Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries

The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.

Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team

BACKGROUND

Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients.

METHODS

We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay.

RESULTS

The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes.

CONCLUSION

Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study

OBJECTIVES

Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021.

DESIGN

We conducted a secondary data analysis with a quasi-experimental design.

SETTING

We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis.

PARTICIPANTS

We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021.

RESULTS

40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001).

CONCLUSIONS

A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Disease incidence and not case fatality drives the rural disadvantage in myocardial-infarction-related mortality in Germany

OBJECTIVE

Demographic and infrastructural developments might compromise medical care provision in rural regions, particularly for acute health conditions. Studying the case of myocardial infarction (MI), we investigated how MI-related mortality at ages 65+ varies between rural and urban regions in Germany and to what extent differences are driven by varying case fatality and disease incidence.

METHODS

The study relies on data containing all hospitalizations, cause-specific deaths and population counts for the total German population between years 2012-2018 and ages 65+. MI-related mortality, MI incidence and case fatality are compared between urban and rural regions in a population-wide analysis. The impacts of changing incidence and case fatality on rural-urban MI-related mortality differences are assessed using a counterfactual approach.

RESULTS

Rural regions in Germany show systematically higher MI-related death rates and MI incidence at ages 65+ compared to urban regions. Higher mortality is primarily the result of higher MI incidence in rural regions, while case fatality is largely similar. The rural excess in MI-related death rates would be nullified and 1 out of 6 MI-related deaths in rural regions could be prevented if rural regions in Germany would have at least the median MI incidence of urban regions.

CONCLUSIONS

MI incidence and not case fatality drives the rural disadvantage in MI-related mortality in Germany. Higher MI incidence points towards potential regional variation in the effectiveness of disease prevention. The findings highlight that improving disease prevention at the patient level carries larger opportunities for reducing regional MI-related mortality inequalities in Germany.

Coastal mortality burden on school holidays 2004-2021: an Australian perspective

INTRODUCTION

School holidays are a known period of increased risk of paediatric drowning. However, the risk of coastal death for all age groups is unknown.

METHODS

This case-control study aimed to identify high-risk demographics and behaviours relating to coastal deaths during the school holidays. We address this knowledge gap by comparing unintentional coastal deaths (drowning deaths and other coastal fatalities) in Australia between 1 July 2004-30 June 2021 to a survey sample representative of the Australian population.

RESULTS

School holidays increased the risk of coastal death increased overall by 1.39 times (95% CI 1.32 to 146, p=0.00019). This increased risk differed across activities, behaviours and demographics. Few between-group differences were detected, indicating that school holidays pose an increased risk to the wider Australian population on the coast, regardless of demographics and practices. Increased school holiday mortality risk was identified broadly across groups, but notably for young adults (risk ratio, RR 1.41, 95% CI 1.31 to 1.53, p<0.001), when attempting a rescue (RR 1.85, 95% CI 1.42 to 2.39, p=0.0002), scuba diving (RR 1.82, 95% CI 1.48 to 2.23, p<0.0001) and swimming/wading (RR 1.72, 95% CI 1.56 to 1.89, p<0.0001). Children did not have a significantly increased risk of death (RR 1.38, 95% CI 1.03 to 1.87, p=0.054).

CONCLUSION

These results highlight that while school holiday risk research regarding drowning has focused on the safety of children, these time periods also pose significant safety concerns to the rest of the population for both drowning deaths and other fatalities. Overall, the research highlights ongoing need for public education for all carers of children, as well as continuing to extend risk education to the broader community. Mitigation strategies, that is, advocacy for extending life-saving service and engaging with accommodation providers during school holidays are proposed.

Wolf Creek XVII Part 5: Mobile AEDs

Introduction

Millions of out-of-hospital cardiac arrests (OHCA) occur globally each year. Survival after OHCA can be improved with the use of automated external defibrillators (AED). The main strategy for facilitating bystander defibrillation has been fixed-location public access defibrillators (PADs). New strategies of mobile AEDs depart from the model of static PADs and have the potential to address known barriers to early defibrillation and improve outcomes.

Methods

Mobile AEDs was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023, in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised, and ranked by all attendees to identify the top 5 for each category.

Results

Top knowledge gaps center around understanding the impact of mobile AEDs on OHCA outcomes in various settings and the impact of novel AED technologies. Top barriers to translation include questionable public comfort/acceptance, financial/regulatory constraints, and a lack of centralized accountability. Top research priorities focus on understanding the impact of the mobile AED strategies and technologies on time to defibrillation and OHCA outcomes.

Conclusion

This work informs research agendas, funding priorities and policy decisions around using mobile AEDs to optimize prehospital response to OHCA.

Predictors, Prevalence, and Clinical Outcomes of Out-of-Hospital Cardiac Arrests in Croatia: A Nationwide Study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains a pivotal health challenge globally. In Croatia, there has been a knowledge gap regarding the prevalence, predictors, and outcomes of OHCA patients. This study aims to determine the prevalence, prediction, and outcomes of OHCA patients in Croatia.

METHODS

An extensive one-year analysis was performed on all OHCA treated by the Emergency Medical Service in Croatia, based on the Utstein recommendations. Data were extracted from Croatian Institute of Emergency Medicine databases, focusing on adult individuals who experienced sudden cardiac arrest in out-of-hospital settings in Croatia.

RESULTS

From 7773 OHCA cases, 9.5% achieved spontaneous circulation pre-hospital. Optimal outcomes corresponded to EMS intervention within ≤13 min post-arrest onset AUC = 0.577 (95% CI: 0.56-0.59; p < 0.001) and female gender OR = 1.81 (95% CI: 1.49-2.19; p < 0.001). Northern Croatia witnessed lower success rates relative to the capital city Zagreb OR = 0.68 (95% CI: 0.50-0.93; p = 0.015).

CONCLUSIONS

Early intervention by EMS, specifically within a 13-min period following the onset of a cardiac arrest, significantly enhances the probability of achieving successful OHCA outcomes. Gender differences and specific initial heart rhythms further influenced the likelihood of successful outcomes. Regional disparities, with reduced success rates in northern Croatia compared to the City of Zagreb, were evident.

