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Objective In the United States, there are few unionized hospitals with air medical transport agencies. When labor disputes and strikes occur, information about the effect on helicopter air ambulances and critical care ground transport services is limited. For this study, a helicopter air ambulance and critical care ground transport agency's volume of transports was examined before, during, and after a strike and compared with volumes from the prior year. Methods This was a retrospective, descriptive comparative review of a unionized hospital's air ambulance and critical care mobile ground transport service records from March 28 to July 22, 2018 (control year, 872 transports) and March 28 to July 22, 2019 (strike year, 863 transports). Results Compared with the prior year, during the strike period alone, the volume of flight transports remained stable; however, there was a significant 31% loss in transports for time-critical diseases including trauma, stroke, and myocardial infarction. Conclusion The unionized helicopter air ambulance experienced little change in overall volume, but there was a statistically and financially significant decline in flight transports for patients with time-critical diseases. When preparing for labor disputes, potential declines in the transportation of this population type should be considered, and future studies should look at patient and requesting agency preferences during strikes.

Objective: Southern California Naval hospitals incur substantial costs through the use of civilian emergency medical services (EMS) as they lack an internal transportation team. This study aimed to quantify the volume and the associated charges for these transports in the Southern California area as these are currently unknown. Methods: This is a retrospective analysis of de-identified billing claims accessed through the Military Health System Management Analysis and Reporting Tool (M2) system. Data collected included the number and type of transports from Naval Hospitals in the Southern California area as well as the resulting charges. Data from Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) were collected over the 2018 and 2019 fiscal years. Results: There were 19,886 and 19,014 total ambulance transports in 2018 and 2019, respectively. Of these, about a quarter (8674/38900, 22.3%) were 9-1-1 calls from the patient's home resulting in an admission at a military treatment facility or network hospital. The majority were interfacility transports (20138/38900, 51.8%). These included transports from hospital discharge to home (3900/38900, 10.0%), transfers between hospitals (1648/38900, 4.2%), transfers from an office to a hospital (1818/38900, 4.7%), and transport for medical care (11682/38900, 30.0%). A large portion of these transports were for unclear transport needs (10088/38900, 25.9%). TRICARE paid $3,872,057 in 2018 and $4,004,996 in 2019 for a total of $7,877,053 spent on ambulance transport over the 2 years analyzed. Outside health insurance paid $10,217,016 over the same timeframe for these same claims. Conclusion: The interfacility transport costs incurred between NMCSD and NHCP are substantial, possibly leaving room for cost savings to be determined by further studies.

Introduction Hemorrhage is the second leading cause of death among urban trauma patients, and the provision of prehospital blood-based resuscitation can be lifesaving. We developed an efficient system to support blood-based resuscitation by an urban advanced life support ambulance system. Methods We worked with our state health department for permission for fire department paramedics to initiate blood transfusion and built protocols for field whole blood resuscitation. Our regional trauma center transfusion service provided 2 units of O positive, low-titer, leukoreduced whole blood in an internally monitored and sealed ice box weighing 10 pounds to the fire department paramedic supervisor. When notified, the supervisor transported the blood to the sites of anticipated need. Total blood use and wastage were recorded. Results Following two public hearings, we obtained state-wide approval for the initiation of emergency uncrossmatched blood transfusion by paramedics. Over a 1-year period beginning August 27, 2019, 160 units of whole blood were made available for use, and 51 units were transfused to 39 patients, 30 of whom were trauma patients. Other recipients include patients in shock from massive gastrointestinal, peripartum, or other suspected bleeding. Unused units were returned to the providing transfusion service after 1 week and used for hospital patient care without loss. The estimated cost of providing blood per mission was $0.28 and per patient transfused was $1138. Conclusions With appropriate attention to detail, it is possible to provide whole blood to an urban paramedical ambulance system with efficient blood component usage, minimal blood wastage, and low cost.

