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Critical care in the era of novel coronavirus disease-2019 (COVID-19) infection has multiple challenges including management of the patient, underlying comorbidities, and the complications. With no end in sight to the pandemic, intensive care unit (ICU) practitioners and hospital administrators have to join hands to prepare for the long battle ahead. Critically ill COVID-19 patients need imaging or image-guided interventions in one form or the other including X-rays, ultrasonography (USG), echocardiography (ECHO), and CT scan. These patients often require renal replacement therapy (RRT) for either the preexisting chronic renal insufficiency or acutely developing kidney injury. Another important component of care is transfer of the patient to and fro from the ICU or to higher care centers. Most of the ICUs are equipped with modern facilities but with increasing number of patients a large number of makeshift arrangements are being made for managing these patients. This position paper outlines important tips to formulate protocols and procedures for critically ill patients, who are managed in the ICU. How to cite this article: Pande RK, Bhalla A, Myatra SN, Yaddanpuddi LN, Gupta S, Sahoo TK, et al. Procedures in COVID-19 Patients: Part-II. Indian J Crit Care Med 2020;24(Suppl 5):S272–S279.

In this paper, an offline drone instrumentalized ambulance (ODIA) mechanism has been discussed. The rapid increase in the urban population directly influences every sector of society. The sectors are maybe food, health care, education, transportation, etc. Normally, it has been observed that when any accidents happen on the urban road or any remote places then, the availability of immediate medical help is very rare. It is not because of the unaware or unavailability of medical facilities rather it happens because of overcrowding on the urban road and geographical odd-isolation of places. Hence, here an ODIA concept has been discussed which uses offline maps and offline first-aid medical videos through which immediate medical help can be made available at the patient end. This model helps to save the life of an accident victim by providing immediate medical attention. The key strength of ODIA is, it is independent of internet service that is why it is more suitable for harsh and hostile environments.

In this paper we report on key findings and lessons from a process mining case study conducted to analyse transport pathways discovered across the time-critical phase of pre-hospital care for persons involved in road traffic crashes in Queensland (Australia). In this study, a case is defined as being an individual patient&rsquo, s journey from roadside to definitive care. We describe challenges in constructing an event log from source data provided by emergency services and hospitals, including record linkage (no standard patient identifier), and constructing a unified view of response, retrieval, transport and pre-hospital care from interleaving processes of the individual service providers. We analyse three separate cohorts of patients according to their degree of interaction with Queensland Health&rsquo, s hospital system (C1:no transport required, C2:transported but no Queensland Health hospital, C3:transported and hospitalisation). Variant analysis and subsequent process modelling show high levels of variance in each cohort resulting from a combination of data collection, data linkage and actual differences in process execution. For Cohort 3, automated process modelling generated &rsquo, spaghetti&rsquo, models. Expert-guided editing resulted in readable models with acceptable fitness, which were used for process analysis. We also conduct a comparative performance analysis of transport segment based on hospital `remoteness&rsquo, With regard to the field of process mining, we reach various conclusions including (i) in a complex domain, the current crop of automated process algorithms do not generate readable models, however, (ii) such models provide a starting point for expert-guided editing of models (where the tool allows) which can yield models that have acceptable quality and are readable by domain experts, (iii) process improvement opportunities were largely suggested by domain experts (after reviewing analysis results) rather than being directly derived by process mining tools, meaning that the field needs to become more prescriptive (automated derivation of improvement opportunities).

