In out of the city area, the shortest average response time interval was in summer and the longest one in autumn. The shortest and the longest average response time intervals in the city area were in June and March, respectively, and in out of the city area, the shortest average response time interval was in June and the longest one in April.

Conclusions:

The shorter response and delivery time interval compared to the other studies may indicate improvement in the provision of EMS. Special attention should be paid to the facilities and equipment of vehicles during cold seasons to be in the shortest possible time. Also, training and informing the staff more about the code of cardiac patients along with general public education can help improve these intervals.

Coding and classification of heroin overdose calls by MPDS dispatch software: Implications for bystander response with naloxone

BACKGROUND AND AIMS

Take-home naloxone, a key response to heroin overdose, may be compromised by the way in which overdose cases are coded in EMS dispatch systems as call-takers direct callers at cardiac arrest events against using any medication. We examined the ways in which confirmed heroin overdose cases attended by ambulances are coded at dispatch to determine whether incorrect coding of overdoses as cardiac arrests may limit the use of take-home naloxone.

METHODS

We conducted a retrospective analysis of coded ambulance clinical records collected in Victoria, Australia from 2012-2017. Counts of heroin overdose cases were examined by dispatch coding (heroin overdose, cardiac/respiratory arrest and 'other'), along with age, sex, GCS and respiratory rate. Data were analysed using chi-square and Poisson regression for quarterly counts, adjusting for age, sex and patient GCS.

RESULTS

A total of 5637 heroin overdose cases were attended over the period 2012-2017 (71.4% male, 36.4% aged under 35 years). Almost half (n = 2674, 47.4%) were coded as cardiac/respiratory arrest at dispatch, with 36.8% (n = 2075) coded as heroin overdose and 15.7% (n = 886) coded as other/unknown.

DISCUSSION AND CONCLUSIONS

Almost half of the heroin overdoses were dispatched according to a protocol that would preclude the use of take-home naloxone prior to ambulance arrival and this changed little over the period in which take-home naloxone programs were operating in Victoria, Australia. EMS should move as quickly as possible to newer versions of dispatch systems that enable the use of naloxone in cases of obvious opioid overdose that may be classified as cardiac/respiratory arrest.

Shortening Ambulance Response Time Increases Survival in Out-of-Hospital Cardiac Arrest

Background

The ambulance response time in out‐of‐hospital cardiac arrest (OHCA) has doubled over the past 30 years in Sweden. At the same time, the chances of surviving an OHCA have increased substantially. A correct understanding of the effect of ambulance response time on the outcome after OHCA is fundamental for further advancement in cardiac arrest care.

Methods and Results

We used data from the SRCR (Swedish Registry of Cardiopulmonary Resuscitation) to determine the effect of ambulance response time on 30‐day survival after OHCA. We included 20 420 cases of OHCA occurring in Sweden between 2008 and 2017. Survival to 30 days was our primary outcome. Stratification and multiple logistic regression were used to control for confounding variables. In a model adjusted for age, sex, calendar year, and place of collapse, survival to 30 days is presented for 4 different groups of emergency medical services (EMS)‐crew response time: 0 to 6 minutes, 7 to 9 minutes, 10 to 15 minutes, and >15 minutes. Survival to 30 days after a witnessed OHCA decreased as ambulance response time increased. For EMS response times of >10 minutes, the overall survival among those receiving cardiopulmonary resuscitation before EMS arrival was slightly higher than survival for the sub‐group of patients treated with compressions‐only cardiopulmonary resuscitation.

Conclusions

Survival to 30 days after a witnessed OHCA decreases as ambulance response times increase. This correlation was seen independently of initial rhythm and whether cardiopulmonary resuscitation was performed before EMS‐crew arrival. Shortening EMS response times is likely to be a fast and effective way of increasing survival in OHCA.

Development and testing of Australian prehospital care quality indicators: study protocol

INTRODUCTION

Historically, ambulance services were established to provide rapid transport of patients to hospital. Contemporary prehospital care involves provision of sophisticated 'mobile healthcare' to patients across the lifespan presenting with a range of injuries or illnesses of varying acuity. Because of its young age, the paramedicine profession has until recently experienced a lack of research capacity which has led to paucity of a discipline-specific, scientific evidence-base. Therefore, the performance and quality of ambulance services has traditionally been measured using simple, evidence-poor indicators forming a deficient reflection of the true quality of care and providing little direction for quality improvement efforts. This paper reports the study protocol for the development and testing of quality indicators (QIs) for the Australian prehospital care setting.

METHODS AND ANALYSIS

This project has three phases. In the first phase, preliminary work in the form of a scoping review was conducted which provided an initial list of QIs. In the subsequent phase, these QIs will be developed by aggregating them and by performing related rapid reviews. The summarised evidence will be used to support an expert consensus process aimed at optimising the clarity and evaluating the validity of proposed QIs. Finally, in the third phase those QIs deemed valid will be tested for acceptability, feasibility and reliability using mixed research methods. Evidence-based indicators can facilitate meaningful measurement of the quality of care provided. This forms the first step to identify unwarranted variation and direction for improvement work. This project will develop and test quality indicators for the Australian prehospital care setting.