Community Interventions for Out-of-Hospital Cardiac Arrest in Resource-Limited Settings: A Scoping Review Across Low, Middle, and High-Income Countries

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited settings are burdened with suboptimal emergency response and worse outcomes than high-resource areas. Engaging the community in the response to OHCA has the potential to improve outcomes, although an overview of community interventions in resource-limited settings has not been provided.

OBJECTIVE

This review evaluated the scope of community-based OHCA interventions in resource-limited settings.

METHODS

Literature searches in electronic databases (MEDLINE, EMBASE, Global Health, CINAHL, Cochrane Central Register of Controlled Clinical Trials) and grey literature sources were performed. Abstract screening, full-text review, and data extraction of eligible studies were conducted independently by two reviewers. The PCC (Population, Concept, and Context) framework was used to assess study eligibility. Studies that evaluated community-based interventions for laypeople (Population), targeting emergency response activation, cardiopulmonary resuscitation (CPR), or automated external defibrillator (AED) use (Concept) in resource-limited settings (Context) were included. Resource-limited settings were identified by financial pressures (low-income or lower-middle-income country, according to World Bank data on year of publication) or geographical factors (setting described using keywords indicative of geographical remoteness in upper-middle-income or high-income country).

RESULTS

Among 14,810 records identified from literature searches, 60 studies from 28 unique countries were included in this review. Studies were conducted in high-income (n = 35), upper-middle-income (n = 2), lower-middle-income (n = 22), and low-income countries (n = 1). Community interventions included bystander CPR and/or AED training (n = 34), community responder programs (n = 8), drone-delivered AED networks (n = 6), dispatcher-assisted CPR programs (n = 4), regional resuscitation campaigns (n = 3), public access defibrillation programs (n = 3), and crowdsourcing technologies (n = 2). CPR and/or AED training were the only interventions evaluated in low-income, lower-middle-income, and upper-middle-income countries.

CONCLUSIONS

Interventions aimed at improving the community response to OHCA in resource-limited settings differ globally. There is a lack of reported studies from low-income countries and certain continental regions, including South America, Africa, and Oceania. Evaluation of interventions other than CPR and/or AED training in low- and middle-income countries is needed to guide community emergency planning and health policies.

Community First Responders' Contribution to Emergency Medical Service Provision in the United Kingdom

STUDY OBJECTIVE

We aimed to investigate community first responders' contribution to emergency care provision in terms of number, rate, type, and location of calls and characteristics of patients attended.

METHODS

We used a retrospective observational design analyzing routine data from electronic clinical records from 6 of 10 ambulance services in the United Kingdom during 2019. Descriptive statistics, including numbers and frequencies, were used to illustrate characteristics of incidents and patients that the community first responders attended first in both rural and urban areas.

RESULTS

The data included 4.5 million incidents during 1 year. The community first responders first attended a higher proportion of calls in rural areas compared with those in urban areas (3.90% versus 1.48 %). In rural areas, the community first responders also first attended a higher percentage of the most urgent call categories, 1 and 2. The community first responders first attended more than 9% of the total number of category 1 calls and almost 5% of category 2 calls. The community first responders also attended a higher percentage of the total number of cardiorespiratory and neurological/endocrine conditions. They first attended 6.5% of the total number of neurological/endocrine conditions and 5.9% of the total number of cardiorespiratory conditions. Regarding arrival times in rural areas, the community first responders attended higher percentages (more than 6%) of the total number of calls that had arrival times of less than 7 minutes or more than 60 minutes.

CONCLUSION

In the United Kingdom, community first responders contribute to the delivery of emergency medical services, particularly in rural areas and especially for more urgent calls. The work of community first responders has expanded from their original purpose-to attend to out-of-hospital cardiac arrests. The future development of community first responders' schemes should prioritize training for a range of conditions, and further research is needed to explore the contribution and potential future role of the community first responders from the perspective of service users, community first responders' schemes, ambulance services, and commissioners.

Higher hospitalization and mortality rates among SARS-CoV-2-infected persons in rural America

PURPOSE

Rural communities are among the most underserved and resource-scarce populations in the United States. However, there are limited data on COVID-19 outcomes in rural America. This study aims to compare hospitalization rates and inpatient mortality among SARS-CoV-2-infected persons stratified by residential rurality.

METHODS

This retrospective cohort study from the National COVID Cohort Collaborative (N3C) assesses 1,033,229 patients from 44 US hospital systems diagnosed with SARS-CoV-2 infection between January 2020 and June 2021. Primary outcomes were hospitalization and all-cause inpatient mortality. Secondary outcomes were utilization of supplemental oxygen, invasive mechanical ventilation, vasopressor support, extracorporeal membrane oxygenation, and incidence of major adverse cardiovascular events or hospital readmission. The analytic approach estimates 90-day survival in hospitalized patients and associations between rurality, hospitalization, and inpatient adverse events while controlling for major risk factors using Kaplan-Meier survival estimates and mixed-effects logistic regression.

FINDINGS

Of 1,033,229 diagnosed COVID-19 patients included, 186,882 required hospitalization. After adjusting for demographic differences and comorbidities, urban-adjacent and nonurban-adjacent rural dwellers with COVID-19 were more likely to be hospitalized (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI], 1.16-1.21 and aOR 1.29, CI 1.24-1.1.34) and to die or be transferred to hospice (aOR 1.36, CI 1.29-1.43 and 1.37, CI 1.26-1.50), respectively. All secondary outcomes were more likely among rural patients.

CONCLUSIONS

Hospitalization, inpatient mortality, and other adverse outcomes are higher among rural persons with COVID-19, even after adjusting for demographic differences and comorbidities. Further research is needed to understand the factors that drive health disparities in rural populations.

The incidence and outcomes of out-of-hospital cardiac arrest in metropolitan versus rural locations: A systematic review and meta-analysis

BACKGROUND/AIMS

Rurality poses a unique challenge to the management of out-of-hospital cardiac arrest (OHCA) when compared to metropolitan (metro) locations. We conducted a systematic review of published literature to understand how OHCA incidence, management and survival outcomes vary between metro and rural areas.

METHODS

We included studies comparing the incidence or survival of ambulance attended OHCA in metropolitan and rural areas, from a search of five databases from inception until 9th March 2022. The primary outcomes of interest were cumulative incidence and survival (return of spontaneous circulation, survival to hospital discharge (or survival to 30 days)). Meta-analyses of OHCA survival were undertaken.