Background Ambulance services have a vital role in the shift towards the delivery of health care outside hospitals, when this is better for patients, by offering alternatives to transfer to the emergency department. The introduction of information technology in ambulance services to electronically capture, interpret, store and transfer patient data can support out-of-hospital care. Objective We aimed to understand how electronic health records can be most effectively implemented in a pre-hospital context in order to support a safe and effective shift from acute to community-based care, and how their potential benefits can be maximised. Design and setting We carried out a study using multiple methods and with four work packages: (1) a rapid literature review; (2) a telephone survey of all 13 freestanding UK ambulance services; (3) detailed case studies examining electronic health record use through qualitative methods and analysis of routine data in four selected sites consisting of UK ambulance services and their associated health economies; and (4) a knowledge-sharing workshop. Results We found limited literature on electronic health records. Only half of the UK ambulance services had electronic health records in use at the time of data collection, with considerable variation in hardware and software and some reversion to use of paper records as services transitioned between systems. The case studies found that the ambulance services’ electronic health records were in a state of change. Not all patient contacts resulted in the generation of electronic health records. Ambulance clinicians were dealing with partial or unclear information, which may not fit comfortably with the electronic health records. Ambulance clinicians continued to use indirect data input approaches (such as first writing on a glove) even when using electronic health records. The primary function of electronic health records in all services seemed to be as a store for patient data. There was, as yet, limited evidence of electronic health records’ full potential being realised to transfer information, support decision-making or change patient care. Limitations Limitations included the difficulty of obtaining sets of matching routine data for analysis, difficulties of attributing any change in practice to electronic health records within a complex system and the rapidly changing environment, which means that some of our observations may no longer reflect reality. Conclusions Realising all the benefits of electronic health records requires engagement with other parts of the local health economy and dealing with variations between providers and the challenges of interoperability. Clinicians and data managers, and those working in different parts of the health economy, are likely to want very different things from a data set and need to be presented with only the information that they need. Future work There is scope for future work analysing ambulance service routine data sets, qualitative work to examine transfer of information at the emergency department and patients’ perspectives on record-keeping, and to develop and evaluate feedback to clinicians based on patient records. Study registration This study is registered as Health and Care Research Wales Clinical Research Portfolio 34166. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 10. See the NIHR Journals Library website for further project information.

ObjectiveThe objective of this scoping review is to systematically map the literature to identify the scope, depth, key concepts and gaps in the evidence regarding care of the patient with invasive meningococcal disease by emergency medical service (EMS) clinicians.DesignScoping review. This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guideline.Eligibility criteriaSources which focused on patients with invasive meningococcal disease (population), where the care of EMS clinicians was the focus (concept), in EMS systems worldwide (context) were eligible for inclusion.Search strategyThis review utilised a comprehensive search strategy including MEDLINE, Embase, Emcare, CINAHL, Scopus, Web of Science, Google Scholar and ‘grey’ literature databases from 1992 to January 2019. The search also included a Google search, a hand-search of relevant journals, screening of reference lists, contact with authors of included sources and use of social media in an attempt to locate all sources of evidence which fit the inclusion criteria of the review. Two reviewers independently screened sources for inclusion.ResultsThe search yielded 1803 unique records, of which 10 were included in the synthesis. No original research papers were identified, with all sources classed as either clinical audit or text and opinion literature. The dominant concept throughout the literature is that early antibiotic therapy is critical in the treatment of invasive meningococcal disease.ConclusionsOverall, there is a very narrow scope and shallow depth of literature on the topic of interest. There are gaps in the evidence regarding the care of the patient with invasive meningococcal disease by EMS clinicians. Despite these shortfalls, current consensus-based guidelines should direct clinical practice. Further research is planned to bridge the gaps in knowledge to support best practice.

Traffic signals are the most convenient method of controlling traffic in a busy junction. Present traffic Signals fail to control the traffic effectively when a particular lane has got more traffic than the other lanes. In this paperan intelligent traffic control system using PLC is proposed. System measures the traffic density on each road bycounting the number of vehicles and then takes the decision. Programming is done using ladder diagram. Seimens S7 1200 PLC is have been used for the system implementation. Traffic management on the road has become a severe problem of todays society because of growth of the urbanization. This leads to traffic jam at the traffic junctions which in turn causes delay to ambulances. In order to overcome this problem, this paper presents a simple ambulance controlled traffic system. The main objective of this system is that to control the traffic, allowing an ambulance to arrive at a particular location without it having to stop anywhere until the destination is reached. This system includes RF Transmitter and Receiver technology and Lab VIEW software. Mamatha R "Traffic light Controller for the Congested Urban Route using PLC & Ambulance Detection using RF Transmitter & Receiver with Lab VIEW" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-2 | Issue-1 , December 2017, URL: https://www.ijtsrd.com/papers/ijtsrd5954.pdf