ETHICS AND DISSEMINATION

This project has been approved by the University of Adelaide Human Research Ethics Committee. Findings will be disseminated by publications in peer-reviewed journals, presentations at appropriate scientific conferences, as well as posts on social media and on the project's website.

The effect of rural hospital closures on emergency medical service response and transport times

OBJECTIVE

To examine the effect of rural hospital closures on EMS response time (minutes between dispatch notifying unit and arriving at scene); transport time (minutes between unit leaving the scene and arriving at destination); and total activation time (minutes between 9-1-1 call to responding unit returning to service), as longer EMS times are associated with worse patient outcomes.

DATA SOURCES/STUDY SETTING

We use secondary data from the National EMS Information System, Area Health Resource, and Center for Medicare & Medicaid Provider of Service files (2010-2016).

STUDY DESIGN

We examined the effects of rural hospital closures on EMS transport times for emergent 9-1-1 calls in rural areas using a pre-post, retrospective cohort study with the matched comparison group using difference-in-difference and quantile regression models.

PRINCIPAL FINDINGS

Closures increased mean EMS transport times by 2.6 minutes (P = .09) and total activation time by 7.2 minutes (P = .02), but had no effect on mean response times. We also found closures had heterogeneous effects across the distribution of EMS times, with shorter response times, longer transport times, and median total activation times experiencing larger effects.

CONCLUSIONS

Rural hospital closures increased mean transport and total activation times with varying effects across the distribution of EMS response, transport, and total times. These findings illuminate potential barriers to accessing timely emergency services due to closures.

Population-based analysis of the effect of a comprehensive, systematic change in an emergency medical services resource allocation plan on 24-hour mortality

BACKGROUND

Resource allocation planning for emergency medical services (EMS) systems determines appropriate resources including what paramedic qualification and how rapidly to respond to patients for optimal outcomes. The British Columbia Emergency Health Services implemented a revised response plan in 2013.

METHODS

A pre- and post-methodology was used to evaluate the effect of the resource allocation plan revision on 24-hour mortality. All adult cases with evaluable outcome data (obtained through linked provincial health administrative data) were analyzed. Multivariable logistic regression was used to adjust for variations in other significant associated factors. Interrupted time series analysis was used to estimate immediate changes in level or trend of outcome after the start of the revised resource allocation plan implementation, while simultaneously controlling for pre-existing trends.

RESULTS

The derived cohort comprised 562,546 cases (April 2012-March 2015). When adjusted for age, sex, urban/metro region, season, day, hour, and dispatch determinant, the probability of dying within 24 hours of an EMS call was 7% lower in the post-resource allocation plan-revision cohort (OR = 0.936; 95% CI: 0.886-0.989; p = 0.018). A subgroup analysis of immediately life-threatening cases demonstrated similar effect (OR = 0.890; 95% CI: 0.808-0.981; p = 0.019). Using time series analysis, the descending changes in overall 24-hour mortality trend and the 24-hour mortality trend in immediately life-threatening cases, were both statistically significant (p < 0.001).

CONCLUSION

Comprehensive, evidence-informed reconstruction of a provincial EMS resource allocation plan is feasible. Despite change in crew level response and resource allocation, there was significant decrease in 24-hour mortality in this pan-provincial population-based cohort.

Prehospital time and mortality in patients requiring a highest priority emergency medical response: a Danish registry-based cohort study

OBJECTIVE

To examine the association between time from emergency medical service vehicle dispatch to hospital arrival and 1-day and 30-day mortality.

DESIGN

Register-based cohort study.

SETTING

North Denmark Region (≈8000 km², catchment population ≈600 000).

PARTICIPANTS

We included all highest priority dispatched ambulance transports in North Denmark Region in 2006-2012.

INTERVENTIONS

Using logistic regression and the g-formula approach, we examined the association between time from emergency dispatch to hospital arrival and mortality for presumed heart, respiratory, cerebrovascular and other presumed medical conditions, as well as traffic or other accidents, as classified by emergency dispatch personnel.

MAIN OUTCOME MEASURES

1-day and 30-day mortality.

RESULTS

Among 93 167 individuals with highest priority ambulances dispatched, 1948 (2.1%) were dead before the ambulance arrived and 19 968 (21.4%) were transported to the hospital under highest priority (median total prehospital time from dispatch to hospital arrival 47 min (25%-75%: 35-60 min); 95th percentile 84 min). Among 18 709 with population data, 1-day mortality was 10.9% (n=2038), and was highest for patients with dyspnoea (20.4%) and lowest for patients with traffic accidents (2.8%). Thirty-day mortality was 18.3% and varied between 36.6% (patients with dyspnoea) and 3.7% (traffic accidents). One-day mortality was not associated with total prehospital time, except for presumed heart conditions, where longer prehospital time was associated with decreased mortality: adjusted OR for >60 min vs 0-30 min was 0.61 (95% CI 0.40 to 0.91). For patients with dyspnoea, OR for >60 min vs 0-30 min was 0.90 (95% CI 0.56 to 1.45), for presumed cerebrovascular conditions OR 1.41 (95% CI 0.53 to 3.78), for other presumed medical conditions OR 0.84 (95% CI 0.70 to 1.02), for traffic accidents OR 0.65 (95% CI 0.29 to 1.48) and for other accidents OR 0.84 (95% CI 0.47 to 1.51). Similar findings were found for 30-day mortality.

