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Jamtli B, Hov MR, Jørgensen TM, Kramer-Johansen J, Ihle-Hansen H, Sandset EC, Kongsgård HW, Hardeland C. Telephone triage and dispatch of ambulances to patients with suspected and verified acute stroke - a descriptive study. BMC Emerg Med 2024; 24:43. [PMID: 38486156 PMCID: PMC10941420 DOI: 10.1186/s12873-024-00962-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/07/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES In this study we aimed to explore EMCC triage of suspected and confirmed stroke patients to gain more knowledge about the initial phase of the acute stroke response chain. Accurate dispatch at the Emergency Medical Communication Center (EMCC) is crucial for optimal resource utilization in the prehospital service, and early identification of acute stroke is known to improve patient outcome. MATERIALS AND METHODS We conducted a descriptive retrospective study based on data from the Emergency Department and EMCC records at a comprehensive stroke center in Oslo, Norway, during a six-month period (2019-2020). Patients dispatched with EMCC stroke criteria and/or discharged with a stroke diagnosis were included. We identified EMCC true positive, false positive and false negative stroke patients and estimated EMCC stroke sensitivity and positive predictive value (PPV). Furthermore, we analyzed prehospital time intervals and identified patient destinations to gain knowledge on ambulance services assessments. RESULTS We included 1298 patients. EMCC stroke sensitivity was 77% (95% CI: 72 - 82%), and PPV was 16% (95% CI: 14 - 18%). EMCC false negative stroke patients experienced an increased median prehospital delay of 11 min (p < 0.001). Upon arrival at the scene, 68% of the EMCC false negative patients were identified as suspected stroke cases by the ambulance services. Similarly, 68% of the false positive stroke patients were either referred to a GP, out-of-hours GP acute clinic, local hospitals or left at the scene by the ambulance services, indicating that no obvious stroke symptoms were identified by ambulance personnel upon arrival at the scene. CONCLUSIONS This study reveals a high EMCC stroke sensitivity and an extensive number of false positive stroke dispatches. By comparing the assessments made by both the EMCC and the ambulance service, we have identified specific patient groups that should be the focus for future research efforts aimed at improving the sensitivity and specificity of stroke recognition in the EMCC.
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Affiliation(s)
- Bjørn Jamtli
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.
- Prehospital affiliationision, Oslo University Hospital, Oslo, Norway.
| | - Maren Ranhoff Hov
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Trine Møgster Jørgensen
- Faculty of Health Sciences, Department for Prehospital Emergency Medicine, Oslo Metropolitan University, Oslo, Norway
| | - Jo Kramer-Johansen
- Air Ambulance department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | | | - Camilla Hardeland
- Faculty of Health and Welfare, Østfold University College, Fredrikstad, Norway
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo University Hospital, Fredrikstad, Norway
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Wenstrup J, Blomberg SN, Christensen H, Folke F, Christensen HC, Kruuse C. Dispatcher Stroke/TIA Recognition in Emergency Medical Call Center and Out-of-Hours Service Calls in Copenhagen, Denmark. Neurol Clin Pract 2023; 13:e200197. [PMID: 37854175 PMCID: PMC10581077 DOI: 10.1212/cpj.0000000000200197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 07/24/2023] [Indexed: 10/20/2023]
Abstract
Background and Objectives Recognition of stroke/TIA symptoms by emergency medical services (EMS) is instrumental in providing timely recanalization treatments. We assessed the recognition of stroke/TIA by EMS via the emergency medical call center (EMCC) dispatchers and out-of-hours health service (OOHS) dispatchers. Methods In a registry study, based on 2015-2020 data from the Copenhagen EMS, we calculated sensitivity, positive predictive value (PPV), specificity, and negative predictive value (NPV) of dispatcher suspicion of stroke or transient ischemic attack (TIA) and compared against discharge diagnosis. Results We included 462,029 contacts to EMCC and 2,573,865 contacts to OOHS. In total, 19,798 contacts had a stroke or TIA diagnosis at hospital discharge. Sensitivity was 0.64 for EMCC dispatchers and 0.25 for OOHS. PPV was 0.28 for EMCC and 0.22 for OOHS; specificity was 0.96 for EMCC and >0.99 for OOHS, and NPV was 0.99 for EMCC and >0.99 for OOHS. Sensitivity improved over the period of the study from 0.62 to 0.68 for EMCC and from 0.20 to 0.25 for OOHS. PPV did not change over the period for EMCC and decreased from 0.26 to 0.19 for OOHS. Both EMCC and OOHS more frequently overlooked stroke in women, in patients calling more than 3 hours after symptom onset, and for more severe strokes. For OHHS, advanced age correlated with lower recognition. Discussion As the first study reporting on OOHS setting dispatcher stroke/TIA recognition, we find a need for the improvement of stroke/TIA recognition both in EMCC and in OOHS. Solutions may include specific training of dispatchers, public awareness campaigns, and new technological solutions.