ObjectiveLow back pain (LBP) could cause serious consequences and has been shown to be prevalent among emergency ambulance workers. Studies on the prevalence of and risk factors for LBP among emergency ambulance workers are scarce in China. The study aimed to determine the prevalence of LBP among ambulance workers, including doctors, nurses and drivers, and to explore the risk factors for ambulance nurses’ chronic LBP (lasting for at least 3 months).DesignCross-sectional study.SettingEmergency ambulance systems from 38 tertiary hospitals in Shandong, China were selected by random cluster sampling.ParticipantsA total of 1560 ambulance workers completed the study.Outcome measuresA paper-based questionnaire that included the Nordic Musculoskeletal Questionnaire, which evaluated LBP, the Dutch Musculoskeletal Questionnaire, which assessed ergonomic factors, and the Job Content Questionnaire, which assessed stress, was used. Multivariate logistic regression analysis was conducted to quantify the association of potential risk factors with chronic LBP among ambulance nurses.ResultsThe 1 year prevalence of LBP lasting for at least 24 hours, 7 days and 3 months was 86.1%, 50.6% and 21.1%, respectively, among 498 ambulance nurses; 70.5%, 36.4% and 15.8% among 519 doctors; and 57.5%, 23.8% and 12.3% among 543 drivers. The factors contributing to chronic LBP among ambulance nurses were the frequent bending of the trunk, heavy or awkward lifting, shift work, low job satisfaction, high psychological fatigue, high psychological job demand, low job control, low supervisor support, older age, female sex and obesity.ConclusionsLBP was more prevalent among ambulance nurses than among ambulance doctors and drivers. Many factors, especially psychosocial and ergonomic factors, contributed to ambulance nurses’ chronic LBP. Comprehensive measures might be needed to control LBP.

Background We sought to understand the main ethical considerations when conducting clinical trials in the prehospital ambulance based setting. Methods A systematic review of the literature on randomised controlled trials in ambulance settings was undertaken. A search of eight databases identified published studies involving recruitment of ambulance service users. Four independent authors undertook abstract and full-text reviews to determine eligibility and extract relevant data. The data extraction concentrated on ethical considerations, with any discussion of ethics being included for further analysis. The resultant data were combined to form a narrative synthesis. Results In all, 56 papers were identified as meeting the inclusion criteria. Issues relating to consent were the most significant theme identified. Type of consent differed depending on the condition or intervention being studied. The country in which the research took place did not appear to influence the type of consent, apart from the USA where exception from consent appeared to be most commonly used. A wide range of terms were used to describe consent. Conclusions Consent was the main ethical consideration in published ambulance based research. A range of consent models were used ranging from informed consent to exception from consent (waiver of consent). Many studies cited international guidelines as informing their choice of consent model but diverse and sometimes confused terms were used to describe these models. This suggests that standardisation of consent models and the terminology used to describe them is warranted. Electronic supplementary material The online version of this article (10.1186/s12874-017-0423-4) contains supplementary material, which is available to authorized users.