RESULTS

We identified 28 studies (30 papers- total of 823,253 patients) across 13 countries of origin. The definition of rurality varied markedly. There was no clear difference in OHCA incidence between metro and rural locations. Whilst there was considerable statistical heterogeneity between studies, the likelihood of return of spontaneous circulation on arrival at hospital was lower in rural than metro locations (OR = 0.53, 95% CI 0.40, 0.70; I² = 89%; 5 studies; 90,934 participants), as was survival to hospital discharge/survival to 30 days (OR = 0.52, 95% CI 0.38, 0.71; I² = 95%; 15 studies; 18,837 participants).

CONCLUSIONS

Overall, while incidence did not vary, the odds of OHCA survival to hospital discharge were approximately 50% lower in rural areas compared to metro areas. This suggests an opportunity for improvement in the prehospital management of OHCA within rural locations. This review also highlighted major challenges in standardising the definition of rurality in the context of cardiac arrest research.

A 13-Year Study of Fatal Falls From Height in Northern Tunisia

INTRODUCTION

Falls from height are a major cause of unintentional injury death, resulting in high disability and mortality. We investigated the characteristics of fatal falls and their relationship with intentionality, injury patterns, and death on impact.

MATERIALS AND METHODS

In this retrospective study, we examined 545 cases of fatal falls from height that underwent autopsy in the forensic department of the Charles Nicolle hospital of Tunis (Tunisia) between January 2008 and December 2020. Cases were reviewed in terms of demographics, fall characteristics, and autopsy findings.

RESULTS

The population was predominately male (86.6%). Four hundred twenty-one (77.3%) originated from accidents, 120 (22%) were found to be suicidal, with 4 homicide cases. A notable decline in cases was noticed following the Jasmine revolution, 2011 (R squared = 0.8). The mean height of falls was 8 m. Higher falls were associated with a set of organ-specific injuries. Organ injury pattern did not differ based on intentionality. Female victims were 2.4 times more likely to sustain pelvic injuries than males. The majority of victims deceased before reaching health care structures. Death on impact was strongly associated with higher falls, cranial impact, and organ-specific injuries, including cardiac, pulmonary, and skull injuries.Falls from height are in many cases preventable. A clearly defined fall safety policy, strict implementation of evidence-based interventions, efficient allocation of resources, and raising safety awareness must to be urgently implemented.

CONCLUSION

Understanding patterns of injury and the factors that influence death on impact may be of further interest in the prevention and management of survivors in the acute period.

Surviving a 400 m Fall on Mount Everest

Mountaineering is a dangerous recreational activity with falls causing severe injuries and deaths. Survival from falls longer than 100 m is uncommon. We present a case of a high-altitude porter on Mount Everest who fell 400 m and survived. He slipped from a ridge at 7000 m (22,900 ft). A rescue party found him above Camp 2 (6600 m, 21,600 ft) and arranged a helicopter rescue. The Everest ER medical team at Everest Base Camp (5400 m, 17,700 ft) received the climber. They identified a head injury without signs of other serious trauma. A doctor provided manual inline stabilization of the cervical spine, airway support, and ventilation for the patient during the helicopter and ground transport to a tertiary hospital in Kathmandu. The time from the fall to definitive hospital care was 2.5 h. The hospital emergency team diagnosed an epidural hematoma and subarachnoid hemorrhage without midline shift and right parietal, orbital, and maxillary fractures. The neurosurgical team evacuated the intracranial bleed. The patient spent 6 d in the hospital. He had a positive neurological outcome. He had mild cognitive impairment and vision loss in his left eye but could perform activities of daily living. He returned to physical work, but not to climbing. This case report provides evidence that survival is possible after falls from extreme heights and sheds light on the challenges of an evacuation from austere environments.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

Emergency medical services in rural and urban Saudi Arabia: A qualitative study of Red Crescent emergency personnel' perceptions of workforce and patient factors impacting effective delivery

Individuals who experience a traumatic injury or an acute illness are often reliant on initial healthcare assessment and support from a pre-hospital emergency medical service (EMS). These community-based support models perform a vital role in the provision of life-saving support, but research indicates that the availability, accessibility and resources of EMS are not equivalent in rural and urban areas, and there has been little recognition of the issues facing rural EMS provision outside of the USA, Europe and Australia. The purpose of the current study was to examine the lived experiences of Saudi Arabian EMS personnel, defined as emergency medical technicians, paramedics and local station managers. A semi-structured interview approach was used to collect data from 20 interviewees (10 each with rural and urban personnel) in the Riyadh region of the Kingdom of Saudi Arabia. This methodology was used to identify the key issues that these staff face in their day-to-day work practice and ascertain factors that may lead to service delivery issues in rural and urban areas. Data analyses identified three thematic categories impacting EMS delivery; two of these, Personnel Factors and Patient Factors, are the focus of this paper. The participants noted a number of key issues, including a lack of appropriate local training and limited resources in rural areas, as well as general areas of concern regarding the wider EMS staff demographic makeup and poor public awareness about the exact role of the EMS. Three key recommendations arising from this study include specialised training and ongoing accessible education for rural EMS staff to allow for better support for patients; consideration of supplementing the current EMS with additional external specialist staff; and the development and implementation of national public education programmes focusing on the role of the EMS within the community.

Environmental Factors Associated with Severe Motorcycle Crash Injury in University Neighborhoods: A Multicenter Study in Taiwan

University neighborhoods in Taiwan have high-volume traffic, which may increase motorcyclists' risk of injury. However, few studies have analyzed the environmental factors affecting motorcycle crash injury severity in university neighborhoods. In this multicenter cross-sectional study, we explored the factors that increase the severity of such injuries, especially among young adults. We retrospectively connected hospital data to the Police Traffic Accident Dataset. Areas within 500 m of a university were considered university neighborhoods. We analyzed 4751 patients, including 513 with severe injury (injury severity score ≥ 8). Multivariate analysis revealed that female sex, age ≥ 45 years, drunk driving, early morning driving, flashing signals, and single-motorcycle crashes were risk factors for severe injury. Among patients aged 18-24 years, female sex, late-night and afternoon driving, and flashing signals were risk factors. Adverse weather did not increase the risk. Time to hospital was a protective factor, reflecting the effectiveness of urban emergency medical services. Lifestyle habits among young adults, such as drunk driving incidents and afternoon and late-night driving, were also explored. We discovered that understanding chaotic traffic in the early morning, flashing signals at the intersections, and roadside obstacles is key for mitigating injury severity from motorcycle crashes in university neighborhoods.