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Affiliation(s)
- Jonathan Wenstrup
- Department of Neurology (JW, CK), Copenhagen University Hospital - Herlev and Gentofte; Emergency Medical Services Copenhagen (JW, FF, HCC), Denmark; Emergency Medical Services (SNB), Region Zealand; Department of Neurology (HC), Copenhagen University Hospital - Bispebjerg and Frederiksberg; Department of Clinical Medicine (HC, FF HCC, CK), University of Copenhagen; and Department of Cardiology (FF), Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Stig N Blomberg
- Department of Neurology (JW, CK), Copenhagen University Hospital - Herlev and Gentofte; Emergency Medical Services Copenhagen (JW, FF, HCC), Denmark; Emergency Medical Services (SNB), Region Zealand; Department of Neurology (HC), Copenhagen University Hospital - Bispebjerg and Frederiksberg; Department of Clinical Medicine (HC, FF HCC, CK), University of Copenhagen; and Department of Cardiology (FF), Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Hanne Christensen
- Department of Neurology (JW, CK), Copenhagen University Hospital - Herlev and Gentofte; Emergency Medical Services Copenhagen (JW, FF, HCC), Denmark; Emergency Medical Services (SNB), Region Zealand; Department of Neurology (HC), Copenhagen University Hospital - Bispebjerg and Frederiksberg; Department of Clinical Medicine (HC, FF HCC, CK), University of Copenhagen; and Department of Cardiology (FF), Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Fredrik Folke
- Department of Neurology (JW, CK), Copenhagen University Hospital - Herlev and Gentofte; Emergency Medical Services Copenhagen (JW, FF, HCC), Denmark; Emergency Medical Services (SNB), Region Zealand; Department of Neurology (HC), Copenhagen University Hospital - Bispebjerg and Frederiksberg; Department of Clinical Medicine (HC, FF HCC, CK), University of Copenhagen; and Department of Cardiology (FF), Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Helle C Christensen
- Department of Neurology (JW, CK), Copenhagen University Hospital - Herlev and Gentofte; Emergency Medical Services Copenhagen (JW, FF, HCC), Denmark; Emergency Medical Services (SNB), Region Zealand; Department of Neurology (HC), Copenhagen University Hospital - Bispebjerg and Frederiksberg; Department of Clinical Medicine (HC, FF HCC, CK), University of Copenhagen; and Department of Cardiology (FF), Copenhagen University Hospital - Herlev and Gentofte, Denmark
| | - Christina Kruuse
- Department of Neurology (JW, CK), Copenhagen University Hospital - Herlev and Gentofte; Emergency Medical Services Copenhagen (JW, FF, HCC), Denmark; Emergency Medical Services (SNB), Region Zealand; Department of Neurology (HC), Copenhagen University Hospital - Bispebjerg and Frederiksberg; Department of Clinical Medicine (HC, FF HCC, CK), University of Copenhagen; and Department of Cardiology (FF), Copenhagen University Hospital - Herlev and Gentofte, Denmark
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3
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Berg KP, Sørensen VFI, Blomberg SNF, Christensen HC, Kruuse C. Recognition of visual symptoms in stroke: a challenge to patients, bystanders, and Emergency Medical Services. BMC Emerg Med 2023; 23:96. [PMID: 37626329 PMCID: PMC10463357 DOI: 10.1186/s12873-023-00870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Identification of visual symptoms as a sign of acute stroke can be challenging for both first line healthcare professionals and lay persons. Failed recognition of visual symptoms by medical dispatchers at the Emergency Medical Dispatch Center (EMDC-112) or personnel at the Out-of-Hours Health Service (OOHS) may delay stroke revascularization. We aimed to identify correct system response to visual symptoms in emergency calls. METHODS Phone calls from patient or bystander to the EMDC-112 or OOHS, which included visual symptoms on patients later verified with stroke/Transient ischemic attack (TIA) diagnosis, were analyzed. Data were stratified