Background Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Data used in handover is not always easily recorded using ambulance based tablets, particularly in time-critical cases. Paramedics have therefore developed pragmatic workarounds (writing on gloves or scrap paper) to record these data. However, such practices can conflict with policy, data recorded can be variable, easily lost and negatively impact on handover quality. Methods This study aimed to measure the feasibility and acceptability of a novel, low tech intervention, designed to support clinical information recording and delivery during pre-alert and handover within the pre-hospital and ED setting. A simple pre and post-test design was used with a historical control. Eligible participants included all ambulance clinicians based at one large city Ambulance Station (n = 69) and all nursing and physician staff (n = 99) based in a city Emergency Department. Results Twenty five (36%) ambulance clinicians responded to the follow-up survey. Most felt both the pre-alert and handover components of the card were either ‘useful-very useful’ (n = 23 (92%); and n = 18 (72%) respectively. Nineteen (76%) used the card to record clinical information and almost all (n = 23 (92%) felt it ‘useful’ to ‘very useful’ in supporting pre-alert. Similarly, 65% (n = 16) stated they ‘often’ or ‘always’ used the card to support handover. For pre-alert information there were improvements in the provision of 8/11 (72.7%) clinical variables. ​ Results from the post-test survey measuring ED staff (n = 37) perceptions of handover demonstrated small (p

Governments deal with increasing health care demand and costs, while budgets are tightened. At the same time, ambulance providers are expected to deliver high-quality service at affordable cost. Maximum reliability and minimal availability models guarantee a minimal performance level at each demand point, in contrast to the majority of facility location and allocation methods that guarantee a minimal performance that is aggregated over the entire ambulance region. As a consequence, existing models generally lead to overstaffing, particularly in ‘mixed’ regions with both urban and rural areas, which leads to unnecessarily high costs. This paper addresses this problem. First, we introduce the concept of demand projection to give fundamental insight into why this overstaffing takes place. Next, we overcome the overstaffing by the so-called adjusted queuing (AQ) solution that provides generalizations of the existing models. We provide mathematical proofs for the correctness of the AQ solution. Finally, to assess the performance of the AQ-solution we have performed extensive numerical experimentation, using real data from four ambulance regions in the Netherlands. The results show that in all cases the AQ-solution indeed leads to better ambulance care than the existing solutions, while reducing staffing cost.

Introduction and Aims: Opioid overdose fatalities are a significant concern globally. Non-fatal overdoses have been described as a strong predictor for future overdoses, and are often attended by the ambulance services. This paper explores characteristics associated with non-fatal overdoses and aims to identify possible trends among these events in an urban area in Norway. Design and Methods: This is a retrospective analysis of non-fatal overdoses from Bergen ambulance services from 2012 to 2013. Demographic, temporal and geographic data were explored. Results: During the two years, 463 non-fatal opioid overdoses were attended by ambulance services. Ambulance call-outs occurred primarily during the late afternoon and evening hours of weekdays. Summer months had more overdoses than other seasons, with a peak in August. Overdoses were nearly twice as likely to occur in a public location in August (risk ratio 1.92, P = 0.042). Ambulance response times were more likely to be longer to private locations, and these victims were more likely to be treated and left at the scene. There was no difference in arrival time for drug-related and non-drug related dispatch. Discussion and Conclusions: The temporal patterns suggest that non-fatal overdoses occur during non-recreational time periods. The longer ambulance response time and disposition for private addresses indicate potential opportunities for peer interventions. Our analysis describes circumstances surrounding non-fatal overdoses and can be useful in guiding relevant, targeted prevention interventions. publishedVersion

An Emergency Medical Service (EMS) plays a fundamental role in providing good quality health care services to citizens, as it provides the first answer in distressing situations. Early response, one of the key factors in a successful treatment of an injury, is strongly influenced by the performance of ambulances, which are sent to rescue the patient. Here we report the research carried on by the authors on the ambulance location and management in the Milano area (Italy), as a part of a wider research project in collaboration with the EMS of Milano and funded by Regione Lombardia. The question posed by the EMS managers was clear and, at the same time, tricky: could decision making tools be applied, based on the currently available data, to provide suggestions for decision makers? To answer such a question, three different studies have been carried on: first the evaluation of the current EMS system performance through statistical analysis; then the study of operational policies which can improve the system performance through a simulation model; and finally the definition of an alternative set of posts through an optimization model. This paper describes the methodologies underlying such studies and reports on how their main findings were crucial to help the EMS in changing its organization model.