CONCLUSIONS

In this study, where time from emergency dispatch to hospital arrival mainly was <80 min, there was no overall relation between this prehospital time measure and mortality.

Indicators to measure prehospital care quality: a scoping review

OBJECTIVE

The purpose of this scoping review was to locate, examine and describe the literature on indicators used to measure prehospital care quality.

INTRODUCTION

The performance of ambulance services and quality of prehospital care has traditionally been measured using simple indicators, such as response time intervals, based on low-level evidence. The discipline of paramedicine has evolved significantly over the last few decades. Consequently, the validity of utilizing such measures as holistic prehospital care quality indicators (QIs) has been challenged. There is growing interest in finding new and more significant ways to measure prehospital care quality.

INCLUSION CRITERIA

This scoping review examined the concepts of prehospital care quality and QIs developed for ambulance services. This review considered primary and secondary research in any paradigm and utilizing any methods, as well as text and opinion research.

METHODS

Joanna Briggs Institute methodology for conducting scoping reviews was employed. Separate searches were conducted for two review questions; review question 1 addressed the definition of prehospital care quality and review question 2 addressed characteristics of QIs in the context of prehospital care. The following databases were searched: PubMed, CINAHL, Embase, Scopus, Cochrane Library and Web of Science. The searches were limited to publications from January 1, 2000 to the day of the search (April 16, 2017). Non-English articles were excluded. To supplement the above, searches for gray literature were performed, experts in the field of study were consulted and applicable websites were perused.

RESULTS

Review question 1: Nine articles were included. These originated mostly from England (n = 3, 33.3%) and the USA (n = 3, 33.3%). Only one study specifically aimed at defining prehospital care quality. Five articles (55.5%) described attributes specific to prehospital care quality and four (44.4%) articles considered generic healthcare quality attributes to be applicable to the prehospital context. A total of 17 attributes were identified. The most common attributes were Clinical effectiveness (n = 17, 100%), Efficiency (n = 7, 77.8%), Equitability (n = 7, 77.8%) and Safety (n = 6, 66.7%). Timeliness and Accessibility were referred to by four and three (44.4% and 33.3%) articles, respectively.Review question 2: Thirty articles were included. The predominant source of articles was research literature (n = 23; 76.7%) originating mostly from the USA (n = 13; 43.3%). The most frequently applied QI development method was a form of consensus process (n = 15; 50%). A total of 526 QIs were identified. Of these, 283 (53.8%) were categorized as Clinical and 243 (46.2%) as System/Organizational QIs. Within these categories respectively, QIs related to Out-of-hospital cardiac arrest (n = 57; 10.8%) and Time intervals (n = 75; 14.3%) contributed the most. The most commonly addressed prehospital care quality attributes were Appropriateness (n = 250, 47.5%), Clinical effectiveness (n = 174, 33.1%) and Accessibility (n = 124, 23.6%). Most QIs were process indicators (n = 386, 73.4%).

CONCLUSION

Whilst there is paucity in research aiming to specifically define prehospital care quality, the attributes of generic healthcare quality definitions appear to be accepted and applicable to the prehospital context. There is growing interest in developing prehospital care QIs. However, there is a need for validation of existing QIs and de novo development addressing broader aspects of prehospital care.

Experiences of pre-hospital emergency medical personnel in ethical decision-making: a qualitative study

Background

Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service (EMS) personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have to deal with every day, ethical decision-making (EDM) has become an inevitable challenge.

Methods

The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method.

Results

The process of data analysis resulted in the emergence of 3 main categories “respecting client’s values”, “performing tasks within the professional manner”, “personal characteristic”, and the emergence of eight (8) sub-categories signifying participants’ experiences with regard to EDM.

Conclusion

According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client’s values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties.

Emergency response time and pre-hospital trauma survival rate of the national ambulance service, Greater Accra (January - December 2014)

BACKGROUND

Every year, about 1.2 million people die through road traffic crashes worldwide. Majority of these deaths occur in Africa where most of their emergency medical services are underdeveloped. In 2004, Ghana established the National Ambulance Council to provide timely and efficient pre-hospital emergency medical care to the sick and injured. Pre-hospital emergency medical service is essential for accident victims since it has the potential of saving lives. The study sought to determine the relationship between pre-hospital trauma survival rate and response time to emergencies and factors associated to pre-hospital trauma survival  in Accra, Ghana.

METHODS

The study was a cross sectional study which reviewed pre-hospital care forms of trauma patients from the fourteen ambulance stations in the Greater Accra region from January to December 2014. Data were extracted from these forms and the response time estimated. Conscious patients who were alert were categorized as responsive under the AVPU scale. The proportion of patients who survived pre-hospital trauma and  the time pre-hospital trauma cases were responded to was estimated. Multiple logistic regression analysis was conducted to determine which variables were associated with survival.

