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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.

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.

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

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

Introduction Trauma is a major global cause of morbidity and mortality. Population-based studies identifying high-risk populations and regions may facilitate primary prevention and the development of optimal trauma systems. This study describes the epidemiology of adult trauma deaths in Norway and identifies high-risk areas by assessing different geographical measures of rurality. Methods All trauma-related deaths in Norway from 1998 to 2007 among individuals aged 16–66 years were identified by accessing national registries. Mortality data were analysed by linkage to population and geographical data at municipal, county and national levels. Three measures of rurality (centrality, population density and settlement density) were compared based on their association with trauma mortality rates. Results The study included 8466 deaths, of which 78% were males. The national annual trauma mortality rate was 28.7 per 100,000. Population density was the best predictor of high-risk areas, and there was a consistent inverse relationship between mortality rates and population density. The most rural areas had 52% higher trauma mortality rates compared to the most urban areas. This difference was largely due to deaths following transport-related injury. Seventy-eight per cent of all deaths occurred in the prehospital phase. Rural areas and death following self-harm had higher proportion of prehospital deaths. Conclusion Rural areas, as defined by population density, are at a higher risk of deaths following traumatic injuries and have higher proportions of prehospital deaths and deaths following transport-related injuries. The heterogeneous characteristics of trauma populations with respect to geography and mode of injury should be recognised in the planning of preventive strategies and in the organisation of trauma care.

Current literature on motor vehicle accidents (MVAs) has few reports regarding field factors that predict the degree of injury. Also, studies of mechanistic factors rarely consider concurrent predictive effects of on-scene patient physiology. The New Injury Severity Score (NISS) has previously been found to correlate with mortality, need for ICU admission, length of hospital stay, and functional recovery after trauma. To potentially increase future precision of trauma triage, we assessed how the NISS is associated with physiologic, demographic and mechanistic variables from the accident site.Using mixed-model linear regression analyses, we explored the association between NISS and pre-hospital Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS) categories of respiratory rate (RR) and systolic blood pressure (SBP), gender, age, subject position in the vehicle, seatbelt use, airbag deployment, and the estimated squared change in vehicle velocity on impact ((Δv)(2)). Missing values were handled with multiple imputation.We included 190 accidents with 353 dead or injured subjects (mean NISS 17, median NISS 8, IQR 1-27). For the 307 subjects in front-impact MVAs, the mean increase in NISS was -2.58 per GCS point, -2.52 per RR category level, -2.77 per SBP category level, -1.08 for male gender, 0.18 per year of age, 4.98 for driver vs. rear passengers, 4.83 for no seatbelt use, 13.52 for indeterminable seatbelt use, 5.07 for no airbag deployment, and 0.0003 per (km/h)(2) velocity change (all p0.002).This study in victims of MVAs demonstrated that injury severity (NISS) was concurrently and independently predicted by poor pre-hospital physiologic status, increasing age and female gender, and several mechanistic measures of localised and generalised trauma energy. Our findings underscore the need for precise information from the site of trauma, to reduce undertriage, target diagnostic efforts, and anticipate need for high-level care and rehabilitative resources.

Background Injury severity is most frequently classified using the Abbreviated Injury Scale (AIS) as a basis for the Injury Severity Score (ISS) and the New Injury Severity Score (NISS), which are used for assessment of overall injury severity in the multiply injured patient and in outcome prediction. European trauma registries recommended the AIS 2008 edition, but the levels of inter-rater agreement and reliability of ISS and NISS, associated with its use, have not been reported. Methods Nineteen Norwegian AIS-certified trauma registry coders were invited to score 50 real, anonymised patient medical records using AIS 2008. Rater agreements for ISS and NISS were analysed using Bland–Altman plots with 95% limits of agreement (LoA). A clinically acceptable LoA range was set at ±9 units. Reliability was analysed using a two-way mixed model intraclass correlation coefficient (ICC) statistics with corresponding 95% confidence intervals (CI) and hierarchical agglomerative clustering. Results Ten coders submitted their coding results. Of their AIS codes, 2189 (61.5%) agreed with a reference standard, 1187 (31.1%) real injuries were missed, and 392 non-existing injuries were recorded. All LoAs were wider than the predefined, clinically acceptable limit of ±9, for both ISS and NISS. The joint ICC (range) between each rater and the reference standard was 0.51 (0.29,0.86) for ISS and 0.51 (0.27,0.78) for NISS. The joint ICC (range) for inter-rater reliability was 0.49 (0.19,0.85) for ISS and 0.49 (0.16,0.82) for NISS. Univariate linear regression analyses indicated a significant relationship between the number of correctly AIS-coded injuries and total number of cases coded during the rater's career, but no significant relationship between the rater-against-reference ISS and NISS ICC values and total number of cases coded during the rater's career. Conclusions Based on AIS 2008, ISS and NISS were not reliable for summarising anatomic injury severity in this study. This result indicates a limitation in their use as benchmarking tools for trauma system performance.

When assessing reliability of three dimensional gait analysis, the coefficient of multiple correlation (CMC), a measure of similarity of waveforms, is frequently used. Several shortcomings of the method have been reported. It is strongly related to the range of motion (ROM); it is supposed to take values from 0 to 1, but is known to obtain complex values and break down. Removing offset before calculations appears to make it insensitive to apparent differences in gait. In the present work we use stochastic simulations to demonstrate why all of this happens, and the consequences thereof. We also demonstrate other, lesser-known, issues with the method, such as the strong dependency on number of subjects and test situations. The results are demonstrated on real data from an inter-rater repeatability study. We conclude that the CMC in its current form is generally unsuitable as a tool for assessing reliability in kinematic gait data.