In todays world, traffic jams during rush hours is one of the major interest. During surge hours, Emergency vehicles like Ambulances get caught in jams. Due to this, these emergency vehicles are not able to reach their target in time, resulting into a loss of human lives. We have Developed a system which is used to provide clearance to any emergency Ambulance vehicle by Turning all the red lights to green on the path of the emergency vehicle, hence providing a Complete green bay to the desired vehicle. A green bay is the synchronization of the green phase Of traffic signals. With a green bay setup, a vehicle transient through a green signal will continue to receive green signals as it travels down the road. Around the world, green bay is used to great effect. In the existing system we dont have automatic control traffic signal, due to this Emergency ambulance not able to reach the hospital within time. For this system we have implemented effective smart ambulance system by using GPS Technology. This project is Targeted to design and develop a real time smart ambulance system. Mrs. S. DurgaDevi | Mr. P. Senthil | T. Keerthana "Controlling Traffic Signals Through GPS for Ambulance" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Special Issue | Active Galaxy , June 2018, URL: https://www.ijtsrd.com/papers/ijtsrd14563.pdf Paper URL: http://www.ijtsrd.com/engineering/computer-engineering/14563/controlling-traffic-signals-through-gps-for-ambulance/mrs-s-durgadevi

Introduction Paramedic practice in Australia has evolved significantly over the past 20 years. With the expansion of the paramedic scope of practice and absence of registration, there is a need to determine what is known about continuing professional development (CPD) for paramedics. Method Selected search terms were entered into three electronic databases to identify relevant publications. Inclusion/exclusion criteria was applied and full texts were reviewed for potential papers. Eight publications were identified as relevant and included in the systematic literature review. Results Initial search yield was 875 publications, removal of duplicate articles and application of the inclusion/exclusion criteria to title and abstract reduced this to 20 publications requiring review. This number was further reduced to eight publications, two of which were qualitative studies, a further five were quantitative design and the final study included both quantitative and qualitative data. Seven of the eight publications highlighted the importance of CPD for paramedics. The remaining article did not yield statistically significant data to conclude improved clinical practice or knowledge through the delivery of the educational intervention. Conclusion The availability of publications relating to CPD for paramedics is extremely limited. The reviewed publications reported highly variable clinical exposure and infrequent reaccreditation processes which are not currently adequately supplemented by CPD. Among the key findings in the literature was the need for increased CPD to supplement the limited clinical exposure, and for paramedics to take ownership of their own professional development. It is evident that further research into paramedicine and CPD is required.