according to hospitalization within and after 4.5 h from symptom onset. Descriptive and multiple logistic regression analysis were performed. RESULTS Of 517 calls identified, 290 calls fulfilled inclusion criteria. Only 30% of the patients received correct visitation by the medical dispatchers and referral to the hospital by a high-priority ambulance. Correct visitation was associated with early contact (adjusted OR: 2.37, 95% CI: 1.11, 5.03), contact to the EMDC-112 (adjusted OR: 3.18, 95% CI: 1.80, 5.62), and when the medical dispatcher asked additional questions on typical stroke symptoms (adjusted OR: 6.36, 95% CI: 3.01, 13.43). No specific visual symptom was associated with stroke recognition and fast hospitalization. CONCLUSIONS First line healthcare professionals had significant problems in identifying visual symptoms as a sign of acute stroke and eliciting correct response. This highlights an urgent need to improve knowledge of visual symptoms in acute stroke and emphasize correct response to stroke symptoms in general.
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Affiliation(s)
- Kristina Parsberg Berg
- Department of Neurology, Copenhagen University Hospital - Herlev Gentofte, Copenhagen, Denmark
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Copenhagen, Denmark
| | - Viktor Frederik Idin Sørensen
- Department of Neurology, Copenhagen University Hospital - Herlev Gentofte, Copenhagen, Denmark
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Copenhagen, Denmark
| | | | - Helle Collatz Christensen
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Copenhagen, Denmark.
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark.
- Emergency Medical Services Region Zealand, Naestved, Denmark.
| | - Christina Kruuse
- Department of Neurology, Copenhagen University Hospital - Herlev Gentofte, Copenhagen, Denmark
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Eddelien HS, Butt JH, Amtoft AC, Nielsen NSK, Jensen ES, Danielsen IMK, Christensen T, Danielsen AK, Hornnes N, Kruuse C. Patient-reported factors associated with early arrival for stroke treatment. Brain Behav 2021; 11:e2225. [PMID: 34087953 PMCID: PMC8413799 DOI: 10.1002/brb3.2225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/29/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Timely evaluation and initiation of treatment is the key for improving stroke outcomes, although minimizing the time from symptom onset to the first contact with healthcare professionals remains a challenge. We aimed to identify patient-related factors associated with early hospital arrival. MATERIALS AND METHODS In this cross-sectional survey, we included patients with stroke or transient ischemic attack admitted directly to one of two noncomprehensive stroke units or transferred to the units from comprehensive stroke centers in the Capital Region of Denmark. Patient-reported factors associated with early hospital arrival were analyzed using multivariable logistic regression analysis adjusted for age, sex, education, living arrangement, brain location of the stroke, stroke severity, patient-perceived symptom severity, history of prior stroke, stroke risk factors, and knowledge of stroke symptoms. RESULTS In total, 479 patients with acute stroke were included (median age 74 (25th-75th percentile, 64-80), 40% women), of whom 46.4% arrived within 180 min of symptom onset. Factors associated with early hospital arrival were patients or bystanders choosing emergency medical service (EMS) for the first contact with a medical professional (adjusted odds ratio (OR), 3.41; 95% confidence interval, CI [1.57, 7.35]) or the patient's perceived symptom severity above the median score of 25 on a 100-point verbal scale (adjusted OR, 2.44; 95% CI [1.57, 3.82]). Living alone reduced the likelihood of early arrival (adjusted OR, 0.53; 95% CI [0.33, 0.86]). CONCLUSIONS Only when patients perceived symptoms as severe or when EMS was selected as the first contact, early arrival for stroke treatment was ensured.