RESULTS

A total of 652 pre-hospital care forms were reviewed. About 87% survived pre-hospital trauma. The average response time to patients was (16.9 ± 0.7) minutes and the median transportation time of the patient was 82 min. Level of consciousness of a patient and response time of patients transported was found to be significantly associated with pre-hospital trauma survival.

CONCLUSION

There was a high trauma patient survival rate among victims attended to by an NAS. The average response time in Greater Accra region in the 14 ambulance stations is 16.9 min which is not different from the 17 min recorded in 2013 by NAS. Factors that were associated with pre-hospital survival were alertness in the level of consciousness and response time less than 17 min.

Factors affecting emergency medical dispatchers' decision-making: a qualitative study

Introduction

Prehospital emergency medical service dispatchers should make prompt and appropriate decisions to save the life of victims. The complexity of timely and reasonable decision-making in life-threatening conditions has driven researchers to investigate varying aspects of the emergency medical dispatch (EMD) process. The purpose of this study was to explore the contributors to appropriate and prompt decision-making among dispatchers.

Methods

A qualitative study through thematic analysis was designed. Data were collected using observation and semistructured interviews with 16 authorities and dispatchers in seven EMDs across Iran.

Results

The study found “responsiveness” as the main category contributing to improved decision-making in EMD. The components introduced in this study for dispatchers’ responsiveness consisted of two categories. The first was “personal values” including faith and belief, eagerness to help, service excellence, altruism, respect, and impartiality in clinical judgment. The second was “professional attitudes” resulting from education and experience, including the recognition of emergency as a threat to health, sensitivity in triage, response to all requests for help, care for early warnings, commitment to organizational goals and standards, attention to the emergency medical service social support responsibility, and professional temperance.

Conclusion

In this study, responsiveness was identified as a main category in improving the decision-making process among dispatchers. To attain responsiveness, institutionalization of its values and establishment of EMD-specific professional attitudes in dispatchers should be taken into consideration.

Knowledge, attitude, and clinical skill of emergency medical technicians from Tehran emergency center in trauma exposure

Introduction:

Prehospital care is the first part of the trauma treatment and care system. Diagnostic and therapeutic measures taken before these patients arrive at the hospital plays significantly reduce mortality and improve their outcomes. Therefore, the present study aimed to determine the knowledge, attitude, and clinical skill of emergency medical technicians in Tehran Emergency Center in trauma exposure.

Methods:

In this descriptive study, 213 participants were selected through stratified random sampling. Data were collected using a four-part questionnaire including demographic information, trauma knowledge questionnaire, trauma attitude questionnaire, and a clinical skill checklist. To compare the level of knowledge, attitude, and clinical skills on the one hand and demographic variables, on the other hand, independent samples t-test and one-way ANOVA were utilized. Then, to examine the normality of data distribution, Kolmogorov–Smirnov test with Bonferroni post hoc test was used to compare mean scores on different levels of the variables in questionnaires. Data were analyzed in SPSS/17 using descriptive and inferential statistics.

Results:

Results showed that the majority of participants (81.1%) had an average knowledge of trauma. Examining their attitude regarding trauma revealed that the majority (88.3%) had a positive attitude toward trauma and taking care of trauma patients. Moreover, the skill of 62.4% of technicians regarding trauma was good. Based on Pearson's correlation, significant positive correlations existed between scores of knowledge and scores of attitude (r = 0.186, P < 0.05), scores of knowledge and scores of clinical skill (r = 0.333, P < 0.05), and scores of attitude and scores of clinical skill (r = 0.258, P < 0.05).

Conclusion:

According to the results, emergency medical technicians in Tehran had a good level of knowledge, attitude, and clinical skills in trauma exposure. However, to maintain and enhance the level of knowledge and skills, in-service training should be continued more vigorously and periodically evaluated in the clinical practice.

A Survey of the Residents of Zhejiang, China on the Knowledge and Awareness of Community Cardiopulmonary Resuscitation and Expectation of the Emergency Medical Service

Objectives

To investigate the opinions and expectations of residents from Zhejiang Province on the prehospital emergency medical services (EMS). To evaluate the differences among main urban areas, county-level areas and rural areas in Zhejiang Province. To provide objective data for relevant departments to make further improvement and promote balanced development of the pre-hospital EMS cause.

Methods

The study was conducted from 1st April 2011 to 30th December 2011. It was carried out in 11 cities and 1,650 residents were included by stratified random sampling method. The survey mainly focused on residents' expectations of EMS and residents' knowledge of emergency skills, the emergency response time, the actions of EMS dispatchers, the fees charged for EMS. Pearson's Chi-Square Test was also used to compare the differences of the current status and residents' expectations of EMS among main urban areas, county-level areas and rural areas.

Results

The survey showed that the top four emergency skills most needed by residents are cardiopulmonary resuscitation (CPR), bandaging to stop bleeding, first aids for heatstroke and drowning. Trauma patients account for 37.5% (95% CI: 35.08-39.92%) of all those who received EMS service, ranking the first place. While the percentage receiving “wound care” was rated as the most needed emergency skill. There were statistically significant differences in the rate of knowing CPR, independently conducting CPR and emergency response time less than 5 minutes among main urban areas, county-level areas and rural areas in Zhejiang Province.