Background: Maternal mortality is one of the most sensitive indicators of the health disparities between poorer and richer nations. It is also one of the most difficult health outcomes to measure reliably. In many settings, major challenges remain in terms of both measuring and reducing maternal mortality effectively. This thesis aims to quantify overall levels, identify specific causes, and evaluate local interventions in relation to efforts to reduce maternal mortality in Tigray Region, Northern Ethiopia, thereby providing a strong empirical basis for decision making by the Tigray Regional Health Bureau using methods that can be scaled at national level. Methods: This study employed a combination of community-based study designs to investigate the level and determinants of maternal mortality in six randomly selected rural districts of Tigray Region. A census of all households in the six districts was conducted to identify all live births and all deaths to women of reproductive age occurring between May 2012 and September 2013. Pregnancy-related deaths were screened through verbal autopsy with the data processed using the InterVA-4 model, which was used to estimate Maternal Mortality Ratio. To identify independent determinants of maternal mortality, a case-control study using multiple logistic regression analysis was done, taking all pregnancy-related deaths as cases and a random sample of geographical and age matched mothers as controls. Uptake of ambulance services in the six districts was determined retrospectively from ambulance logbooks, and the trends in pregnancy-related death were analyzed against ambulance utilization, distance from nearest health center, and mobile network coverage at local area level. Lastly, implementation of the Family Folder paper health register, and its potential for accurately capturing demographic and health events, were evaluated using a capture-recapture assessment. Results: A total of 181 deaths to women of reproductive age and 19,179 live births were documented from May 2012 to April2013. Of the deaths, 51 were pregnancy-related. The maternal mortality ratio for Tigray region was calculated at 266 deaths per 100,000 live births (95% CI 198-350), which is consistently lower than previous “top down” MMR estimates. District–level MMRs showed strong inverse correlation with population density (r2 = 0.86). Direct obstetric causes accounted for 61% of all pregnancy–related deaths, with hemorrhage accounting for 34%. Non-membership in the voluntary Women’s Development Army (AOR 2.07, 95% CI 1.04-4.11), low husband or partner involvement during pregnancy (AOR 2.19, 95% CI 1.14-4.18), pre-existing history of other illness (AOR 5.58, 95% CI 2.17-14.30), and never having used contraceptives (AOR 2.58, 95% CI 1.37-4.85) were associated with increased risk of maternal death in a multivariable regression model. In addition, utilization of free ambulance transportation service was strongly associated with reduced MMR at district level. Districts with above-average ambulance utilization had an MMR of 149 per 100,000 LB (95% CI: 77-260) compared with 350 per 100,000 (95% CI: 249-479) in districts with below average utilization. The Family Folder implementation assessment revealed some inconsistencies in the way Health Extension Workers utilize the Family Folders to record demographic and health events. Conclusion: This work contributes to understanding the status of and factors affecting maternal mortality in Tigray Region. It introduces a locally feasible approach to MMR estimation and gives important insights in to the effectiveness of various interventions that have been targeted at reducing maternal mortality in recent years.

Background In The Netherlands, standard prehospital trauma care is provided by emergency medical services and can be supplemented with advanced trauma care by Mobile Medical Teams. Due to observed over and undertriage in the dispatch of the Mobile Medical Team for major trauma patients, the accuracy of the dispatch criteria has been disputed. In order to obtain recommendations to invigorate the dispatch criteria, this study aimed at reaching consensus in expert opinion on the question; which acute trauma patient is in need of care by a Mobile Medical Team? In this paper we describe the protocol of the DENIM study (a Delphi-procedure on the identification of prehospital trauma patients in need of care by Mobile Medical Teams). Methods A national three round digital Delphi study will be conducted to reach consensus. Literature was explored for relevant topics. After agreement on the themes of interest, the steering committee will construct questions for the first round. In total, 120 panellists with the following backgrounds; Mobile Medical Team physicians and nurses, trauma surgeons, ambulance nurses, emergency medical operators will be invited to participate. Group opinion will be fed back between each round that follows, allowing the panellists to revise their previous opinions and so, converge towards group consensus. Discussion Successful prehospital treatment of trauma patients greatly depends on the autonomous decisions made by the different professionals along the chain of prehospital trauma care. Trauma patients in need of care by the Mobile Medical Team need to be identified by those professionals in order to invigorate deployment criteria and improve trauma care. The Delphi technique is used because it allows for group consensus to be reached in a systematic and anonymous fashion amongst experts in the field of trauma care. The anonymous nature of the Delphi allows all experts to state their opinion whilst eliminating the bias of dominant and/or hierarchical individuals on group opinion.

