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BACKGROUND Video played an important role in health communication throughout the COVID-19 pandemic. It was used to communicate pandemic information to the public, with a variety of formats, presenters, and topics. Evidence regarding the effectiveness of video features is available, while how individual characteristics of recipients influence communication comprehension is still limited. OBJECTIVE The aim of this study was to test six individual characteristics and assess their effect on the comprehension of pandemic video communication. METHODS Short health communication videos were presented to a large sample of subjects, receiving questionnaire-responses from 1194 participant. Individual characteristics consisted of age, sex, living area, education level, income level, and belief in science. Communication comprehension consisted of both perceived and objective comprehension. The data was analyzed by multiple linear regression. RESULTS Age had a negative effect on both perceived and objective comprehension – increasing age is associated with lower comprehension. There were sex differences with higher perceived comprehension among women than men, while lower objective comprehension among women compared to men. Living in an urban or a rural area had no significant effect. The level of education and income had a positive effect on both subjective and objective comprehension. Finally, the belief in science had a positive effect on perceived comprehension, while no statistically significant effect on objective comprehension. CONCLUSIONS The main differences between those who think they understand pandemic communication and those who comprehend it better are gender (women have a higher perception of having comprehended, while men have higher levels of objective comprehension) and belief in science (higher belief in science leads to higher perceived comprehension, while it does not have any impact on objectively understanding the message conveyed).

Not all data sets have explanatory variables and outcomes. The data may nevertheless contain associations that are worth revealing.

ObjectivesThe objective for this systematic review was to examine how the record linkage process was reported and to understand challenges related to accessing, linking, and analysing linked routinely collected data used for multimorbidity research. ApproachA systematic search for relevant studies was conducted in three online databases (Medline, Web of Science and Embase) in May 2021 using predefined search terms, and inclusion and exclusion criteria. Studies using linked routinely collected data for multimorbidity research were included. Information was extracted on how the linkage process was reported, which conditions were studied together, which data sources were used, as well as challenges encountered during the linkage process or with the linked dataset. The findings from this study will feed into further guidance to understand and minimise bias due to linkage error in medical research. ResultsTwenty studies were included, of which seventeen looked at the relationship between two specified long-term conditions. Fourteen studies received the linked dataset from an external data linkage provider. Hospital Episode Statistics was the most common source of data (n=5). Eight studies reported variables used for the data linkage, while only two studies reported pre-linkage checks. The quality of the linkage was assessed by three studies, of which two reported linkage rate and one reported raw linkage figures. Only one study checked for bias by comparing patient characteristics of linked and non-linked records. ConclusionsThe linkage process was poorly reported in multimorbidity research, even though this might introduce bias and potentially lead to inaccurate inferences drawn from the results. There is therefore a need for increased awareness of linkage bias and transparency of the linkage processes, which could be achieved through better adherence to reporting guidelines.

Background: Datasets from multi-sources that routinely collect healthcare information such as patient medical records, admissions and disease registries are increasingly used for medical research. In some cases, multiple sources are combined using data linkage techniques to create comprehensive datasets. The patient records are linked on an individual level using available person level identifiers. Errors in this process can introduce bias of unknown size and direction. the objective of this systematic review was to examine how the record linkage process was reported and to understand challenges related to accessing, linking, and analysing linked routinely collected data. Methods: A systematic search for relevant studies was conducted in three online databases (Medline, Web of Science and Embase) in May 2021 using predefined search terms, and inclusion and exclusion criteria. All published studies using linked routinely collected data for multimorbidity research were included. Information was extracted on how the linkage process was reported, which conditions were studied together, which data sources were used, as well as challenges encountered during the linkage process or with the linked dataset. Results: Twenty studies were included, of which seventeen investigated at the relationship between two specified long-term conditions. Fourteen studies received the linked dataset from a trusted third party. Hospital Episode Statistics was the most common source of data (n = 5). Eight studies reported variables used for the data linkage, while only two studies reported pre-linkage checks. The quality of the linkage was assessed only by three studies, of which two reported linkage rate and one reported raw linkage figures. Only one study checked for bias by comparing patient characteristics of linked and non-linked records. Conclusions: The linkage process was poorly reported in multimorbidity research, even though this might introduce bias and potentially lead to inaccurate inferences drawn from the results. There is therefore a need for increased awareness of linkage bias and transparency of the linkage processes, which could be achieved through better adherence to reporting guidelines.

BACKGROUND Time spent in the prehospital phase of acute stroke care is multifactorial and have an effect on possibilities for acute treatment. Communication between paramedics and the in-hospital stroke team directly affects time to treatment. A mutual stroke scale like National Institutes of Health Stroke Scale (NIHSS) may improve communication quality. The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped wedge randomised trial of stroke screening using NIHSS in the ambulance where the intervention was training paramedics in stroke and NIHSS, use of NIHSS made into a mobile application guiding the examination and facilitating communication with the in-hospital stroke team. OBJECTIVE The aim of this study was to validate the digital training model from the ParaNASPP clinical trial. METHODS Twenty-four paramedics were recruited from Oslo University Hospital (OUS) in Norway, completing the ParaNASPP training model. Twenty exclusive videos with pre-defined NIHSS scores were recorded. Four stroke physicians from OUS were included for reference. Bland Altman plots with 95% Limits of Agreement (LoA) were calculated comparing first paramedics and stroke physicians to the pre-defined scores, and then with each other. A pre-defined LoA was set to +/-3 points. To align with clinical practice NIHSS scores were also dichotomized into 0-5 (minor stroke) or ≥6 (moderate and major stroke), and agreement calculated using Cohen’s Kappa. RESULTS The videos (n=20) had a median (range) NIHSS score 7 (0-31). The paramedics’ scores were slightly higher than the pre-defined scores with a mean difference of -0.38 and LoA ranged from -4.04 to 3.29. The paramedics scored higher than the stroke physicians with a mean difference of -0.39, with LoA ranging from -4.58 to 3.80. Dichotomizing, Cohen’s Kappa was 0.89 between pre-defined scores and paramedics, 0.92 between pre-defined scores and stroke physicians, and 0.81 between paramedics and stroke physicians, all indicating very good agreement. CONCLUSIONS The standardized digital training model used in the ParaNASPP clinical trial seems to result in very good agreement in NIHSS scoring between paramedics and both pre-defined scores and stroke physician scores. This study also demonstrates possibilities for transfer of clinical competence in digital simulation training. CLINICALTRIAL N/A