Conclusions

Residents of Zhejiang Province lack knowledge and awareness of emergency skills. Their mastery and expectation of emergency skills vary greatly from rural areas to urban areas. Trauma patients have become the main receiver of EMS in these three different regions. The emergency response time, as well as the services provided by EMS dispatchers, is far below the expectation of residents. In addition, the majority of respondents expect EMS to send patients to the nearest hospital and most of the trained paramedics are qualified for the pre-hospital care. (Hong Kong j.emerg.med. 2014;21:237-248)

Characteristics and prognoses of patients treated by an anaesthesiologist-manned prehospital emergency care unit. A retrospective cohort study

OBJECTIVE

When planning and dimensioning an emergency medical system, knowledge of the population serviced is vital. The amount of literature concerning the prehospital population is sparse. In order to add to the current body of literature regarding prehospital treatment, thus aiding future public health planning, we describe the workload of a prehospital anaesthesiologist-manned mobile emergency care unit (MECU) and the total population it services in terms of factors associated with mortality.

PARTICIPANTS

The study is a register-based study investigating all missions carried out by a MECU operating in a mixed urban/rural area in Denmark from 1 May 2006 to 31 December 2014. Information on missions was extracted from the local MECU registry and linked at the individual level to the Danish population-based databases, the National Patient Registry and the Civil Registration System.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were number of missions and number of patient contacts. Secondary patient variables were mortality and association between mortality and age, sex, comorbidity, prior admission to hospital and response time.

RESULTS

The MECU completed 41 513 missions (mean 13.1 missions/day) having 32 873 patient contacts, corresponding to 19.2 missions and 15.2 patient encounters per 1000 patient years. Patient variables: the median age was 57 years (range 0-108 years), 42.8% (42.3% to 43.4%) were women. For patients admitted to hospital alive, 30-day mortality was 5.7% (5.4% to 6.0%); 90-day mortality was 8.1% (7.8% to 8.5%) while 2-year mortality was 16.4% (16.0% to 16.8%). Increasing age, male sex, comorbidity and prior admission to hospital but not response time were associated with mortality.

CONCLUSIONS

Mortality following an incident requiring the assistance of a MECU was high in the first 2 years following the incident. MECU response time assessed as a continuous parameter was not associated with patient outcome.

Determinants of out-of-hours service users' potentially inappropriate referral or non-referral to an emergency department: a retrospective cohort study in a local health authority, Veneto Region, Italy

BACKGROUND

A growing presence of inappropriate patients has been recognised as one of the main factors influencing emergency department (ED) overcrowding, which is a very widespread problem all over the world. On the other hand, out-of-hours (OOH) physicians must avoid delaying the diagnostic and therapeutic course of patients with urgent medical conditions. The aim of this study was to analyse the appropriateness of patient management by OOH services, in terms of their potentially inappropriate referral or non-referral of non-emergency cases to the ED.

METHODS

This was an observational retrospective cohort study based on data collected in 2011 by the local health authority No. 4 in the Veneto Region (Italy). After distinguishing between patients contacting the OOH service who were or were not referred to the ED, and checking for patients actually presenting to the ED within 24 hours thereafter, these patients' medical management was judged as potentially appropriate or inappropriate.

RESULTS

The analysis considered 22 662 OOH service contacts recorded in 2011. The cases of potentially inappropriate non-referral to the ED were 392 (1.7% of all contacts), as opposed to 1207 potentially inappropriate referrals (5.3% of all contacts). Age, nationality, type of disease and type of intervention by the OOH service were the main variables associated with the appropriateness of patient management.

CONCLUSIONS

These findings may be useful for pinpointing the factors associated with a potentially inappropriate patient management by OOH services and thus contribute to improving the deployment of healthcare and the quality of care delivered by OOH services.

The CPR outcomes of online medical video instruction versus on-scene medical instruction using simulated cardiac arrest stations

BACKGROUND

Non-traumatic cardiac arrest is a fatal emergency condition. Its survival rate and outcomes may be better with quick and effective cardiopulmonary resuscitation (CPR). Telemedicine such as telephone or real time video has been shown to improve chest compression procedures. There are limited data on the effects of telemedicine in cardiac arrest situations in the literature particularly in Asian settings.

METHODS

This study was conducted by using two simulated cardiac arrest stations during the 2014 annual Thai national conference in emergency medicine. These two stations, nos. 5 and 11, were a part of the conference activity called "EMS rally" which was comprised of 14 stations. Both stations were shockable and out-of-hospital cardiac arrest situations; station 5 was online instructed, while station 11 was on-scene instructed. There were 14 representative teams from each province from all over Thailand who participated in the rally. Each team had one physician, one nurse, and two emergency medicine technicians. Eight CPR outcomes were evaluated and compared between the online versus on-scene situations.