Tokai University has been conducting research on ambulances and related onboard systems for transmitting video images from vehicles in motion via the quasi-zenith satellite, which are scheduled to be launched by the Communications Research Laboratory (CRL) and the NASDA. This paper describes a newly-developed high-precision satellite tracking system, which has been developed for use with this system. The core of this tracking system comprises a few mutually complementing independent signal processing subsystems. Within this system, the absolute coordinates of the satellite are estimated by a quadrant detector (QD), while its relative coordinates are estimated by a GPS-based continuous kinematic positioning technique and calculations of six orbit elements. As it is intended to use Ka-band transponder and to use narrow beam antenna of the vehicle. So here, it would be desirable to discuss the effect of absolute coordinate with the quadrant detector to track satellite at urban area., 資料番号: AA0046101001, レポート番号: NAL SP-58T

El progresivo envejecimiento de la población española conlleva un aumento de la atención sanitaria, por los servicios de urgencias extrahospitalarias (SUE), a este grupo de edad. El objetivo de este trabajo es evidenciar la importancia de realizar una valoración global del anciano en el contexto domiciliario y comunitario, que contemple tanto los aspectos físicos como los psicosociales y ambientales de la persona en situación de urgencia. Para ello, se desarrolla un caso clínico, que se apoya en la evidencia científica, para determinar la actuación más adecuada que mejore las intervenciones de los servicios de urgencias extrahospitalarias. El análisis del caso se estructura en tres apartados: la valoración de enfermería, el registro de los datos y la transmisión de la información a otros equipos de salud. Como conclusión, se identifica la necesidad de valorar y registrar datos sobre el estado físico y fisiológico del anciano al mismo tiempo que se recoge información sobre su contexto familiar, comunitario o ambiental, para proporcionar unos cuidados integrales y de calidad. Asimismo, se recomienda el desarrollo de herramientas de valoración geriátrica específicas para utilizar en situaciones de urgencias extrahospitalarias. The progressive aging of the Spanish population leads to increased health care for Outpatient Emergency Services (EUS), in this age group. The aim of this paper is to highlight the importance of an overall assessment of the elderly in the household and community context, which involves both the physical and psychosocial in the emergency environmental. To do this, we develop a clinical case, which is based on scientific evidence, to determine the most appropriate action to improve interventions in emergency services. The case analysis is divided into three sections: nursing assessment, data recording and transmission of information to other health teams. In conclusion, it identifies the need to assess and record data on physical and physiological status of the elderly, at the same time it collects information about family background, community or environmental, to provide a comprehensive and quality care. It also recommends the development of specific geriatric assessment tools for use in emergency situations.

Introduction: During the past 40 years the ambulance service in Sweden has evolved from mainly being a source of transport to today’s high-tech caring facilities that enable qualified care to start already in the patient’s home. This first level of care is now provided by registered nurses and registered nurses with specialist training in pre hospital care. At the same time as the care provided is becoming more advanced, results from studies demonstrate that the amount of dispatches to patients that lack the need for ambulance care and transport is increasing. Nurses in pre-hospital care possess the knowledge, training and authority to perform an initial assessment of patients and also treat patients according to local and national guidelines. After the treatment it would sometimes be possible for the patients to remain at home without having to use ambulance transport to an emergency department or in other cases find other means of transport to hospital. Today this is, in Sweden, an accepted standard for by district nurses who are mandated to refer, even after only telephone consulting, the patients to self-care. Ambulance nurses lack this according to present guidelines. If a patient is to remain on-scene or home, a strict protocol of documentation has to be filled-in as well as the ambulance crew being in contact with a doctor. In this study, the authors visualize what patient categories stay on-scene or home, what types of examinations was performed and if the patient safety is ensured. Objective: The aim of this study was to visualize patient safety when the patient is not transported to hospital by ambulance. Method: A quantitative, descriptive and retrospective design and analysis of 137 ambulance medical records where the patient was left at home after the initial assessment. Results: The results demonstrate that the patients who wish to remain on-scene have various different conditions. The majority stayed home at their own request and without any further treatment being performed by the pre hospital care provider. In 28 per cent the patients received some kind of treatment, and in some of the cases patients refused ambulance transport even when the ambulance nurse strongly recommended this. This study also demonstrated that, in many cases, the patients´ history as well as the patients´ status were incomplete documented. The ambulance nurse performed, in median, four different examinations on the patients. In more than half of the cases the nurses had documented that the patient had some kind of attendance. Counseling was given both to patients and sometimes to the patients’ family member. A lack of sufficient documentation in the patients’ medical record was found and also that consultation of a doctor only has been completed in 15 per cent. Of a total of 137 patients there were three patients who called for an ambulance within the following 24 hours. One of these became aggressive during the first time of visit, and therefore the nurse wasn´t able to examine her thoroughly. The two other patients do not differ regarding the extent of the examination compared to those who didn´t call for ambulance again. Conclusion: Although this paper demonstrates that patients´ safety has not been compromised in the examined records, the authors recommend further studies on patient safety when patient remain on-scene. There is also a need for more specific and valid indicators. Documentation and adherence to guidelines were, however, in this study found to be insufficient. Key words: patient safety, ambulance, patient, specialist nurse in pre hospital care science, nurse, transport, journal.