Background Science communication can provide people with more accurate information on pandemic health risks by translating complex scientific topics into language that helps people make more informed choices on how to protect themselves and others. During pandemics, experts in medicine, science, public health, and communication are important sources of knowledge for science communication. This study uses the COVID-19 pandemic to explore these experts’ opinions and knowledge of what to communicate to the public during a pandemic. The research question is: What are the key topics to communicate to the public about health risks during a pandemic? Method We purposively sampled 13 experts in medicine, science, public health, and communication for individual interviews, with a range of different types of knowledge of COVID-19 risk and communication at the national, regional and hospital levels in Norway. The interview transcripts were coded and analysed inductively in a qualitative thematic analysis. Results The study’s findings emphasise three central topics pertaining to communication about pandemic health risk during the first year of the COVID-19 pandemic in Norway: 1) how the virus enters the human body and generates disease; 2) how to protect oneself and others from being infected; and 3) pandemic health risk for the individual and the society. Conclusion The key topics emerging from the expert interviews relate to concepts originating from multiple disciplinary fields, and can inform frameworks for interprofessional communication about health risks during a pandemic. The study highlights the complexity of communicating pandemic messages, due to scientific uncertainty, fear of risk amplification, and heterogeneity in public health and scientific literacy. The study contributes with insight into the complex communication processes of pandemic health risk communication.

Pandemic video communication aimed at the general public often lacks creativity and fails to reach large audiences. Yet, the scientific content should not be compromised by attempts to improve the creativity or reach. This study explores the processes utilised by various health experts and professional communicators when creating communication, to identify similarities and differences, and how pandemic video communication thus can be improved through an interdisciplinary approach. We interviewed 12 individuals from 6 different professional domains: health, public health, film/science communication, video journalism, advertising, and social media/YouTube. Semi-structured individual interviews were conducted using the same interview guide. The interview data were subjected to thematic analysis with both deductive and inductive coding, and the results were visualised in a bubble chart. Our study has highlighted both similarities and differences between health professionals and creative communicators relating to their creative processes and their approaches to pandemic video communication. We found that participants from health domains assigned great importance to and efforts on the content, but were unsure or lacked experience in how content is translated through form and creativity. Creative communicators, on the other hand, emphasise and specialise in form, yet depend on health professionals, experts, and scientists to provide and validate content. The key to improving pandemic-related video communication appears to lie in striking the right balance between high-quality and evidence-based content and creativity. This study found that both health professionals and creative communicators play crucial roles in reaching a solid end result, and we suggest a fusion model approach to interdisciplinary collaboration.

Background Humans struggle to grasp the extent of exponential growth, which is essential to comprehend the spread of an infectious disease. Exponential growth bias is the tendency to linearize exponential functions when assessing them intuitively. Effective public health communication about the nonlinear nature of infectious diseases has strong implications for the public’s compliance with strict restrictions. However, there is a lack of synthesized knowledge on the communication of the exponential growth of infectious diseases and on the outcomes of exponential growth bias. Objective This systematic review identifies, evaluates, and synthesizes the findings of empirical studies on exponential growth bias of infectious diseases. Methods A systematic review will be conducted using the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 statement. Eligibility criteria include empirical studies of exponential growth bias of infectious diseases regardless of methodology. We include studies both with and without interventions/strategies. For information sources, we include the following five bibliographic databases: MEDLINE, Embase, Cochrane Library, PsychINFO, and Web of Science Core Collection. The risk of bias will be assessed using RoB 2 (Risk of Bias 2) and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Data synthesis will be achieved through a narrative synthesis. Results By February 2022, we included 11 experimental studies and 1 cross-sectional survey study. Preliminary themes identified are the presence of exponential growth bias, the effect of exponential growth bias, and communication strategies to mitigate exponential growth bias. Data extraction, narrative synthesis, and the risk of bias assessment are to be completed by February 2023. Conclusions We anticipate that this systematic review will draw some lines related to how people comprehend and misperceive exponential growth and its consequences for infectious disease mitigation and communication. Furthermore, the study will conclude with the limitations of the research and suggestions for future research. International Registered Report Identifier (IRRID) DERR1-10.2196/37441

BACKGROUND Humans have fundamental difficulties to grasp the extent of exponential growth, which is fundamental to grasp the extent of a spreading infectious disease. Exponential growth bias is the pervasive tendency to linearize exponential functions when assessing them intuitively. OBJECTIVE This systematic review aims to identify, evaluate and synthesise the findings of empirical studies concerning exponential growth bias of infectious diseases METHODS A systematic review will be conducted using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Risk of bias will be assessed using ROBINS-2 and STROBE. Data synthesis will be achieved through a narrative synthesis RESULTS As of February 2022, we included 11 studies, see PRISMA flow diagram, figure 1. This comprises 10 quasi-experimental studies and one cross sectional survey study. Preliminary themes identified are: The presence and effect of EGB of infectious diseases, visual and educational strategies to mitigate EGB of infectious diseases. Data extraction, narrative synthesis and risk of bias assessment will be expected to be due June 2022. CONCLUSIONS This systematic review concludes on limitation of the research and drawing some lines related to how people comprehend and misperceive exponential growth and its’ consequences for mitigating infectious diseases. Furthermore, the study will give recommendations for communication of exponential growth of infectious diseases and suggestion for future research.