RESULTS

There were 14 representative teams that participated in the study; a total of 14 physicians, 14 nurses, and 28 emergency medicine technicians. The average ages of participants in all three occupations were between the second and third decade of life. The percentages of participants with more than 3 years in ambulance experience was 7.1, 64.3, and 53.6 % in the physicians, nurses, and EMTs groups. The median times of all outcomes were significantly longer in the online group than the on-scene group including times from start to chest compression (total 102 vs 36 s), total times from the start to VT/VF detection (187 vs 99 s); times from VT/VF detection to the first defibrillation (57 vs 28 s); and times from the start of adrenaline injection (282 vs 165 s). The percentages of using amiodarone (21.43 % vs 57.14 %; p value < 0.001), establishment of a definitive airway (35.71 % vs 100 %; p value 0.003), and correct detections of pulseless electrical activity (PEA) (28.57 % vs 100 %; p value < 0.001) were significantly lower in the online group than the on-scene group. The high quality CPR outcomes between the online group and on-scene group were comparable.

CONCLUSIONS

The online medical instruction may have worse CPR outcomes compared with on-scene medical instruction in shockable, simulated CPR scenarios. Further studies are needed to confirm these results.

Pre-Hospital Emergency in Iran: A Systematic Review

CONTEXT

Pre-hospital care plays a vital role in saving trauma patients.

OBJECTIVES

This study aims to review studies conducted on the pre-hospital emergency status in Iran.

DATA SOURCES

Data were sourced from Iranian electronic databases, including SID, IranMedex, IranDoc, Magiran, and non-Iranian electronic databases, such as Medline, Embase, Cochrane Library, Scopus, and Google Scholar. In addition, available data and statistics for the country were used.

DATA SELECTION

All Persian-language articles published in Iranian scientific journals and related English-language articles published in Iranian and non-Iranian journals indexed on valid sites for September 2005 - 2014 were systematically reviewed.

DATA EXTRACTION

To review the selected articles, a data extraction form developed by the researchers as per the study's objective was adopted. The articles were examined under two categories: structure and function of pre-hospital emergency.

RESULTS

A total of 19 articles were selected, including six descriptive studies (42%), four descriptive-analytical studies (21%), five review articles (16%), two qualitative studies (10.5%), and two interventional (experimental) studies (10.5%). In addition, of these, 14 articles (73.5%) had been published in the English language. The focus of these selected articles were experts (31.5%), bases of emergency medical services (26%), injured (16%), data reviews (16%), and employees (10.5%). A majority of the studies (68%) investigated pre-hospital emergency functions and 32% reviewed the pre-hospital emergency structure.

CONCLUSIONS

The number of studies conducted on pre-hospital emergency services in Iran is limited. To promote public health, consideration of prevention areas, processes to provide pre-hospital emergency services, policymaking, foresight, systemic view, comprehensive research programs and roadmaps, and assessments of research needs in pre-hospital emergency seem necessary.

Knowledge and Beliefs of EMS Providers toward Lights and Siren Transportation

Introduction

The use of warning lights and siren (WLS) increases the risk of ambulance collisions. Multiple studies have failed to demonstrate a clinical benefit to the patients. We sought to investigate the degree to which providers understand the data and incorporate it into their practice.

Methods

The authors distributed an anonymous survey to prehospital providers under their medical direction at staff and quality assurance meetings. The surveys asked the providers’ degree of agreement with four statements: transport with lights and siren shortens transport times; transport with lights and siren improves patient outcome; transport with lights and siren increases the risk of collision during transport; and transport with lights and siren reduces the utilization of “mutual aid” service. We compared responses between providers who had been in prior ambulance collisions and those who had not.

Results

Few responses reached statistical significance, but respondents tended towards agreement that WLS use shortens transport times, that it does not improve outcomes, and that it increases the risk of collision. Despite the overall agreement with the published literature, respondents report >80% of transports are conducted using WLS.

Conclusion

The data demonstrate the surveyed providers are aware of the risk posed by WLS to themselves, their patients, and the public. Nevertheless, their practice in the absence of rigid protocols suggests they disregard this knowledge. Despite a large number of prior ambulance collisions among the surveyed group, a high number of transports are conducted using WLS.

Time is money, but how much? The monetary value of response time for Thai ambulance emergency services

OBJECTIVE

To calculate the monetary value of the time factor per minute and per year for emergency services.

METHODS

The monetary values for ambulance emergency services were calculated for two different time factors, response time, which is the time from when a call is received by the emergency medical service call-taking center until the response team arrives at the emergency scene, and operational time, which includes the time to the hospital. The study was performed in two steps. First, marginal effects of reduced fatalities and injuries for a 1-minute change in the time factors were calculated. Second, the marginal effects and the monetary values were put together to find a value per minute.

RESULTS

The values were found to be 5.5 million Thai bath/min for fatality and 326,000 baht/min for severe injury. The total monetary value for a 1-minute improvement for each dispatch, summarized over 1 year, was 1.6 billion Thai baht using response time.

CONCLUSIONS

The calculated values could be used in a cost-benefit analysis of an investment reducing the response time. The results from similar studies could for example be compared to the cost of moving an ambulance station or investing in a new alarm system.