Objectives To study an unexpected, significant increase in glucose measurements during 7 year recruitment to a cohort study. Design and methods Measurements of quality control solutions and blood glucose in pregnant women were done by Accu-Chek Sensor glucometer. Time-trends were analysed by regression models and control charts. Results Cohort measurements were de-trended by weighted linear regressions based on independent control values. Conclusions Biologically implausible trends in data can be corrected by using independent control values.

Analysis of variations in normal gait has received considerable attention over the last years. However, most such analyses are carried out on one explanatory variable at a time, and adjustments for other possibly influencing factors are often done using ad hoc methods. As a result, it can be difficult to know whether observed effects are actually a result of the variable under study. We wanted to simultaneously statistically test the effect of gender, age and walking speed on gait in a normal population, while also properly adjusting for the possibly confounding effects of body height and weight. Since point-by-point analysis does not take into account the time dependency in the data, we turned to functional data analysis (FDA). In FDA the whole gait curve is represented not by a set of points, but by a mathematical function spanning the whole gait cycle. We performed several multiple functional regression analyses, and the results indicate that walking speed is the main factor influencing gait in the reference material at our motion analysis laboratory. This effect is also largely unaffected by the presence of other variables in the model. A gender effect was also apparent in several planes and joints, but this effect was often more outspoken in the multiple than in the univariate regression analyses, highlighting the importance of adjusting for confounders like body height and weight.

Background Bosnia and Herzegovina did not have invasive cardiac diagnosis or cardiac surgery before the recent war. With assistance from the United States and Norway, a cardiovascular clinic was developed. This study reports center-specific and surgeon-specific clinical outcomes. Since off-pump coronary bypass grafting surgery was prioritized in the treatment of coronary disease, a comparison was made between operations performed with and without cardiopulmonary bypass. Methods Surgeons and key staff members were trained in the United States. A Norwegian data management system for cardiac surgery was implemented and cases entered after quality review of the data. A total of 1276 patients were entered; operations were performed with cardiopulmonary bypass in 540 and without in 736. The primary surgeon was entered as a variable in an anonymous fashion. Results Overall mortality for coronary bypass grafting surgery was 1.6%, and the major complication rate was 4.5%. Patients operated on off-pump received fewer grafts and had a shorter length of stay. Unfavorable outcome was more common in patients when cardiopulmonary bypass was used in the operation. Regression analysis demonstrated that the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and use of cardiopulmonary bypass were predictors of poor outcome. The individual surgeon factor did not impact on outcomes. Conclusions Our study confirms that coronary artery bypass grafting surgery may be performed safely in a poor country in a hospital without experience with cardiac surgery. Selection of talented staff and cooperation with international cardiac centers are crucial. Off-pump coronary artery bypass grafting surgery is suitable for a new center and does not require more training than standard procedures.

Introduction: The question of reliability is essential for any measurement method, and when investigating reliability of 3DGA kinematic curves the coefficient of multiple correlations (CMC) [1] is frequently used, despite the reports of methodological issues [2]. Theaimof the current studywas toperformasystematic evaluation of theCMCusing stochastic simulations. The results are exemplified on an inter-rater reliability study of 3DGA data related to marker placement. Patients/materials and methods: Synthetic gait curves were generated from a stochastic model where amplitude, vertical offset and a possible horizontal shift due to random error and timing issues were included as stochastic variables. The model was used hierarchically. First a “true” curve for each subject was sampled; then curves from each of the different test situations, e.g. different tester teams, was sampled using this “true” curve as the mean. The CMC is a measure of similarity of waveforms, e.g. curve data [1], comparing multiple curves from several subjects across test situations, e.g. testers. The CMC was calculated based on the synthetic data with systematic variations in curve amplitude, frequency, vertical curve offset, and number of subjects and number of test situations. Confidence intervals were estimated using bootstrapping. Seven healthy adult volunteers gave written informed consent to take part in the accompanying inter-rater reliability study. The subjects were tested on two consecutive days by two different tester teams. 3DGA data was recorded during bare feet, level walking along a 10m walkway at self-selected comfortable walking speed, using six Vicon MX13 cameras, and the PluginGait model. For each subject, one left cycle from each test situation was selected, based on similarity in walking speed. Results: Joints with large amplitudes, i.e. above 15◦, resulted in CMC>0.9. High sampling frequencies, i.e. above 20 points per gait cycle, also resulted in CMC>0.9. Increasing offsets resulted in decreasing CMC values. For two test situations 20 subjects resulted inwider CIs for the CMC than five subjects on five test situations. In the inter-rater reliability study, the CMC calculations consistently broke down, i.e. could not be computed, for jointswith a lowamplitude. In curves with a visually apparent systematic vertical offset, the CMC was still approximately 0.9. Discussion and conclusions: The CMC is sensitive to the amplitude of the curve, demonstrating how the signal-to-noise ratio is a problem issue. As the CMC does not adjust for the inter-gait-curve correlation between data points, higher sample frequency leads to high CMCs, merely due to high correlation between data in the calculations. The frequently used reliability design of two tester teams was demonstrated to show comparably high CIs. In conclusion, in our study the CMC did not show the statistical properties that are needed for it to be an overall measurement of curve similarity. Other methods than the CMC must be used to assess reliability of 3DGA data. References