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Affiliation(s)
- Heidi S Eddelien
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jawad H Butt
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - André C Amtoft
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nicholine S K Nielsen
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Emilie S Jensen
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ida M K Danielsen
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Christensen
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurology, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anne K Danielsen
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Gastroenterology, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nete Hornnes
- Department of Neurology, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Kruuse
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Nguyen TTM, Kruyt ND, Pierik JGJ, Doggen CJM, van der Lugt P, Ramessersing SAV, Wijers NT, Brouwers PJAM, Wermer MJH, den Hertog HM. Stroke patient's alarm choice: General practitioner or emergency medical services. Acta Neurol Scand 2021; 143:164-170. [PMID: 32885417 PMCID: PMC7821309 DOI: 10.1111/ane.13341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/12/2020] [Accepted: 08/25/2020] [Indexed: 11/28/2022]
Abstract
Objectives Stroke patients should be treated as soon as possible since the benefit of reperfusion therapies is highly time‐dependent. The proportion of patients eligible for reperfusion therapy is still limited, as many patients do not immediately alarm healthcare providers. The choice of healthcare system entrance influences the time of arrival in the hospital. Therefore, we assessed differences in these choices to obtain insight for strategies to reduce time delays in acute stroke patients. Materials and Methods Patients with suspected acute stroke admitted to the participating hospitals received a questionnaire. We assessed differences between patients who initially alarmed the general practitioner (GP) and patients who directly alarmed the emergency medical services (EMS). Additionally, we assessed regional differences and patient trajectories after medical help was sought. Results We included 163 patients. Most patients alarmed the GP as primary healthcare provider (n = 104; 64%), and median onset‐to‐door times were longer in these patients (466 minutes [IQR 149–1586]) compared to patients directly alarming the EMS (n = 59; 36%) (90 minutes [IQR 45–286]). This was even more pronounced in less densely populated areas. Patients who alarmed the GP first, more often had patient delay >15 minutes, hesitated to burden healthcare providers and underestimated symptomatology. Conclusions Our results showed that patients who alarmed the GP first instead of the EMS differed in several factors that are potentially modifiable. Strategies to achieve reduction of vital prehospital time delays and to improve patient outcome are optimizing public awareness campaigns and GP triage along with adjusting current guidelines by enabling and focusing on immediate involvement of the EMS once acute stroke is suspected.
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Affiliation(s)
- T. Truc My Nguyen
- Department of Neurology Leiden University Medical Centre Leiden The Netherlands
| | - Nyika D. Kruyt
- Department of Neurology Leiden University Medical Centre Leiden The Netherlands
| | - Jorien G. J. Pierik
- Department of Transmural Care Medisch Spectrum Twente Enschede The Netherlands
| | - Carine J. M. Doggen
- Department of Health Technology & Services Research and Faculty of Behavioral, Management and Social Sciences Technical Medical Centre Enschede the Netherlands
- Department of Science Rijnstate Arnhem Arnhem The Netherlands
| | | | | | - Naomi T. Wijers
- Department of Neurology Leiden University Medical Centre Leiden The Netherlands
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Knowledge on Signs and Risk Factors in Stroke Patients. J Clin Med 2020; 9:jcm9082557. [PMID: 32784554 PMCID: PMC7463706 DOI: 10.3390/jcm9082557] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/26/2020] [Accepted: 08/05/2020] [Indexed: 12/20/2022] Open
Abstract
Background: There is a pressing need to contribute evidence to the improvement in the early identification of signs and symptoms associated with strokes, and address the treatment-seeking delays. The objective of this study is to describe the knowledge regarding the warning signs and risk factors (RFs) among stroke patients, as well as of their attitudes toward a suspected event, and the analysis of its possible relationship with the socio-demographic and clinical characteristics of these patients. Method: A cross-sectional study was designed, in which all stroke patients admitted consecutively to the Burgos University Hospital (Spain) were included. The principal outcomes were the patient’s ability to identify two RFs and two warning signs and the patient’s hypothetical response to a possible stroke event. The possible factors associated with the knowledge of warning signs, RFs, and the correct response to a new event were studied using univariate and multivariate regression analysis. Results: A total of 529 patients were included. Having a higher education level or a history of prior stroke were associated with a greater degree of knowledge of warning signs (odds ratio (OR) 3.19, 95% confidence interval (CI) 1.70–5.74, p = 0.003; OR 3.54, 95%CI 2.09–5.99, p ≤ 0.001, respectively), RFs (OR 3.15, 95%CI 1.75–5.67, p = 0.008; OR 4.08, 95%CI 2.41–6.91, p = 0.002, respectively), and the correct response to a possible stroke (OR 1.82, 95%CI 1.16–2.86; p = 0.030; OR 2.11, 95%CI 1.29–3.46, p = 0.022, respectively). Conclusion: Knowledge of warning signs or stroke RFs is low in the hospitalized patients. A previous stroke or secondary/higher education levels are the predictor factors that increase the probability of knowledge of warning signs, RFs, or reaction to possible event.