BackgroundPrehospital delay contributes to treatment delay in acute stroke. Numerous prehospital stroke scales exist for stroke identification, but they lack the diagnostic accuracy of the in-hospital National Institutes of Health Stroke Scale (NIHSS). We have developed a mobile application to aid paramedics assessing prehospital NIHSS. This study explores agreement between NIHSS scores obtained using the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) application compared with conventional assessment.Methods25 physicians working with stroke were randomised to an application group or control. 20 unique videos portraying acute stroke symptoms were scored by both groups. 95% limits of agreement (LoA) were calculated using Bland-Altman’s method, comparing the groups to predefined scores, and each other. LoAs within ±3 NIHSS points were considered acceptable. Cohen’s kappa was calculated on dichotomised NIHSS scores.ResultsThe ParaNASPP application group had 95% LoA of −2.33 to 2.71. The control group had LoA of −2.60 to 2.55. Direct comparison between the groups gave LoA of −3.12 to 3.55. When compared with the dichotomised predefined scores kappa was 0.93 in the application group and 0.89 in the control group. Kappa was 0.84 for direct comparison between the groups.DiscussionThere was very good agreement between the application and both the predefined score and the control group. Scores from the ParaNASPP application differ slightly more than our predefined goal when compared with the control group, but is well within when compared with the predefined NIHSS scores. We consider this acceptable and the ParaNASPP application validated for further clinical studies.

Introduction Optimal dispatch of emergency medical services relies on accurate time estimates of the various prehospital stages. Hoist rescue work time intervals performed by the search and rescue (SAR) helicopter service in Norway have not been studied to date. We aimed to describe the epidemiologic, operational, and medical aspects of the SAR service in southeast Norway. To complement the prehospital timeline, we performed simulated hoist operations. Methods We reviewed time and patient descriptors and medical interventions in hoist operations performed at a SAR base over 5 y. In addition, a simulation study measuring hoist rescue time intervals was performed. Data are presented as mean ± SD, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as modes. Results There were 148 hoist operations performed during the study period, involving 180 patients. Time to take-off was 13 ± 7 min. There were 88 patients (49%) who were injured; 53 (29%) had a medical condition, and 39 (22%) were evacuees. The mode of the NACA score was 3. Forty-five patients (25%) had an NACA score of 4 to 6. Medical interventions were performed on 77 patients (43%) in 73 operations (49%). Nine patients (5%) were endotracheally intubated, and 1 thoracostomy was performed. The simulated rescuer access time was 4 ± 2 min, the simulated anesthesiologist access time was 6 ± 2 min, and the simulated hoist extrication time was 13 ± 2 min. Conclusions Hoist rescue was performed in 10% (n=148) of the SAR operations. New information about hoist extrication time intervals can improve rescue helicopter dispatch accuracy.

Incivility has been identified as a prevalent and crucial issue in workplaces and one that may be associated with detrimental effects on employees and organizational outcomes, such as turnover intention. Many studies have been published regarding the effects of incivility, but there is a lack of integrative reviews and meta-analyses. The aim of the present study is to conduct an early meta-analysis of the relationship between employees’ perceptions of workplace incivility and their turnover intentions. Six databases, including ISI Web of Science, PsychInfo, Scopus, Emerald, Hospitality & Tourism Complete, and Soc Index, were searched to identify empirical articles for this meta-analytical paper. The results of statistical meta-analyses and meta-regression suggest that there is a positive relationship between perceived incivility and turnover intentions in employees and that relationship is consistent across different sources of workplace incivility. However, we did observe a possible interaction effect of “supervisor” and “coworker incivility”. The results also suggest that the relationship between workplace incivility and turnover intention is stronger in the academic sector than in other industries and stronger in the United States than in other countries.

BackgroundA worldwide pandemic of a new and unknown virus is characterised by scientific uncertainty. Yet, health authorities still need to communicate complex health risk information to the public – despite this uncertainty. The mental models approach to risk communication describes how people perceive and make decisions regarding complex risks, with the aim of identifying decision-relevant information that can be targeted in risk communication interventions. This study used COVID-19 as a case to explore how people make sense of scientific information and apply it to their lives and behaviour using the concept of mental models.MethodsThis qualitative study included 15 male and female participants of different ages and from different geographical regions in Norway, occupational areas and with different education levels. The participants were interviewed individually, and the interview data analysed via directed content analysis, with predetermined themes and codes derived the Norwegian Institute of Public Health’s official website. Materials in the interview data not represented by deductive codes were coded inductively. The participants’ perceptions and behaviours related to health risk information were analysed across three themes: virus transmission, exposure to risk and consequences of COVID-19. ResultsThe results imply that people put different meanings to the medical and scientific words used by experts to explain the pandemic, e.g. virus transmission and the reproduction number. And while some people expressed the need to comprehend why certain behavior and activities involve a high risk, others preferred simple, clear messages focusing on what to do and how to protect themselves. Similarly, information about health consequences caused panic for some and awareness for others. ConclusionThere is no one-size fits all to public health risk communication, and empowering people with decision-relevant information necessitates targeted and balanced risk communication.

BACKGROUND The nonlinear nature of contagious diseases and the potential for exponential growth can be difficult to grasp for the general public. This has strong implications for public health communication, which needs to be both easily accessible and efficient. A pandemic is an extreme situation, and the accompanying strict societal measures are generally easier to accept if one understands the underlying reasoning behind them. Bringing about informed attitude change and achieving compliance to strict restrictions requires explanations of scientific concepts and terminologies that laypersons can understand. OBJECTIVE The aim of the project is to develop effective, evidence-based modes of video communication for translating complex, but important, health messages about pandemics to both the general population and decision makers. The study uses COVID-19 as a case to learn and prepare society for handling the ongoing and future pandemics, as well as to provide evidence-based tools for the science communication toolbox. METHODS The project applies a mixed methods design, combining qualitative methods (eg, interviews, observational studies, literature reviews) and quantitative methods (eg, randomized controlled trials [RCTs]). The project brings together researchers from a wide range of academic fields, as well as communication industry professionals. RESULTS This study has received funding from the Trond Mohn Foundation through the Research Council of Norway’s “COVID-19 Emergency Call for Proposals” March 2020. Recruitment and data collection for the exploratory first phase of the project ran from February 2021 to March 2021. Creative communication work started in May 2021, and the production of videos for use in the RCTs in the final phase of the project started in September 2021. CONCLUSIONS The COVCOM project will take on several grand challenges within the field of communicating science and provide evidence-based tools to the science communication toolbox. A long-term goal of the project is to contribute to the creation of a more resilient health care system by developing communication responses tailormade for different audiences, preparing society for any future pandemic. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/34275