Injury mortality and accessibility to emergency care in Japan: an observational epidemiological study

BACKGROUND

Unintentional injury is a major cause of death across the globe. The accessibility to emergency medical services may affect the rate of preventable trauma deaths. The purpose of this study was to analyze the accessibility to emergency medical hospitals in municipalities in Japan and to clarify whether accessibility was associated with the mortality rate attributed to unintentional injuries.

METHODS

An observational epidemiological study was conducted in all 1,742 municipalities in Japan. Measurements assessed were population size, accessibility to emergency hospitals, and mortality rates attributed to unintentional injuries. Accessibility of each municipality to their nearest emergency hospital was calculated with a computer simulation using a geographic information system. After calculating demographic statistics and the Gini coefficient of accessibility, multivariate analyses were used to examine the correlation between accessibility time and mortality. Municipalities were divided into six groups according to accessibility time, and we then performed a correlation analysis between accessibility time and mortality using analysis of covariance.

RESULTS

The median time of accessibility to emergency hospitals was 34.5 minutes. The Gini coefficient of accessibility time was 0.410. A total of 385 municipalities (23.4%) had an accessibility time of over 60 minutes. Accessibility was significantly related to mortality (beta coefficient =0.006; P<0.001). The mortality rate in municipalities with an accessibility time of <15 minutes was lower than that in all other groups. The mortality rate in municipalities with an accessibility time of 15-30 minutes was lower than that in municipalities with an accessibility time of >30 minutes, and the mortality rate in municipalities with an accessibility time of 30-45 minutes was lower than that in municipalities with an accessibility time of 60-90 minutes (P<0.001).

CONCLUSION

The geographical disparities for emergency care accessibility were related to the rate of death by unintentional injury. Improving accessibility to emergency hospitals could help decrease the mortality rate of preventable trauma. Meanwhile, our findings suggest the need for substantially shorter accessibility times to emergency care facilities in many municipalities in Japan.

Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy

Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.

Which emergency medical dispatch codes predict high prehospital nontransport rates in an urban community?

BACKGROUND

The Medical Priority Dispatch System (MPDS) is a commonly used computer-based emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. There are five major priority classes used to dispatch 9-1-1 calls in the San Francisco System; Alpha codes are the lowest priority (lowest expected acuity) and Echo are the highest priority.

OBJECTIVE

We sought to determine which MPDS dispatch codes are associated with high prehospital nontransport rates (NTRs).

METHODS

All unique MPDS call categories from 2009 in a highly urbanized, two-tier advanced life support (ALS) system were sorted according to highest NTRs. There are many reasons for nontransport, such as "gone on arrival," and "patient denied transport." Those categories with greater than 100 annual calls were further evaluated. MPDS groups that included multiple categories with NTRs exceeding 25% were then identified and each category was analyzed. Results. EMS responded to a total of 81,437 calls in 2009, of which 18,851 were not transported by EMS. The majority of the NTRs were found among "cardiac/ respiratory arrest/death," "assault/sexual assaults," "unknown problem/man down," "traffic/transportation accidents," and "unconscious/fainting." "Cardiac or respiratory arrest/death -obvious death" (9B1) had the highest overall nontransport rate, 99.25% (1/134), most likely due to declaration of death. "Unknown problem -man down -medical alert notification" had the second highest NTR, 67.22% (138/421). However, Echo priority codes had the highest overall nontransport rates (45.45%) and Charlie had the lowest (13.84%).

CONCLUSIONS

The nontransport rates of individual MPDS categories vary considerably and should be considered in any system design. We identified 52 unique call categories to have a 25% or greater NTR, 18 of which exceeded 40%. The majority of NTRs occurred among the "cardiac/respiratory arrest/death," "assault/sexual assaults," "unknown problem/man down," "traffic/transportation accidents," and "unconscious/fainting" categories. The higher the priority code within each subset (AB vs. CDE), the less likely the patient was to be transported. Charlie priority codes had a lower NTR than Delta, and Delta was lower than Echo. Charlie codes were therefore the strongest predictors of hospital transport, while Echo codes (highest priority) were those with the highest nontransport rates and were the worst predictors of hospital transport in the emergent subset.

Implementing a nationwide criteria-based emergency medical dispatch system: a register-based follow-up study

BACKGROUND

A criteria-based nationwide Emergency Medical Dispatch (EMD) system was recently implemented in Denmark. We described the system and studied its ability to triage patients according to the severity of their condition by analysing hospital admission and case-fatality risks.

METHODS

This was a register-based follow-up study of all 1-1-2 calls in a 6-month period that were triaged according to the Danish Index - the new criteria-based dispatch protocol. Danish Index data were linked with hospital and vital status data from national registries. Confidence intervals (95%) for proportions with binomial data were computed using exact methods. To test for trend the Wald test was used.

RESULTS

Information on level of emergency according to the Danish Index rating was available for 67,135 patients who received ambulance service. Emergency level A (urgent cases) accounted for 51.4% (n = 34,489) of patients, emergency level B for 46.3% (n = 31,116), emergency level C for 2.1% (n = 1,391) and emergency level D for 0.2% (n = 139). For emergency level A, the median time from call receipt to ambulance dispatch was 2 min 1 s, and the median time to arrival was 6 min 11 s. Data concerning admission and case fatality was available for 55,270 patients. The hospital admission risk for emergency level A patients was 64.4% (95% CI = 63.8-64.9). There was a significant trend (p < 0.001) towards lower admission risks for patients with lower levels of emergency. The case fatality risk for emergency level A patients on the same day as the 1-1-2 call was 4.4% (95% CI = 4.1-4.6). The relative case-fatality risk among emergency level A patients compared to emergency level B-D patients was 14.3 (95% CI: 11.5-18.0).