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Falkenberg HK, Mathisen TS, Ormstad H, Eilertsen G. "Invisible" visual impairments. A qualitative study of stroke survivors` experience of vision symptoms, health services and impact of visual impairments. BMC Health Serv Res 2020; 20:302. [PMID: 32293430 PMCID: PMC7158142 DOI: 10.1186/s12913-020-05176-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Visual impairments (VIs) have a negative impact on life and affect up to 60% of stroke survivors. Despite this, VIs are often overlooked. This paper explores how persons with VIs experience vision care within stroke health services and how VIs impact everyday life the first 3 months post stroke. METHODS Individual semi-structured interviews were conducted with 10 stroke survivors 3 months post stroke, and analyzed using qualitative content analysis. RESULTS The main theme, "Invisible" visual impairments, represents how participants experience VIs as an unknown and difficult symptom of stroke and that the lack of attention and appropriate visual care leads to uncertainty about the future. VIs were highlighted as a main factor hindering the participants living life as before. The lack of acknowledgement, information, and systematic vision rehabilitation leads to feelings of being unsupported in the process of coping with VIs. CONCLUSION VIs are unknown symptoms pre stroke and sequelas after stroke that significantly affect everyday life. VIs and vision rehabilitation needs more attention through all phases of stroke health services. We request a greater awareness of VIs as a presenting symptom of stroke, and that visual symptoms should be included in stroke awareness campaigns. Further, we suggest increased competence and standardized evidence-based clinical pathways for VIs to advance all stroke health services including rehabilitation in order to improve outcomes and adaptation to future life for stroke survivors with VIs.
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Affiliation(s)
- Helle K Falkenberg
- National Centre for Optics, Vision and Eye Care, Faculty of Health and Social Sciences, University of South-Eastern Norway, Hasbergs vei 36, 3616, Kongsberg, Norway. .,USN Research Group of Older Peoples` Health, University of South-Eastern Norway, Drammen, Norway.
| | - Torgeir S Mathisen
- National Centre for Optics, Vision and Eye Care, Faculty of Health and Social Sciences, University of South-Eastern Norway, Hasbergs vei 36, 3616, Kongsberg, Norway.,USN Research Group of Older Peoples` Health, University of South-Eastern Norway, Drammen, Norway
| | - Heidi Ormstad
- Department of Nursing and Health Science, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Grethe Eilertsen
- USN Research Group of Older Peoples` Health, University of South-Eastern Norway, Drammen, Norway.,Department of Nursing and Health Science, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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Søvsø MB, Huibers L, Bech BH, Christensen HC, Christensen MB, Christensen EF. Acute care pathways for patients calling the out-of-hours services. BMC Health Serv Res 2020; 20:146. [PMID: 32106846 PMCID: PMC7045402 DOI: 10.1186/s12913-020-4994-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In Western countries, patients with acute illness or injury out-of-hours (OOH) can call either emergency medical services (EMS) for emergencies or primary care services (OOH-PC) in less urgent situations. Callers initially choose which service to contact; whether this choice reflect the intended differences in urgency and severity is unknown. Hospital diagnoses and admission rates following an OOH service contact could elucidate this. We aimed to investigate and compare the prevalence of patient contacts, subsequent hospital contacts, and the age-related pattern of hospital diagnoses following an out-of-hours contact to EMS or OOH-PC services in Denmark. METHODS Population-based observational cohort study including patients from two Danish regions with contact to EMS or OOH-PC in 2016. Hospital contacts were defined as short (< 24 h) or admissions (≥24 h) on the date of OOH service contact. Both regions have EMS, whereas the North Denmark Region has a general practitioner cooperative (GPC) as OOH-PC service and the Capital Region