Higher rates but similar causes of young out-of-hospital cardiac arrest in rural Australian patients

OBJECTIVE

To determine whether young rural Australians have higher rates or different underlying causes of out-of-hospital cardiac arrest (OHCA).

DESIGN

A case-control design identified patients experiencing an OHCA, then compared annual OHCA rates and underlying causes in rural versus metropolitan Victoria. OHCA causes were defined as either cardiac or non-cardiac, with specific aetiologies including coronary disease, cardiomyopathy, unascertained cause of arrest, drug toxicity, respiratory event, neurological event and other cardiac and non-cardiac. For OHCAs with confirmed cardiac aetiology, cardiovascular risk profiles were compared.

SETTING

A state-wide prospective OHCA registry (combining ambulance, hospital and forensic data) in the state of Victoria, Australia (population 6.5 million).

PARTICIPANTS

Victorians aged 1-50 years old experienced an OHCA between April 2019 and April 2020.

MAIN OUTCOME MEASURES

Rates and underlying causes of OHCA in young rural and metropolitan Victorians.

RESULTS

Rates of young OHCA were higher in rural areas (OHCA 22.5 per 100 000 rural residents vs. 13.4 per 100 000 metropolitan residents, standardised incidence ratio 168 (95% CI 101-235); confirmed cardiac cause of arrest 12.1 per 100 000 rural residents versus 7.5 per 100 000 metropolitan residents, standardised incidence ratio 161 (95% CI 71-251). The underlying causation of the OHCA and cardiovascular risk factor burden did not differ between rural and metropolitan areas.

CONCLUSION

Higher rates of OHCA occur in young rural patients, with standardised incidence ratio of 168 compared to young metropolitan residents. Rural status did not influence causes of cardiac arrest or known cardiovascular risk factor burden in young patients experiencing OHCA.

Factors associated with the workload of health professionals in hospital at home: a systematic review

BACKGROUND

Understanding the factors related to workload, could help hospital at home (HaH) managers to make decisions on the most appropriate and efficient use of the HaH services. Published studies on this topic are scarce, so we have conducted a systematic review to identify such factors according to published evidence.

METHODS

Due to the heterogeneity of HaH models, HaH was defined as a care that provides a set of medical and nursing care and attention of hospital rank to patients at home, when they no longer require hospital infrastructure but still need active monitoring and complex care. The electronic data base literature search was conducted in MEDLINE (Ovid), EMBASE (Ovid), and Cinahl (EBSCOhost) from inception to December 2021, including grey literature. Search terms related to `hospital at home´, `workload´ and `care time´ were used. There was no restriction on language, type of study or year of publication. Quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist and certainty in the body of evidence was assessed using the GRADE Pro Tool. Results were summarised in a tabulated format.

RESULTS

Eighteen studies with 56,706 patients were included. Workload was measured as time, number of visits or both. The predictive factors of the workload included variables related to patient characteristics and other valid and reliable patient classification systems, as well as characteristics of the institutions where the studies were conducted. The factors associated with higher workloads were: being older, male, living in a rural environment, presenting a higher number of diagnoses, having worse functional status and being unable to assume self-care.

CONCLUSIONS

The identified predictors of workload are mostly associated with home nursing care. The results could be useful and applicable to different organisational models of HaH health systems. More studies that include physicians and proxy measures of workload are needed.

Artificial intelligence in Emergency Medical Services dispatching: assessing the potential impact of an automatic speech recognition software on stroke detection taking the Capital Region of Denmark as case in point

BACKGROUND AND PURPOSE

Stroke recognition at the Emergency Medical Services (EMS) impacts the stroke treatment and thus the related health outcome. At the EMS Copenhagen 66.2% of strokes are detected by the Emergency Medical Dispatcher (EMD) and in Denmark approximately 50% of stroke patients arrive at the hospital within the time-to-treatment. An automatic speech recognition software (ASR) can increase the recognition of Out-of-Hospital cardiac arrest (OHCA) at the EMS by 16%. This research aims to analyse the potential impact an ASR could have on stroke recognition at the EMS Copenhagen and the related treatment.

METHODS

Stroke patient data (n = 9049) from the years 2016-2018 were analysed retrospectively, regarding correlations between stroke detection at the EMS and stroke specific, as well as personal characteristics such as stroke type, sex, age, weekday, time of day, year, EMS number contacted, and treatment. The possible increase in stroke detection through an ASR and the effect on stroke treatment was calculated based on the impact of an existing ASR to detect OHCA from CORTI AI.

RESULTS

The Chi-Square test with the respective post-hoc test identified a negative correlation between stroke detection and females, the 1813-Medical Helpline, as well as weekends, and a positive correlation between stroke detection and treatment and thrombolysis. While the association analysis showed a moderate correlation between stroke detection and treatment the correlation to the other treatment options was weak or very weak. A potential increase in stroke detection to 61.19% with an ASR and hence an increase of thrombolysis by 5% in stroke patients calling within time-to-treatment was predicted.

CONCLUSIONS

An ASR can potentially improve stroke recognition by EMDs and subsequent stroke treatment at the EMS Copenhagen. Based on the analysis results improvement of stroke recognition is particularly relevant for females, younger stroke patients, calls received through the 1813-Medical Helpline, and on weekends.

TRIAL REGISTRATION

This study was registered at the Danish Data Protection Agency (PVH-2014-002) and the Danish Patient Safety Authority (R-21013122).

Understanding the importance of social determinants and rurality for the long-term outcome after acute myocardial infarction: study protocol for a single-centre cohort study

INTRODUCTION

Acute myocardial infarction (AMI) is a major public health issue in Germany with considerable regional differences in morbidity and mortality. Possible reasons for regional differences include a higher prevalence of cardiovascular risk factors, infrastructural deficits, different levels of healthcare quality or social determinants. We aim to study associations of social determinants and of rural infrastructure with the quality of medical care (eg, time to reperfusion or medication adherence) and on the long-term outcome after myocardial infarction.