Background A worldwide pandemic of a new and unknown virus is characterised by scientific uncertainty. However, despite this uncertainty, health authorities must still communicate complex health risk information to the public. The mental models approach to risk communication describes how people perceive and make decisions about complex risks, with the aim of identifying decision-relevant information that can be incorporated into risk communication interventions. This study explored how people use mental models to make sense of scientific information and apply it to their lives and behaviour in the context of COVID-19. Methods This qualitative study enrolled 15 male and female participants of different ages, with different levels of education and occupational backgrounds and from different geographical regions of Norway. The participants were interviewed individually, and the interview data were subjected to thematic analysis. The interview data were compared to a expert model of COVID-19 health risk communication based on online information from the Norwegian Institute of Public Health. Materials in the interview data not represented by expert model codes were coded inductively. The participants’ perceptions of and behaviours related to health risk information were analysed across three themes: virus transmission, risk mitigation and consequences of COVID-19. Results The results indicate that people placed different meanings on the medical and scientific words used by experts to explain the pandemic (e.g., virus transmission and the reproduction number). While some people wanted to understand why certain behaviour and activities were considered high risk, others preferred simple, clear messages explaining what to do and how to protect themselves. Similarly, information about health consequences produced panic in some interviewees and awareness in others. Conclusion There is no one-size-fits-all approach to public health risk communication. Empowering people with decision-relevant information necessitates targeted and balanced risk communication.

Background Time spent in the prehospital phase of acute stroke care is multifactorial and has an effect on the possibilities for acute treatment. Communication between paramedics and the in-hospital stroke team directly affects time to treatment. A mutual stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) may improve communication quality. The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped-wedge, randomized trial of stroke screening using NIHSS in the ambulance where the intervention was training paramedics in stroke and the NIHSS, with the use of NIHSS made into a mobile app to guide the examination and facilitate communication with the in-hospital stroke team. Objective The aim of this study was to validate the digital training model from the ParaNASPP clinical trial. Methods In total, 24 paramedics were recruited from Oslo University Hospital in Norway to complete the ParaNASPP training model; 20 exclusive videos with predefined NIHSS scores were recorded; and 4 stroke physicians from Oslo University Hospital were included for reference. Bland-Altman plots with 95% limits of agreement (LoA) were calculated—first comparing paramedics and stroke physicians to the predefined scores and then with each other. The predefined LoA were set to 3 points. To align with clinical practice, NIHSS scores were also dichotomized into 2 categories: from 0-5 (minor stroke) or ≥6 (moderate and major stroke), and agreement was calculated using Cohen κ. Results The videos (n=20) had a median (range) NIHSS score of 7 (0-31). The paramedics’ scores were slightly higher than the predefined scores with a mean difference of –0.38 and the LoA ranging from –4.04 to 3.29. The paramedics scored higher than the stroke physicians with a mean difference of –0.39, with the LoA ranging from –4.58 to 3.80. When the NIHSS scores were dichotomized, Cohen κ was 0.89 between the predefined scores and paramedics, 0.92 between the predefined scores and stroke physicians, and 0.81 between the paramedics and stroke physicians, all indicating very good agreement. Conclusions The paramedics scored higher than both the predefined scores and stroke physicians’ scores, hence the predefined LoA were not met. However, the width of the LoA was smaller than seen when experienced neurologists are compared. When the NIHSS scores were dichotomized, the paramedics achieved very good agreement with both the predefined scores and stroke physicians’ scores. This study demonstrates the possibilities for the transfer of clinical competence in digital simulation training.

Background Responses from the H1N1 swine flu pandemic and the recent COVID-19 coronavirus pandemic provide an opportunity for insight into the role of health authorities’ ways of communicating health risk information to the public. We aimed to synthesise the existing evidence regarding different modes of communication used by health authorities in health risk communication with the public during a pandemic. Methods We conducted a rapid scoping review. MEDLINE and EMBASE were searched for publications in English from January 2009 through October 2020, covering both the full H1N1 pandemic and the response phase during the COVID-19 pandemic. The search resulted in 1440 records, of which 48 studies met our eligibility criteria. Results The present review identified studies across a broad interdisciplinary field of health risk communication. The majority focused on the H1N1 pandemic and the COVID-19 pandemic. A content analysis of the studies identified three categories for modes of communication: i) communication channels, ii) source credibility and iii) how the message is communicated. The identified studies on social media focused mainly on content and engagement, while studies on the effect of the use of social media and self-protective behaviour were lacking. Studies on the modes of communication that take the diversity of receivers in the field into account are lacking. A limited number of studies of health authorities’ use of graphic and audio-visual means were identified, yet these did not consider/evaluate creative communication choices. Conclusion Experimental studies that investigate the effect of health authorities’ videos and messages on social media platforms and self-protective behaviour are needed. More studies are needed across the fields of health risk communication and media studies, including visual communication, web design, video and digital marketing, at a time when online digital communication is central to reaching the public.