of Copenhagen the Medical Helpline 1813 (MH-1813), together representing all Danish OOH service types. Calling an OOH service is mandatory prior to a hospital contact outside office hours. RESULTS OOH-PC handled 91% (1,107,297) of all contacts (1,219,963). Subsequent hospital contacts were most frequent for EMS contacts (46-54%) followed by MH-1813 (41%) and GPC contacts (9%). EMS had more admissions (52-56%) than OOH-PC. For both EMS and OOH-PC, short hospital contacts often concerned injuries (32-63%) and non-specific diagnoses (20-45%). The proportion of circulatory disease was almost twice as large following EMS (13-17%) compared to OOH-PC (7-9%) in admitted patients, whereas respiratory diseases (11-14%), injuries (15-22%) and non-specific symptoms (22-29%) were more equally distributed. Generally, admitted patients were older. CONCLUSIONS EMS contacts were fewer, but with a higher percentage of hospital contacts, admissions and prevalence of circulatory diseases compared to OOH-PC, perhaps indicating that patients more often contact EMS in case of severe disease. However, hospital diagnoses only elucidate severity of diseases to some extent, and other measures of severity could be considered in future studies. Moreover, the socio-demographic pattern of patients calling OOH needs exploration as this may play an important role in choice of entrance.
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Affiliation(s)
- Morten Breinholt Søvsø
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
| | | | | | - Erika Frischknecht Christensen
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
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Søvsø MB, Christensen MB, Bech BH, Christensen HC, Christensen EF, Huibers L. Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes. BMC Health Serv Res 2019; 19:813. [PMID: 31699103 PMCID: PMC6839230 DOI: 10.1186/s12913-019-4674-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Out-of-hours (OOH) healthcare services in Western countries are often differentiated into out-of-hours primary healthcare services (OOH-PC) and emergency medical services (EMS). Call waiting time, triage model and intended aims differ between these services. Consequently, the care pathway and outcome could vary based on the choice of entrance to the healthcare system. We aimed to investigate patient pathways and 1- and 1-30-day mortality, intensive care unit (ICU) stay and length of hospital stay for patients with acute myocardial infarction (AMI), stroke and sepsis in relation to the OOH service that was contacted prior to the hospital contact. METHODS Population-based observational cohort study during 2016 including adult patients from two Danish regions with an OOH service contact on the date of hospital contact. Patients <18 years were excluded. Data was retrieved from OOH service databases and national registries, linked by a unique personal identification number. Crude and adjusted logistic regression analyses were performed to assess mortality in relation to contacted OOH service with OOH-PC as the reference and cox regression analysis to assess risk of ICU stay. RESULTS We included 6826 patients. AMI and stroke patients more often contacted EMS (52.1 and 54.1%), whereas sepsis patients predominately called OOH-PC (66.9%). Less than 10% (all diagnoses) of patients contacted both OOH-PC & EMS. Stroke patients with EMS or OOH-PC & EMS contacts had higher likelihood of 1- and 1-30-day mortality, in particular 1-day (EMS: OR = 5.33, 95% CI: 2.82-10.08; OOH-PC & EMS: OR = 3.09, 95% CI: 1.06-9.01). Sepsis patients with EMS or OOH-PC & EMS contacts also had higher likelihood of 1-day mortality (EMS: OR = 2.22, 95% CI: 1.40-3.51; OOH-PC & EMS: OR = 2.86, 95% CI: 1.56-5.23) and 1-30-day mortality. Risk of ICU stay was only significantly higher for stroke patients contacting EMS (EMS: HR = 2.38, 95% CI: 1.51-3.75). Stroke and sepsis patients with EMS contact had longer hospital stays. CONCLUSIONS More patients contacted OOH-PC than EMS. Sepsis and stroke patients contacting EMS solely or OOH-PC & EMS had higher likelihood of 1- and 1-30-day mortality during the subsequent hospital contact. Our results suggest that patients contacting EMS are more severely ill, however OOH-PC is still often used for time-critical conditions.