Introduction: Serious cardiac toxicity due to lithium toxicity is uncommon and generally only occurs in individuals with underlying heart disease. Cardiac impairment may result in dysrhythmias, including sinus bradycardia, sinoatrial block, and first-degree atrioventricular block. This paper describes a patient with complete AV block in the course of chronic lithium treatment. Case report: Fifty-seven year-old female was brought into the emergency department (ED) due to altered mental status and malaise by ambulance from hospice. She had hypertension, type-II diabetes mellitus, and depression. The caregivers told that she had been fine yesterday, had taken regular medications (lysinopril, furosemid, acetyl salicylic acid, oral antidiabetic tablets and lithium (300 mg tb/day)). Her vital signs were; blood pressure: 70/45 mmHg, pulse: 37 bpm, respiratory rate: 22 bpm, and oxygen saturation 86%. She was confused and unresponsive to verbal stimulation. Her EKG revealed total atrioventricular block. Initial biochemical results were unremarkable except for a lithium level of 2.2 mmol/l (therapeutic range 0.5-0.8 mmol/l) and an increased creatinine of 2.11 mg/dl. A transvenous pacing electrode was introduced into the right ventricle, which allowed rapid restoration of haemodynamic and neurological status. Her neurologic examination was completely normal in the follow-up period and she was discharged without sequelae. Conclusion: In conclusion, emergency physicians should bear in mind that complete AV block can ensue in the course of lithium toxicity and it is an entity that should be included in the differential diagnosis. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

As the demand for faster and more effective health care increases, there is a growing need to establish mobile, high-speed communications between a moving ambulance and a consultation point (usually a hospital). The recent addition of HSPA (HSDPA and HSUPA) into the UMTS suite provides higher bandwidth and reduced delays, making this choice ideal for real-time telemedical applications. In this paper, we will describe a set of scenarios that took place in a typical large city area, along with their equivalent results: a moving ambulance was linked with a consultation station using HSPA and several videoconferencing sessions were initiated. Best-case, worst-case and average scenarios were recorded. Furthermore, in areas where the UMTS reception was marginal, a repeater was placed on top of the vehicle to boost up the signal power and thus maintain the higher bandwidth. Finally, treating doctors were asked to evaluate the effectiveness of this system's outputs, based on a variety of objective and subjective criteria.

Minimising the time required for a patient to receive primary care has always been the concern of the Accidents and Emergency units. Ambulances are usually the first to arrive on the scene and to administer first aid. However, as the time that it takes to transfer the patient to the hospital increases, so does the fatality rate. In this paper, a mobile teleconsultation system is presented, based primarily on third generation mobile links and on Wi-Fi hotspots around a city. This system can be installed inside an ambulance and will permit high-resolution videoconferencing between the moving vehicle and a doctor or a consultant within a base station (usually a hospital). In addition to video and voice, high quality still images and screenshots from medical equipment can also be sent. The test was carried out in Athens, Greece where a 3G system was recently deployed by Vodafone. The results show that the system can perform satisfactory in most conditions and can effectively increase the patient’s quality of service, while having a modest cost.