BACKGROUND The importance of effective communication during public health emergencies has been highlighted by the World Health Organization, and it has published guidelines for effective communication in such situations. With video being a popular medium, video communication has been a growing area of study over the past decades and is increasingly used across different sectors and disciplines, including health. Health-related video communication gained momentum during the SARS-CoV-2 pandemic, and video was among the most frequently used modes of communication worldwide. However, although much research has been done regarding different characteristics of video content (the message) and its delivery (the messenger), there is a lack of knowledge about the role played by the characteristics of the recipients for the creation of effective communication. OBJECTIVE The aim of this review is to identify how health video communication outcomes are shaped by recipient characteristics, as such characteristics might affect the effectiveness of communication. The main research question of the study is as follows: do the characteristics of the recipients of health videos affect the outcomes of the communication? METHODS A scoping review describing the existing knowledge within the field was conducted. We searched for literature in 3 databases (PubMed, Scopus, and Embase) and defined eligibility criteria based on the relevance to the research question. Recipient characteristics and health video communication outcomes were identified and classified. RESULTS Of the 1040 documents initially identified, 128 (12.31%) met the criteria for full-text assessment, and 39 (3.75%) met the inclusion criteria. The included studies reported 56 recipient characteristics and 42 communication outcomes. The reported associations between characteristics and outcomes were identified, and the potential research opportunities were discussed. Contributions were made to theory development by amending the existing framework of the Integrated-Change model, which is an integrated model of motivational and behavioral change. CONCLUSIONS Although several recipient characteristics and health video communication outcomes were identified, there is a lack of robust empirical evidence on the association between them. Further research is needed to understand how the preceding characteristics of the recipients might affect the various outcomes of health video communication.

Current management principles of hemorrhagic shock after trauma emphasize earlier transfusion therapy to prevent dilution of clotting factors and correct coagulopathy. London's Air Ambulance (LAA) was the first UK civilian prehospital service to routinely offer prehospital red blood cell (RBC) transfusion (phRTx). We investigated the effect of phRTx on mortality.Retrospective trauma database study comparing mortality before implementation with after implementation of phRTx in exsanguinating trauma patients. Univariate logistic regression was performed for the unadjusted association between phRTx and mortality was performed, and multiple logistic regression adjusting for potential confounders.We identified 623 subjects with suspected major hemorrhage. We excluded 84 (13.5%) patients due to missing data on survival status. Overall 187 (62.3%) patients died in the before phRTx period and 143 (59.8%) died in the after phRTx group. There was no significant improvement in overall survival after the introduction of phRTx (P = 0.554). Examination of prehospital mortality demonstrated 126 deaths in the pre-phRTx group (42.2%) and 66 deaths in the RBC administered group (27.6%). There was a significant reduction in prehospital mortality in the group who received RBC (P 0.001).phRTx was associated with increased survival to hospital, but not overall survival. The "delay death" effect of phRTx carries an impetus to further develop inhospital strategies to improve survival in severely bleeding patients.

IntroductionMedical simulation is used in helicopter emergency services as a tool for training the crew. Using in situ simulation we aimed to evaluate the degree of implementation, factors for successful simulation and the crew’s attitude towards this form for training.MethodsA one year prospective study on simulation at all Norwegian helicopter emergency services bases and one search and rescue base. Local facilitators were educated and conducted simulations at their own discretion.ResultsAll bases participated, but the number of simulations attempted at each base varied from 1 to 46. Busier bases had a significantly higher number of aborted simulations. Regardless of base and number of attempted simulations, participating crews scored self-evaluated satisfaction with this form of training highly. The number of local facilitators and their travel distance to work seemed to make no difference to the number of attempted simulations.DiscussionOur study reveals large differences in the number of attempted simulations between bases. Our findings suggest that the local facilitator is a key factor for successful implementation of simulation based training in helicopter emergency services.

Background Individualized treatment is a common principle in hospitals. Treatment decisions are made based on the patient’s condition, including comorbidities. This principle is equally relevant out-of-hospital. Furthermore, comorbidity is an important risk-adjustment factor when evaluating pre-hospital interventions and may aid therapeutic decisions and triage. The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is included in templates for reporting data in physician-staffed pre-hospital emergency medical services (p-EMS) but whether an adequate full pre-event ASA-PS can be assessed by pre-hospital physicians remains unknown. We aimed to explore whether pre-hospital physicians can score an adequate pre-event ASA-PS with the information available on-scene. Methods The study was an inter-rater reliability study consisting of two steps. Pre-event ASA-PS scores made by pre- and in-hospital physicians were compared. Pre-hospital physicians did not have access to patient records and scores were based on information obtainable on-scene. In-hospital physicians used the complete patient record (Step 1). To assess inter-rater reliability between pre- and in-hospital physicians when given equal amounts of information, pre-hospital physicians also assigned pre-event ASA-PS for 20 of the included patients by using the complete patient records (Step 2). Inter-rater reliability was analyzed using quadratic weighted Cohen’s kappa (κw). Results For most scores (82%) inter-rater reliability between pre-and in-hospital physicians were moderate to substantial (κw 0,47-0,89). Inter-rater reliability was higher among the in-hospital physicians (κw 0,77 to 0.85). When all physicians had access to the same information, κw increased (κw 0,65 to 0,93). Conclusions Pre-hospital physicians can score an adequate pre-event ASA-PS on-scene for most patients. To further increase inter-rater reliability, we recommend access to the full patient journal on-scene. We recommend application of the full ASA-PS classification system for reporting of comorbidity in p-EMS.

Background: Selecting which variables to include in multiple regression models is a pervasive problem in medical research. Objectives: Based on questionnaire data (n = 18538, 69.9% men) from the Norwegian Opioid Maintenance Treatment Program, this study aims to compare the performance of different variable selection methods and the potential clinical consequences of choice of method. The effect of missing data is also explored. Methods: The dependent variable was engagement in criminal behavior while in treatment. Twenty-nine potential covariates on demographics, psychosocial factors and drug use were tested for inclusion in a multiple logistic regression model. Both complete case and multiply imputed data were considered. We compared the results from variable selection methods ranging from expert-based and purposeful variable selection, through stepwise methods, to more recently developed penalized regression using the Least Absolute Shrinkage and Selection Operator (LASSO). Results: The various variable selection methods resulted in regression models including from 9 to 22 covariates. The stepwise selection procedures generated the models with the most covariates included. The choice of variable selection method directly affected the estimated regression coefficients, both in effect size and statistical significance. For several variables the expert-based approach disagreed with all data-driven methods. Conclusions: The choice of variable selection method may strongly affect the resulting regression model, along with accompanying effect sizes and confidence intervals. This may affect clinical conclusions. The process should consequently be given sufficient consideration in model building. We recommend combining expert knowledge with a data-driven variable selection method to explore the models’ robustness.