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Affiliation(s)
- Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | | | - Bodil Hammer Bech
- Department of Public Health, Research Unit of Epidemiology, Aarhus University, Aarhus, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
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Blinkenberg J, Pahlavanyali S, Hetlevik Ø, Sandvik H, Hunskaar S. General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study. BMC Health Serv Res 2019; 19:568. [PMID: 31412931 PMCID: PMC6693245 DOI: 10.1186/s12913-019-4419-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/09/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Primary care doctors have a gatekeeper function in many healthcare systems, and strategies to reduce emergency hospital admissions often focus on general practitioners' (GPs') and out-of-hours (OOH) doctors' role. The aim of the present study was to investigate these doctors' role in emergency admissions to somatic hospitals in the Norwegian public healthcare system, where GPs and OOH doctors have a distinct gatekeeper function. METHODS A cross-sectional analysis was performed by linking data from the Norwegian Patient Registry (NPR) and the physicians' claims database. The referring doctor was defined as the physician who had sent a claim for a consultation with the patient within 24 h prior to an emergency admission. If there was no claim registered prior to hospital arrival, the admission was defined as direct, representing admissions from ambulance services, referrals from nursing home doctors, and admissions initiated by in-hospital doctors. RESULTS In 2014 there were 497,845 emergency admissions to somatic hospitals in Norway after excluding birth related conditions. Referrals by OOH doctors were most frequent (36%), 35% were direct admissions, 28% were referred by GPs, whereas only 2% were referred from outpatient clinics or private specialists with public contract. Direct admissions were more common in central areas (45%), here GPs’ referrals constituted only 18%. The prehospital paths varied with the hospital discharge diagnosis. For anaemias, 52–56% were referred by GPs, for acute appendicitis and mental/alcohol related disorders 57% and 56% were referred by OOH doctors, respectively. For malignant neoplasms 56% and cardiac arrest 57% were direct admissions. CONCLUSIONS GPs or OOH doctors referred many emergencies to somatic hospitals, and for some clinical conditions GPs' and OOH doctors' gatekeeping role was substantial. However, a significant proportion of the emergency admissions was direct, and this reduces the impact of the GPs' and OOH doctors' gatekeeper roles, even in a strict gatekeeping system.
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Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018 Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
| | - Sahar Pahlavanyali
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018 Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018 Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018 Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
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Harpaz D, Eltzov E, Seet RCS, Marks RS, Tok AIY. Point-of-Care-Testing in Acute Stroke Management: An Unmet Need Ripe for Technological Harvest. BIOSENSORS 2017; 7:E30. [PMID: 28771209 PMCID: PMC5618036 DOI: 10.3390/bios7030030] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 12/20/2022]
Abstract
Stroke, the second highest leading cause of death, is caused by an abrupt interruption of blood to the brain. Supply of blood needs to be promptly restored to salvage brain tissues from irreversible neuronal death. Existing assessment of stroke patients is based largely on detailed clinical evaluation that is complemented by neuroimaging methods. However, emerging data point to the potential use of blood-derived biomarkers in aiding clinical decision-making especially in the diagnosis of ischemic stroke, triaging patients for acute reperfusion therapies, and in informing stroke mechanisms and prognosis. The demand for newer techniques to deliver individualized information on-site for incorporation into a time-sensitive work-flow has become greater. In this review, we examine the roles of a portable and easy to use point-of-care-test (POCT) in shortening the time-to-treatment, classifying stroke subtypes and improving patient's outcome. We first examine the conventional stroke management workflow, then highlight situations where a bedside biomarker assessment might aid clinical decision-making. A novel stroke POCT approach is presented, which combines the use of quantitative and multiplex POCT platforms for the detection of specific stroke biomarkers, as well as data-mining tools to drive analytical processes. Further work is needed in the development of POCTs to fulfill an unmet need in acute stroke management.
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Affiliation(s)
- Dorin Harpaz
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
| | - Evgeni Eltzov
- Agriculture Research Organization (ARO), Volcani Centre, Rishon LeTsiyon 15159, Israel.
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Robert S Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
| | - Alfred I Y Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
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