METHODS AND ANALYSIS

We will employ a prospective cohort study design. Patients who are admitted with AMI will be invited to participate. We aim to recruit a total of 1000 participants over the course of 5 years. Information on outpatient care prior to AMI, acute healthcare of AMI, healthcare-related environmental factors and social determinants will be collected. Baseline data will be assessed in interviews and from the electronic data system of the hospital. Follow-up will be conducted after an observation period of 1 year via patient interviews. The outcomes of interest are cardiac and all-cause mortality, changes in quality of life, changes in health status of heart failure, major adverse cardiovascular events and participation in rehabilitation programmes.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee of Brandenburg Medical School (reference: E-01-20200923). Research findings will be disseminated and shared in different ways and include presenting at international and national conferences, publishing in peer-reviewed journals and facilitating dissemination workshops within local communities with patients and healthcare professionals.

TRIALS REGISTRATION NUMBER

DRKS00024463.

Socio-spatial disparities in access to emergency health care-A Scandinavian case study

Having timely access to emergency health care (EHC) depends largely on where you live. In this Scandinavian case study, we investigate how accessibility to EHC varies spatially in order to reveal potential socio-spatial disparities in access. Distinct measures of EHC accessibility were calculated for southern Sweden in a network analysis using a Geographical Information System (GIS) based on data from 2018. An ANOVA test was carried out to investigate how accessibility vary for different measures between urban and rural areas, and negative binominal regression modelling was then carried out to assess potential disparities in accessibility between socioeconomic and demographic groups. Areas with high shares of older adults show poor access to EHC, especially those in the most remote, rural areas. However, rurality alone does not preclude poor access to EHC. Education, income and proximity to ambulance stations were also associated with EHC accessibility, but not always in expected ways. Despite indications of a well-functioning EHC, with most areas served within one hour, socio-spatial disparities in access to EHC were detected both between places and population groups.

Exploring variation in ambulance calls and conveyance rates for adults with diabetes mellitus who contact the Northern Ireland Ambulance Service: a retrospective database analysis

Background:

People with diabetes frequently contact the ambulance service about acute problems. Overall, treating diabetes and its associated complications costs the NHS 10% of the annual budget. Reducing unnecessary hospital admissions and ambulance attendances is a high priority policy for the NHS across the UK. This study aimed to determine the characteristics of emergency calls for people with diabetes who contact the ambulance service and are subsequently conveyed to hospital by the Northern Ireland Ambulance Service (NIAS).

Methods:

A retrospective dataset from the NIAS was obtained from the NIAS Trust’s Command and Control system relating to calls where the final complaint group was ‘Diabetes’ for the period 1 January 2017 to 23 November 2019.

Results:

Of a total 11,396 calls related to diabetes, 63.2% of callers to the NIAS were conveyed to hospital. Over half of the calls related to males, with 35.5% of callers aged 60–79. The more deprived areas had a higher frequency of calls and conveyance to hospital, with this decreasing as deprivation decreased. Calls were evenly distributed across the week, with the majority of calls originating outside of GP working hours, although callers were more likely to be conveyed to hospital during working hours. Calls from healthcare professionals were significantly more likely to be conveyed to hospital, despite accounting for the minority of calls.

Conclusion:

This research found that older males were more likely to contact the ambulance service but older females were more likely to be conveyed to hospital. The likelihood of conveyance increased if the call originated from an HCP or occurred during GP working hours. The availability of alternative care pathways has the potential to reduce conveyance to hospital, which has been particularly important during the COVID-19 pandemic. Integration of data is vitally important to produce high quality research and improve policy and practice in this area.

Online Newspaper Reports on Ambulance Accidents in Austria, Germany, and Switzerland: Retrospective Cross-sectional Review

Background

Ambulance accidents are an unfortunate indirect result of ambulance emergency calls, which create hazardous environments for personnel, patients, and bystanders. However, in European German-speaking countries, factors contributing to ambulance accidents have not been optimally researched and analyzed.

Objective

The objective of this study was to extract, analyze, and compare data from online newspaper articles on ambulance accidents for Austria, Germany, and Switzerland. We hope to highlight future strategies to offset the deficit in research data and official registers for prevention of ambulance and emergency vehicle accidents.

Methods

Ambulance accident data were collected from Austrian, German, and Swiss free web-based daily newspapers, as listed in Wikipedia, for the period between January 2014 and January 2019. All included newspapers were searched for articles reporting ambulance accidents using German terms representing “ambulance” and “ambulance accident.” Characteristics of the accidents were compiled and analyzed. Only ground ambulance accidents were covered.

Results

In Germany, a total of 597 ambulance accidents were recorded, corresponding to 0.719 (95% CI 0.663-0.779) per 100,000 inhabitants; 453 of these accidents left 1170 people injured, corresponding to 1.409 (95% CI 1.330-1.492) per 100,000 inhabitants, and 28 of these accidents caused 31 fatalities, corresponding to 0.037 (95% CI 0.025-0.053) per 100,000 inhabitants. In Austria, a total of 62 ambulance accidents were recorded, corresponding to 0.698 (95% CI 0.535-0.894) per 100,000 inhabitants; 47 of these accidents left 115 people injured, corresponding to 1.294 (95% CI 1.068-1.553) per 100,000 inhabitants, and 6 of these accidents caused 7 fatalities, corresponding to 0.079 (95% CI 0.032-0.162) per 100,000 inhabitants. In Switzerland, a total of 25 ambulance accidents were recorded, corresponding to 0.293 (95% CI 0.189-0.432) per 100,000 inhabitants; 11 of these accidents left 18 people injured, corresponding to 0.211(95% CI 0.113-0.308) per 100,000 inhabitants. There were no fatalities. In each of the three countries, the majority of the accidents involved another car (77%-81%). In Germany and Switzerland, most accidents occurred at an intersection. In Germany, Austria, and Switzerland, 38.7%, 26%, and 4%, respectively, of ambulance accidents occurred at intersections for which the ambulance had a red light (P<.001). In all three countries, most of the casualties were staff and not uncommonly a third party. Most accidents took place on weekdays and during the daytime. Ambulance accidents were evenly distributed across the four seasons. The direction of travel was reported in 28%-37% of the accidents and the patient was in the ambulance approximately 50% of the time in all countries. The cause of the ambulance accidents was reported to be the ambulance itself in 125 (48.1% of accidents where the cause was reported), 22 (42%), and 8 (40%) accidents in Germany, Austria, and Switzerland, respectively (P=.02), and another vehicle in 118 (45.4%), 29 (56%), and 9 (45%) accidents, respectively (P<.001). A total of 292 accidents occurred while blue lights and sirens were used, which caused 3 deaths and 577 injuries.