Objective Prehospital personnel who lack advanced airway management training must rely on basic techniques when transporting unconscious trauma patients. The supine position is associated with a loss of airway patency when compared to lateral recumbent positions. Thus, an inherent conflict exists between securing an open airway using the recovery position and maintaining spinal immobilization in the supine position. The lateral trauma position is a novel technique that aims to combine airway management with spinal precautions. The objective of this study was to compare the spinal motion allowed by the novel lateral trauma position and the well-established log-roll maneuver. Methods Using a full-body cadaver model with an induced globally unstable cervical spine (C5-C6) lesion, we investigated the mean range of motion (ROM) produced at the site of the injury in six dimensions by performing the two maneuvers using an electromagnetic tracking device. Results Compared to the log-roll maneuver, the lateral trauma position caused similar mean ROM in five of the six dimensions. Only medial/lateral linear motion was significantly greater in the lateral trauma position (1.4 mm (95% confidence interval [CI] 0.4, 2.4 mm)). Conclusions In this cadaver study, the novel lateral trauma position and the well-established log-roll maneuver resulted in comparable amounts of motion in an unstable cervical spine injury model. We suggest that the lateral trauma position may be considered for unconscious non-intubated trauma patients.

INTRODUCTION The current management of severely injured patients includes damage control resuscitation strategies that minimise the use of crystalloids and emphasise earlier transfusion of red blood cells (RBC) to prevent coagulopathy. In 2012, London's air ambulance (LAA) became the first UK civilian pre-hospital service to routinely carry RBC to the trauma scene. OBJECTIVE To investigate the effect of pre-hospital RBC transfusion (phRTx) on overall blood product consumption. METHODS A retrospective trauma database study compares before implementation with after implementation of phRTx in exsanguinating trauma patients transported directly to one major trauma centre. Pre-hospital deaths were excluded. Univariate and multivariate Poisson regression analyses on data subject to multiple imputation were conducted. RESULTS We included 137 and 128 patients in the before and after the implementation of phRTx groups, respectively. LAA transfused 304 RBC units (median 2, inter quartile range 1-3). We found a significant reduction in total RBC usage and reduced early use of platelets and fresh-frozen plasma (FFP) after the implementation of phRTx in both univariate (P

BACKGROUND AND PURPOSE In acute stroke, thromboembolism or spontaneous hemorrhage abruptly reduces blood flow to a part of the brain. To limit necrosis, rapid radiological identification of the pathological mechanism must be conducted to allow the initiation of targeted treatment. The aim of the Norwegian Acute Stroke Prehospital Project is to determine if anesthesiologists, trained in prehospital critical care, may accurately assess cerebral computed tomography (CT) scans in a mobile stroke unit (MSU). METHODS In this pilot study, 13 anesthesiologists assessed unselected acute stroke patients with a cerebral CT scan in an MSU. The scans were simultaneously available by teleradiology at the receiving hospital and the on-call radiologist. CT scan interpretation was focused on the radiological diagnosis of acute stroke and contraindications for thrombolysis. The aim of this study was to find inter-rater agreement between the pre- and in-hospital radiological assessments. A neuroradiologist evaluated all CT scans retrospectively. Statistical analysis of inter-rater agreement was analyzed with Cohen's kappa. RESULTS Fifty-one cerebral CT scans from the MSU were included. Inter-rater agreement between prehospital anesthesiologists and the in-hospital on-call radiologists was excellent in finding radiological selection for thrombolysis (kappa .87). Prehospital CT scans were conducted in median 10 minutes (7 and 14 minutes) in the MSU, and median 39 minutes (31 and 48 minutes) before arrival at the receiving hospital. CONCLUSION This pilot study shows that anesthesiologists trained in prehospital critical care may effectively assess cerebral CT scans in an MSU, and determine if there are radiological contraindications for thrombolysis.

Background Wastewater-based epidemiology is an alternative method for estimating the collective drug use in a community. We applied functional data analysis, a statistical framework developed for analysing curve data, to investigate weekly temporal patterns in wastewater measurements of three prescription drugs with known abuse potential: methadone, oxazepam and methylphenidate, comparing them to positive and negative control drugs. Methods Sewage samples were collected in February 2014 from a wastewater treatment plant in Oslo, Norway. The weekly pattern of each drug was extracted by fitting of generalized additive models, using trigonometric functions to model the cyclic behaviour. From the weekly component, the main temporal features were then extracted using functional principal component analysis. Results are presented through the functional principal components (FPCs) and corresponding FPC scores. Results Clinically, the most important weekly feature of the wastewater-based epidemiology data was the second FPC, representing the difference between average midweek level and a peak during the weekend, representing possible recreational use of a drug in the weekend. Estimated scores on this FPC indicated recreational use of methylphenidate, with a high weekend peak, but not for methadone and oxazepam. Conclusion The functional principal component analysis uncovered clinically important temporal features of the weekly patterns of the use of prescription drugs detected from wastewater analysis. This may be used as a post-marketing surveillance method to monitor prescription drugs with abuse potential. Copyright © 2016 John Wiley & Sons, Ltd.

Background Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template. Methods The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher’s Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties. Results All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method. Conclusions We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture. Electronic supplementary material The online version of this article (10.1186/s12913-019-3976-6) contains supplementary material, which is available to authorized users.