CONCLUSION

The majority of patients were assessed as Danish Index emergency level A or B. Case fatality and hospital admission risks were substantially higher for emergency level A patients than for emergency level B-D patients. Thus, the newly implemented Danish criteria-based dispatch system seems to triage patients with high risk of admission and death to the highest level of emergency. Further studies are needed to determine the degree of over- and undertriage and prognostic factors.

Frequent callers to and users of emergency medical systems: a systematic review

BACKGROUND

There appears to be a paucity of studies examining the characteristics and impact of frequent users upon emergency medical services (EMS).

OBJECTIVE

To review current primary research on frequent users of EMS and to identify possible gaps in the literature.

METHODS

Ovid, PubMed and CINAHL/Medline were systematically searched for articles that were published in English and either referred to frequent callers to or users of an EMS, or referred to frequent users of other services where admissions were via ambulance. Studies were included regardless of quality.

FINDINGS

Eighteen studies were included. Ten were emergency department based, seven in EMS and one in a psychiatric emergency service. In emergency department studies, frequent users were more likely to arrive via ambulance than infrequent users. In EMS studies, between 0.2% and 23% of patients using EMS were frequent users accounting for 1.4% to 40% of all ambulance use. No two EMS studies used the same definition of a frequent user. No studies focused on characteristics of callers to EMS. Two studies explored interventions for frequent callers to EMS, with mixed results in reducing ambulance use.

DISCUSSION

It is unknown to what extent frequent callers impact upon EMS resources. Research should identify predictors and characteristics of frequent users of EMS, and a consistent definition of a frequent caller to or user of EMS would provide greater comparability. The lack of studies identified in this review suggests that further research is needed in order to inform policy and practice.

Higher energy prices are associated with diminished resources, performance and safety in Australian ambulance systems

OBJECTIVE

To evaluate the impact of changing energy prices on Australian ambulance systems.

METHODS

Generalised estimating equations were used to analyse contemporaneous and lagged relationships between changes in energy prices and ambulance system performance measures in all Australian State/Territory ambulance systems for the years 2000-2010. Measures included: expenditures per response; labour-to-total expenditure ratio; full-time equivalent employees (FTE) per 10,000 responses; average salary; median and 90th percentile response time; and injury compensation claims. Energy price data included State average diesel price, State average electricity price, and world crude oil price.

RESULTS

Changes in diesel prices were inversely associated with changes in salaries, and positively associated with changes in ambulance response times; changes in oil prices were also inversely associated with changes in salaries, as well with staffing levels and expenditures per ambulance response. Changes in electricity prices were positively associated with changes in expenditures per response and changes in salaries; they were also positively associated with changes in injury compensation claims per 100 FTE.

CONCLUSION

Changes in energy prices are associated with changes in Australian ambulance systems' resource, performance and safety characteristics in ways that could affect both patients and personnel. Further research is needed to explore the mechanisms of, and strategies for mitigating, these impacts. The impacts of energy prices on other aspects of the health system should also be investigated.

A validation of ground ambulance pre-hospital times modeled using geographic information systems

Background

Evaluating geographic access to health services often requires determining the patient travel time to a specified service. For urgent care, many research studies have modeled patient pre-hospital time by ground emergency medical services (EMS) using geographic information systems (GIS). The purpose of this study was to determine if the modeling assumptions proposed through prior United States (US) studies are valid in a non-US context, and to use the resulting information to provide revised recommendations for modeling travel time using GIS in the absence of actual EMS trip data.

Methods

The study sample contained all emergency adult patient trips within the Calgary area for 2006. Each record included four components of pre-hospital time (activation, response, on-scene and transport interval). The actual activation and on-scene intervals were compared with those used in published models. The transport interval was calculated within GIS using the Network Analyst extension of Esri ArcGIS 10.0 and the response interval was derived using previously established methods. These GIS derived transport and response intervals were compared with the actual times using descriptive methods. We used the information acquired through the analysis of the EMS trip data to create an updated model that could be used to estimate travel time in the absence of actual EMS trip records.

Results

There were 29,765 complete EMS records for scene locations inside the city and 529 outside. The actual median on-scene intervals were longer than the average previously reported by 7–8 minutes. Actual EMS pre-hospital times across our study area were significantly higher than the estimated times modeled using GIS and the original travel time assumptions. Our updated model, although still underestimating the total pre-hospital time, more accurately represents the true pre-hospital time in our study area.

Conclusions

The widespread use of generalized EMS pre-hospital time assumptions based on US data may not be appropriate in a non-US context. The preference for researchers should be to use actual EMS trip records from the proposed research study area. In the absence of EMS trip data researchers should determine which modeling assumptions more accurately reflect the EMS protocols across their study area.