Conclusions

This study draws attention to much needed auxiliary sources of data that may allow for creation of a contemporary registry of all ambulance accidents in Austria, Germany, and Switzerland. To improve risk management and set European standards, it should be mandatory to collect standardized goal-directed and representative information using various sources (including the wide range presented by the press and social media), which should then be made available for audit, analysis, and research.

A One-Year Cross Sectional Analysis of Emergency Medical Services Utilization and Its Association with Hypertension in Pregnancy

Objective: To evaluate the prehospital obstetric population that utilizes emergency medical services (EMS) and their association with hypertensive disorders of pregnancy.Methods: We conducted a retrospective evaluation of one year of all medical calls from a large, municipal, midwestern fire department. Inclusion criteria included all pregnant patients transported to a hospital by EMS. Descriptive statistics were calculated to evaluate prehospital event information (e.g., zip code, time, and duration of call), patient characteristics, and clinical management data regarding blood pressure. Census data were used to compare neighborhood information with poverty rates.Results: Of the 1,575 identified patients, 64.4% (1015/1575) presented with obstetric complaints, 57.4% (700/1220) were in their third trimester and 72.7% (686/944) were multiparous. The median call duration was 17 (interquartile range 12-22) minutes. In the areas where EMS usage was highest, one quarter of individuals lived below the poverty level. Of the studied population, 32.0% (504/1575) were found to be hypertensive; 14.9% (75/504) of hypertensive patients were found to have severe hypertension. Only one patient (1/1575, 0.06%) presented with a chief complaint of hypertension; the rest were discovered by EMS. The highest rates of hypertension were noted in wealthier areas of the city. Patients with severe hypertension were more likely to present with seizures, consistent with eclampsia.Conclusion: Hypertension is common in the obstetric population using EMS. Prehospital management of hypertensive disorders of pregnancy may focus on identification and treatment of severe pre-eclampsia or eclampsia. Areas with longer call times may consider treatment of severe hypertension. Prehospital treatment of hypertensive disorders of pregnancy could be optimized.

Severe penetrating trauma in Switzerland: first analysis of the Swiss Trauma Registry (STR)

PURPOSE

The purpose of this study was to examine the epidemiology, demographics, injury characteristics and outcomes of patients who presented to Swiss trauma centers following severe penetrating trauma.

METHODS

Swiss Trauma Registry (STR)-cohort analysis including patients with severe (ISS ≥ 16 or AIS head ≥ 3) penetrating trauma between 2017 and 2019. Primary outcome was mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), and prehospital times.

RESULTS

During the 3-year study period, 134 (1.6% of entire STR) patients with severe penetrating trauma were identified [64 (48%) gunshot wounds (GSW), 70 (52%) stab wounds (SW)]. Median age was 40.5 (IQR 29.0-59.0) and 82.8% were male. Mortality rate was 50% for GSW; 9% for SW. Overall, prehospital time [incident to arrival emergency department (ED)] was 65 (IQR 45-94) minutes. The median number of patients admitted for a severe GSW/SW per center and year was 2 (range 0-14). Of 64 patients who sustained a GSW, 42 (65.6%) were self-inflicted. Mortality in self-inflicted GSW reached 66.7%, with the head being severely injured in 78.6%. The 67 patients with severe isolated torso GSW/SW had an ISS of 20 (IQR 16-26) and a mortality of 15%. Multivariable analysis identified severe chest trauma, ED Glasgow Coma Scale ≤ 8, age, self-infliction, massive blood transfusion and ISS as independent predictors for mortality.

CONCLUSION

Severe penetrating trauma is very rare in Switzerland. Mortality ranges from 9% in SW to 67% in self-inflicted GSW. Particularly in the setting of GSW/SW to the torso, reduction in prehospital time may further improve patient outcomes.

EMS non-conveyance: A safe practice to decrease ED crowding or a threat to patient safety?

BACKGROUND

The safety of the Emergency Medical Service's (EMS's) non-conveyance decision was evaluated by EMS re-contacts, primary health care or emergency department (ED) visits, and hospitalization within 48 h. The secondary outcome was 28-day mortality.

METHODS

This cohort study used prospectively collected data on non-conveyed EMS patients from three different regions in Finland between June 1 and November 30, 2018. The Adjusted International Classification of Primary Care (ICPC2) as the reason for care was compared to hospital discharge diagnoses (ICD10). Multivariable logistic regressions were used to determine factors that were independently associated with adverse outcomes. Results are presented with adjusted odds ratios (aORs) together with 95% confidence intervals (CIs). Data regarding deceased patients were reviewed by the study group.

RESULTS

Of the non-conveyed EMS patients (n = 11,861), 6.3% re-contacted the EMS, 8.3% attended a primary health care facility, 4.2% went to the ED, 1.6% were hospitalized, and 0.1% died 0-24 h after the EMS mission. The 0-24 h adverse event rate was higher than 24-48 h. After non-conveyance, 32 (0.3%) patients were admitted to an intensive care unit within 24 h. Primary non-urgent EMS mission (aOR 1.49; 95% CI 1.25 to 1.77), EMS arrival at night (aOR 1.82; 95% CI 1.58 to 2.09), ALS unit type vs BLS (aOR 1.43; 95% CI 1.16 to 1.77), rural area (aOR 1.74; 95% CI 1.51 to 1.99), and older patient age (aOR 1.41; 95% CI 1.20 to 1.66) were associated with subsequent primary health care visits (0-24 h).