Background: Mobile Stroke Units (MSU) diagnose and treat stroke prehospitally to reduce time from symptom onset-to-treatment (OTT). Several MSU-models exist world wide, but the best framework for MSUs are still unknown. Many models depend on in-hospital personnel working in the prehospital field. The MSU in Treat-NASPP (Norwegian Acute Stroke Prehospital Project) mimics the Norwegian Helicopter Emergency Medical Services and adds diagnostics and treatment of acute stroke to the existing prehospital emergency system. Objective: To investigate if the Treat-NASPP MSU-model is timesaving and safe. Methods: Treat-NASPP started 15th of May 2017 and is an ongoing, prospective, controlled intervention study. The inclusion criteria are: age over 18 years, not pregnant and clinical stroke symptoms with onset within the last 4 hours. The MSU is manned with an anesthesiologist trained in prehospital critical care, a nurse and a paramedic, and it is active 8 a.m. to 8 p.m. on weekdays 2 weeks per month. The control group is dispatch with ordinary ambulance and in-hospital treatment. The emergency medical communication center dispatches the MSU and/or ordinary ambulance whenever acute stroke is suspected. Results: By 1st of July 2018, 74 patients are included in the study. In the intervention group (N=49) 23 (46%) received thrombolysis, and in the control group (N=25), 10 (40%) received thrombolysis. Median (quartiles) OTT time was 98 minutes (72-184) in the MSU-group and 120,5 (107-169) in the control group, p=0,211. Median (quartiles) emergency call-to-treatment time was 29,5 minutes shorter in the MSU group compared with the control group (62 (52-71) vs 91,5 (75-97), p=0.006). Median (quartiles) mRS day 30 was 0 (0-1) in the MSU group and 0,5 (0-1,75) in the control group. No serious adverse events or symptomatic intracranial hemorrhages have occurred. Conclusion: The preliminary results indicate that adding diagnostics and treatment of acute stroke to the work-list of prehospital critical care physicians in an MSU-system, is timesaving and safe.

Supplemental Digital Content is available in the text., Background Cerebral revascularization in acute stroke requires robust diagnostic tools close to symptom onset. The quantitative National Institute of Health Stroke Scale (NIHSS) is widely used in-hospital, whereas shorter and less specific stroke scales are used in the prehospital field. This study explored the accuracy and potential clinical benefit of using NIHSS prehospitally. Patients and methods Thirteen anesthesiologists trained in prehospital critical care enrolled patients with suspected acute stroke in a mobile stroke unit. NIHSS was completed twice in the acute phase: first prehospitally and then by an on-call resident neurologist at the receiving hospital. The agreement between prehospital and in-hospital NIHSS scores was assessed by a Bland–Altman plot, and inter-rater agreement for predefined clinical categories was tested using Cohen’s κ. Results This Norwegian Acute Stroke Prehospital Project study included 40 patients for analyses. The mean numerical difference between prehospital and in-hospital NIHSS scores was 0.85, with corresponding limits of agreement from − 5.94 to 7.64. Inter-rater agreement (κ) for the corresponding clinical categories was 0.38. A prehospital diagnostic workup (NIHSS and computed tomographic examination) was completed in median (quartiles) 10 min (range: 7–14 min). Time between the prehospital and in-hospital NIHSS scores was median (quartiles) 40 min (32–48 min). Conclusion Critical care physicians in a mobile stroke unit may use the NIHSS as a clinical tool in the assessment of patients experiencing acute stroke. The disagreement in NIHSS scores was mainly for very low values and would not have changed the handling of the patients.

BackgroundAmbulance services play a crucial role in providing pre-hospital emergency care. In order to ensure quick responses, the location of the bases, and the distribution of available ambulances among these bases, should be optimized. In mixed urban-rural areas, this optimization typically involves a trade-off between backup coverage in high-demand urban areas and single coverage in rural low-demand areas. The aim of this study was to find the optimal distribution of bases and ambulances in the Vestfold region of Norway in order to optimize ambulance coverage.MethodThe optimal location of bases and distribution of ambulances was estimated using the Maximum Expected Covering Location Model. A wide range of parameter settings were fitted, with the number of ambulances ranging from 1 to 15, and an average ambulance utilization of 0, 15, 35 and 50%, corresponding to the empirical numbers for night, afternoon and day, respectively. We performed the analysis both conditioned on the current base structure, and in a fully greenfield scenario.ResultsFour of the five current bases are located close to the mathematical optimum, with the exception of the northernmost base, in the rural part of the region. Moving this base, along with minor changes to the location of the four other bases, coverage can be increased from 93.46% to 97.51%. While the location of the bases is insensitive to the workload of the system, the distribution of the ambulances is not. The northernmost base should only be used if enough ambulances are available, and this required minimum number increases significantly with increasing system workload.ConclusionAs the load of the system increases, focus of the model shifts from providing single coverage in low-demand areas to backup coverage in high-demand areas. The classification rule for urban and rural areas significantly affects results and must be evaluated accordingly.

Wastewater-based epidemiology is a novel approach in drug use epidemiology, which may provide more objective estimates of illicit drug use in a community. Functional data analysis (FDA) is a statistical framework specifically developed for analysing curves. We applied FDA to study weekly temporal patterns in wastewater curves for six different drugs in Italy. Wastewater samples were collected over seven consecutive days in November 2013, from the inlet of 17 wastewater treatment plants in 17 Italian cities. The weekly temporal features of the drug loads throughout the week were extracted using functional principal component analysis (FPCA), obtaining functional principal component (FPC) curves and corresponding FPC score variables. The FPC score variables were used as outcome variables in linear regression analyses. The most important weekly features of the drug loads were captured by the first three FPCs. The first FPC represented the general level of drug in the wastewater, while the second and third FPCs represented the discrepancy between the weekend peak and midweek level, and the weekend peak timing respectively. Cannabis was the predominant drug in the Italian wastewater, while ecstasy (MDMA) was the drug with the highest discrepancy between the weekend peak and midweek level. The Italian cities showed different patterns of drug use depending on several characteristics of the cities. FPCA extracted detailed features of the weekly temporal patterns of the use of drugs derived from the wastewater analysis. This may help in understanding and monitoring the profile of drug use in a specific community.