CONCLUSIONS

Four in five non-conveyed patients did not have any re-contact in follow-up period. EMS non-conveyance seems to be a relatively safe method of focusing ED resources and avoiding ED crowding.

Characteristics and Injury Patterns of Road Traffic Injuries in Urban and Rural Uganda-A Retrospective Medical Record Review Study in Two Hospitals

In the ongoing Second Decade of Action for Road Safety, road traffic crashes pose a considerable threat especially in low-income countries. Uganda shows a vast burden of non-fatal injuries and resides at the top range of countries with the highest death rates due to unsafe roads. However, little is known about the differences in road traffic associated injuries between urban and rural areas and potential influence factors. Here, we used a cross-sectional study conducted by a retrospective medical record review from trauma cases admitted in 2016 to hospitals in rural and urban areas in Uganda. Injury severity scores were calculated and descriptive analysis was carried out while multivariate logistic regression was applied to assess significant covariates. According to the 1683 medical records reviewed, the mean age of trauma patients in the dataset under investigation was 30.8 years with 74% male. The trauma in-hospital mortality was 4% while prevalence of traumatic injuries is 56.4%. Motorcycle users (49.6%) and pedestrians (33.7%) were identified as the most vulnerable groups in both urban and rural setting while mild injuries of extremities (61.6%) and the head/neck-region (42.0%) were registered most. The frequency of road traffic injuries was homogenous in the urban and rural hospitals investigated in this study; interventions should therefore be intensified ubiquitously. The identification of significant differences in road traffic crash and injury characteristics provides the opportunity for specific programmes to decrease the socio-economic and health burden of unsafe roads. In addition to law enforcement and introduction of a Systems Thinking approach to road safety including infrastructural and educational concepts, the strengthening of trauma care and health resources is recommended.

Evaluation of ambulance calls for patients over 65 years of age in İzmir, Turkey: a two- year retrospective analysis

Background/aim

Analysis of interventions for special patient groups is important for the planning of health services, especially emergency medical services. In this study, we aimed to evaluate emergency medical service (EMS) interventions for the elderly and determine the decisive factors affecting transfer to the hospital of EMS team over 2 years (2017 and 2018) in İzmir.

Materials and methods

Records of 112 emergency calls that were made between 2017 and 2018 followed up with interventions for patients aged 65 years and older were obtained from the 112 system. The reasons for the calls, outcomes, possible diagnoses of the patients, differences in time intervals and seasons, characteristics of the patients transferred to the hospital, and factors affecting the need for transfer to the hospital were investigated.

Results

A total of 176,104 elderly patients with a mean age of 78.02 ± 8.0 years required ambulance services, and out of them, 66% were transferred to the hospital. Transfer to the hospital was significantly associated with the event location, sex, time interval, international classification of diseases (ICD) codes, and physical examination findings.

Conclusion

Ambulance interventions are more frequently required in urban areas than in the countryside, and calls are mostly made during daytime hours and during winter months. The decision to transfer a patient to the hospital is based on the patient’s respiratory status, skin examination, state of consciousness, pulse, systolic blood pressure, call time, and the preliminary diagnosis of the crew.

Organisational factors affecting emergency medical services' performance in rural and urban areas of Saudi Arabia

Background

There is a disparity in outcomes between rural and urban emergency medical services (EMS) around the world. However, there is a scarcity of research that directly asks EMS staff in both rural and urban areas how service delivery could be improved. The aim of the present study is to gain insights from frontline workers regarding organisational factors that may underpin discrepancies between rural and urban EMS performance.

Subject and methods

The study was undertaken in the Riyadh region of Saudi Arabia. Potential participants were currently employed by Saudi Red Crescent EMS as either a technician, paramedic or an EMS station manager, and had a minimum of five years experience with the EMS. Semi-structured interviews were undertaken between October 2019 and July 2020 with first respondents to a call for participants, and continued until data saturation was reached. All interviews were conducted in Arabic and transcribed verbatim. The Arabic transcript was shared with each participant, and they were asked to confirm their agreement with the transcription. The transcribed interviews were then translated into English; the English versions were shared with bi-lingual participants for validation, while independent certification of the translations were performed for data from participants not fluent in English. A thematic analysis methodological approach was used to examine the data.

Results

The final sample involved 20 participants (10 rural, 10 urban) from Saudi Red Crescent EMS. Data analyses identified key organisational factors that resulted in barriers and impediments for EMS staff. Differences and similarities were observed between rural and urban respondents, with identified issues including response and transportation time, service coordination, reason for call-out, as well as human and physical resourcing.

Conclusion

The findings identified key issues impacting on EMS performance across both rural and urban areas. In order to address these problems, three changes are recommended. These recommendations include a comprehensive review of rural EMS vehicles, with a particular focus on the age; incentives to improve the numbers of paramedics in rural areas and more localised specialist training opportunities for rurally-based personnel; and the implementation of national public education program focusing on the role of the EMS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06565-3.

Nontransported Cases after Emergency Medical Service Callout in the Rural and Urban Areas of the Riyadh Region

Background

Callouts resulting in patient nontransportation can impact the overall quality of prehospital Emergency Medical Service (EMS), as resources in health care are finite. While some studies have investigated the causes of nontransportation, few have examined whether there are differences between urban and rural patients. Similarly, there has been limited research focused on rural EMS in locations such as the Middle East.

Objectives

This study investigated EMS cases that resulted in nontransportation in the urban and rural areas of the Riyadh region in the Kingdom of Saudi Arabia.

Methods

A cross-sectional study of 800 (400 rural and 400 urban) patient records was undertaken, using 12 months (January 1 to December 31, 2017) of data from the Saudi Red Crescent EMS. A random sampling method was used to select ambulance records from the 78 urban and rural EMS stations in the Riyadh region, with demographic data and reasons for patient nontransport analyzed comparatively.

Results

A total of 310 cases were nontransported (39%) (rural: 146; urban = 164). The highest rates of nontransportation cases were of medical and trauma callouts (44.6% and 39.6%, respectively), which was consistent in both areas. The most common reason for nontransportation in both urban and rural areas was refusal of treatment and transportation (66.5% and 59.9%, respectively). Further, 10 patients were treated on-scene and released by rural EMS, while no urban patients were treated and released. Overall, the case presentations of nontransported patients did not differ significantly between both areas, and it was found that gender, age, and geographic location were not predictors for nontransportation.