Background Knowledge of how to improve consumer satisfaction with the outcome of co-production in services with high levels of interaction is important for achieving and maintaining a competitive advantage in the service industry. Objectives The aim of this paper is to review and meta-analyse research on the relationship between aspects of feedback to customers in interaction-intense encounters and the customer's satisfaction with the outcome. Methods We followed recommendations of the Cochrane Handbook for Systematic Review and Interventions to do a review and meta-analysis of relevant empirical research. From January 2018 to July 2018, we systematically searched PsycINFO, Business Source Complete, Science Direct and Web of Science for relevant studies. Results A total of six articles – consisting of 22 RCTs – were identified and included in the meta-analysis. Results indicate that feedback valence, with an effect size of 0.61 (0.43, 0.78), and feedback style, with an effect size of 0.82 (0.08, 1.57), have an impact on customers’ satisfaction with the outcome of co-production. For feedback interventions, effect size -0.29 (-0.69, 0.11), and feedback medium, effect size 0.43 (-0.00, 0.86), the results are inconclusive. Conclusions The present study suggest that there is a significant relationship between satisfaction with the outcome of co-production and feedback style and valence. To satisfy customers, service providers should offer positive feedback. In order to extend our knowledge, more studies on the effect of different feedback styles on customers' satisfaction with the outcome of co-production are needed., Business; Meta-analysis; Feedback; Systematic review; Consumers’ satisfaction; Intervention; Experience-based services

Aim Over the last decades out-of-hour services in Norway have been centralised to cover lager geographical areas, resulting in longer response times for the on-call GP. Reports indicate an unintended increase in requests of helicopter emergency medical services (HEMS) as a result. We aimed to investigate alteration in the requests for HEMS and NACA-score of the patients transported. Method In 2009 nine municipalities in the county of Sogn og Fjordane relocated all local out-of-hour services into one large casualty clinic (SYS-IKL). We included all primary HEMS requests in the county from 2004–2013 and compared missions within the area of SYS-IKL to missions in the rest of the county. Results Preliminary data included 7310 requests. Within SYS-IKL requests were 4.4 per week in the period. Completed and cancelled requests were 3.0 and 1.3 per week before 2009 compared to 2.7 and 1.6 per week after 2009. Outside SYS-IKL requests were 8.9 per week before 2009 and 10.4 per week after 2009. Completed and cancelled requests were 5.1 and 3.4 per week before 2009 compared to 5.5 and 4.6 per week after 2009. Mean NACA-score within SYS-IKL was 3.98 and 3.87 (p=0.115) compared to 3.78 and 3.77 (p=0,786) outside SYS-IKL before and after 2009, respectively. Conclusion Preliminary results did not confirm the hypothesised increase in use of HEMS or reduced NACA-score due to centralization of out-of-hour services. However, further statistical analyses are required. Conflict of interest None Funding Norwegian Air Ambulance Foundation.

Objective. The main objective of the Norwegian air ambulance service is to provide advanced emergency medicine to critically ill or severely injured patients. The government has defined a time frame of 45 minutes as the goal within which 90% of the population should be reached. The aims of this study were to document accurate flying times for rotor wing units to the scene and to determine the rates of acute primary missions in Norway. Methods. We analyzed operational data from every acute primary mission from all air ambulance bases in Norway in 2011, focusing on the flying time taken to reach scene, the municipality requesting the flight, and the severity score data. Results. A total of 5,805 acute primary missions were completed in Norway in 2011. The median flying time was 19 minutes (25%-75% percentiles: 13-28). The mean mission rate for the 17 bases was 7.5 (95% confidence interval, 7.4-7.8 per 10,000 inhabitants). The overall mean (standard deviation) National Committee on Aeronautics score for all missions was 4.07 (1.30). Conclusion. The government's expectation of serving the entire population via HEMS within 45 minutes appears to be achieved on a national level. However, vast differences remain in the flying times and rates between bases. Helicopter emergency medical services (HEMS) are an integral part in many health care systems in the developed world. The effect of HEMS is still subject to debate although they have several theoretical advantages, such as bringing advanced medical care and medical competence to the scene, shortening the transport time, providing access to remote areas, and reducing the time elapsed until definitive care is available. Several outcome studies have found positive associations with increased survival under the care of HEMS, whereas the opposite effects have also been well documented. However, many of these studies have been subject to methodological limitations, selection bias, and noncomparable study settings or designs. A position paper by several American air medical societies initiated the process of establishing national guidelines to facilitate the beneficial effects of HEMS implementation. The paper stated that clinical benefit could be provided by minimizing the time to definitive care in time-sensitive medical conditions, providing necessary competence and equipment on the scene, and accessing patients who are otherwise inaccessible by other modes of transport.4 These objectives are consistent with national guidelines in other countries. Based on international experiences, a Norwegian national air ambulance (AA) service was established in 1988. A paramount principle in Norwegian health legislation is that all citizens should have equal access to publicly funded health care regardless of their residential pattern. In that sense, well-developed air emergency services have a compensatory effect that adjusts for geographic dispersion and potential unequal access to advanced emergency medical care. A time frame of 45 minutes, including up to a 15-minute reaction time from alarm to takeoff, has been defined as the national goal to reach 90% of the population. In 2002, Heggestad and Børsheim published results on the accessibility and distribution of the Norwegian national air emergency service. In their study, the mean reaction time was 8 minutes in acute missions (from alarm until takeoff), and the mean total response time from alarm until scene arrival was 26 minutes. Nearly 98% of the population was reached within 60 minutes. Within the last decade, the population has increased, enhanced medical capabilities have been developed, and additional helicopter bases have been implemented. Hence, the aims of this study were to document the accurate flying times of rotor wing units to the scene as well as the rates of acute primary missions in Norway. publishedVersion