Conclusions

The high rate of nontransportation, particularly in medical and trauma callouts, indicates that a review of current EMS protocols may be required, along with consideration of relevant community education programs.

Disparities between Rural and Urban Areas of the Central Region of Saudi Arabia in the Utilization and Time-Centeredness of Emergency Medical Services

The purpose of this study was to explore differences in characteristics of missions dispatched by Emergency Medical Services (EMS) between rural and urban areas of Riyadh province in Saudi Arabia (SA). It also aimed at identifying weaknesses related to utilization and Response Time (RT). The study retrospectively evaluated 146,639 completed missions in 2018 by measuring the utilization rate in rural and urban areas. The study shows there are six times more ambulance crews available for rural areas compared to urban. There were 22.1 missions per 1000 urban inhabitants and 11.2 missions per 1000 in rural areas. The median RT for high urgent trauma cases was 20.2 min in rural compared to 15.2 min in urban areas (p < 0.001). In urban areas, the median RT for high urgent medical cases was 16.1 min, while it was 15.2 min for high urgent trauma cases. Around 62.3% of emergency cases in urban and 56.5% in rural areas were responded to within 20.00 min. Women utilized EMS less frequently. The RT was increased in urban areas compared to previous studies. The RT in the central region of SA has been identified as equal, or less than 20.00 min in 62.4% of all emergency cases. To further improve adherence to the 20' target, reorganizing the lowest urgent cases in the rural areas seems necessary.

"Drones are a great idea! What is an AED?" novel insights from a qualitative study on public perception of using drones to deliver automatic external defibrillators

Background

The quickest way to ensure survival in an out-of-hospital cardiac arrest (OHCA) is for a bystander to provide immediate cardiopulmonary resuscitation (CPR) and apply an automated external defibrillator (AED). The urgency of OHCA treatment has led to the proposal of alternative avenues for better access to AEDs, particularly in rural settings. More recently, using unmanned aerial vehicles (or drones) to deliver AEDs to rural OHCA sites has proven promising in improving survival rates.

Objective

A pilot drone AED delivery program is currently being piloted in the community of Caledon, Ontario. The purpose of this study was to develop an understanding of public perception and acceptance of the use of drones for this purpose and to identify tailored community engagement strategies to ensure successful uptake.

Methods

In-depth qualitative descriptive study using interviews and focus group data collection and inductive thematic analysis. Purposive sampling was used to recruit 67 community members (40 interviews; 2 focus groups of 15) at existing community events in the project area. Interview guides were used to ensure consistency across data collection events. Detailed field notes were recorded when audio-recording was not possible.

Results

The central message seen throughout the data was quickly identified as the potential impact of low levels of CPR and AED literacy in the community over anything else including concerns about the drone. The impact of the community's existing relationship with the EMS; the need for bystander CPR & AED promotion prior to the program launch; and the value the community places on transparency and accountability related to the research and the drones were also key findings. In general, the drone concept was found to be acceptable but concerns about providing CPR and using the AED was what created anxieties in the lay public that we underestimated.

Conclusion

Drone-delivered AEDs may be feasible and effective but successful uptake in smaller communities will require a deep understanding of a community's cardiac arrest literacy levels, information needs and readiness for innovation. This work will inform a robust community engagement plan that will be scalable to other locations considering a drone AED program.

Rural Stroke Patients Have Higher Mortality: An Improvement Opportunity for Rural Emergency Medical Services Systems

PURPOSE

Early recognition and prompt prehospital care is a cornerstone of acute stroke treatment. Residents of rural areas have worse access to stroke services than urban residents. The purpose of this study was to (1) describe US trends in rural-urban stroke mortality and (2) identify possible factors associated with rural-urban stroke case-fatality disparities.

METHODS

This study was a nationwide retrospective cohort study of stroke admissions. The primary exposure was rurality of patient's residence. The primary outcome was death during hospital encounter. The secondary outcome was discharge to a care facility or home healthcare. Univariable and multivariable logistic regressions estimated the odds of mortality by subject rurality among stroke subjects.

FINDINGS

Rural stroke subjects had higher mortality than nonrural counterparts (18.6% rural vs 16.9% nonrural). After adjustment for patient and hospital factors, patient rurality was associated with increased odds of mortality (aOR = 1.11; 95% CI: 1.06-1.15; P < .001). For the secondary outcome of discharge to home, rural stroke subjects were less likely to be discharged to a care facility than nonrural stroke visits (aOR 0.94; 95% CI: 0.91-0.97; P < .001). Results were similar after adjusting for thrombolytics administration and transfer status.

CONCLUSIONS

Rural stroke patients have higher mortality than their urban counterparts likely due to their increased burden of chronic disease, lower health literacy, and reduced access to prompt prehospital care. There may be an opportunity for emergency medical services systems to assist in increasing stroke awareness for both patients and clinicians and to establish response patterns to expedite emergency care.

Epidemiological profile of emergency medical services in Japan: a population-based descriptive study in 2016

Aim

The aim of our study is to describe the characteristics of patients who use emergency medical services (EMS), EMS performance, and regional variations in Japan.

Methods

We undertook a nationwide, population‐based, descriptive review of anonymized ambulance transport records obtained from the Fire and Disaster Management Agency in Japan. All emergency patients transported to emergency medical institutions by EMS personnel from January to December 2016 were enrolled in this study, excluding patients who were not transported.

Results

During the study period, 5,097,838 patients were transported to a hospital. Their median age was 69 years, 51.4% were male, and 56.5% were over 65 years old. Median durations from EMS call to EMS arrival on scene were similar among the regions, ranging from 7 to 9 min. However, the longest median duration from EMS call to hospital arrival was 38 min, and the shortest was 31 min across the regions. Among all patients, 350,865 (6.9%) were assessed as being in a severe condition, 14,410 (0.3%) were in very severe condition, and 74,780 (1.5%) were confirmed to be dead at the time of initial medical examination in the emergency department.

Conclusions

We described the characteristics of emergency patients and EMS performance in Japan. This registry serves as a basis for providing relevant information to improve prehospital emergency medical systems.