Objective: The purpose of this study is to understand the nature and source of disruptions in an ambulance during the telemedicine-based caregiving process for stroke patients to enhance the ambulance design for supporting telemedicine-based care. Background: Telemedicine is emerging as an efficient approach to provide timely remote assessment of patients experiencing acute stroke in an ambulance. These consults are facilitated by connecting the patient and paramedic with a remotely located neurologist and nurse using cameras, audio systems, and computers. However, ambulances are typically retrofitted to support telemedicine-enabled care, and the placement of these systems inside the ambulance might lead to spatial challenges and disruptions during patient evaluation. Method: Video recordings of 13 simulated telemedicine-based stroke consults were coded and analyzed using an existing systems-based flow disruption (FD) taxonomy. For each observed disruption—the type, severity or impact, location in the ambulance, and equipment involved in the disruption were recorded. Results: Seat size, arrangement of assessment equipment, location of telemedicine equipment (computer workstation), and design of telemedicine camera were among the factors that impacted telemedicine-related disruptions. The left ambulance seat zone and head of the patient bed were more involved in environmental hazard–related disruptions, while the right zone of the ambulance was more prone to interruptions and communication-related disruptions. Conclusion: Adequate evaluation space for the paramedic, proper placement of evaluation equipment, and telemedicine computer location could facilitate the stroke care evaluation process and reduce FDs in the ambulance.

Introduction:Since December 2019, emergency services and Emergency Medical Service (EMS) systems have been at the forefront of the fight against the coronavirus disease 2019 (COVID-19) pandemic world-wide.Objective:The objective of this study was to examine the reasons and the necessity of transportation to the emergency department (ED) by ambulance and the outcomes of these cases with the admissions during the COVID-19 pandemic period and during the same period in 2019.Methods:A retrospective descriptive study was conducted in which patients transported to the ED by ambulance in April 2019 and April 2020 were compared. The primary outcomes were the changes in the number and diagnoses of patients who were transferred to the ED by ambulance during the COVID-19 period. The secondary outcome was the need for patients to be transferred to the hospital by ambulance.Results:A total of 4,466 patients were included in the study. During the COVID-19 period, there was a 41.6% decrease in ED visits and a 31.5% decrease in ambulance calls. The number of critically ill patients transported by ambulance (with diagnoses such as decompensated heart failure [P Conclusions:Understanding how the COVID-19 pandemic is affecting EMS use is important for evaluating the current state of emergency health care and planning to manage possible future outbreaks.

Objectives Studies describing linkage of ambulance trips and emergency department (ED) visits of patients with opioid-related overdose (ORO) are limited. We linked records of patients experiencing ORO from ambulance trip and ED visit records in Massachusetts during April 1–June 30, 2017. Methods We estimated the positive predictive value of ORO-capturing definitions by examining the narratives and triage notes of a sample of OROs from each data source. Because of a lack of common unique identifiers, we deterministically linked OROs to records in the counter data set on date of birth, incident date, facility, and sex. To validate the linkage strategy, we compared ambulance trip narratives with ED triage notes and chief complaints for a sample of pairs. Results Of 3203 ambulance trips for ORO and 3046 ED visits for ORO, 82% and 63%, respectively, matched a record in the counter data set on date of birth, incident date, facility, and sex. In 200 randomly selected linked pairs from a final linked data set of 3006 paired records, only 5 (3%) appeared to be false matches. Practice Implications This exercise demonstrated the feasibility of linking ORO records between 2 data sets without a unique identifier. Future analyses of the linked data could produce insights not available from analyzing either data set alone. Linkage using 2 rapidly available data sets can actively inform the state’s public health opioid overdose response and allow for de-duplicating counts of OROs treated by ambulance, in an ED, or both.

Emergency medical services (EMS) activation is an integral component in managing individuals with myocardial infarction (MI). EMS play a crucial role in early MI symptom recognition, prompt transport to percutaneous coronary intervention centres and timely administration of management. The objective of this study was to examine sex differences in prehospital EMS care of patients hospitalized with Ml using data from a retrospective population-based cohort study of linked health administrative data for people with a hospital diagnosis of MI in Australia (2001-18).

BACKGROUND: Hospital arrival via ambulance influences treatment of acute stroke. We aimed to determine the factors associated with use of ambulance and access to evidence-based care among patients with stroke. METHODS: Patients with first-ever strokes from the Australian Stroke Clinical Registry (2010-2013) were linked with administrative data (emergency, hospital admissions). Multilevel, multivariable regression models were used to determine patient, clinical and system factors associated with arrival by ambulance. RESULTS: Among the 6,262 patients with first-ever stroke, 4,737 (76%) arrived by ambulance (52% male; 80% ischaemic). Patients who were older, frailer, with comorbidities or were unable to walk on admission (stroke severity) were more likely to arrive by ambulance to hospital. Compared to those using other means of transport, those who used ambulances arrived to hospital sooner after stroke onset (minutes, 124 vs 397) and were more likely to receive reperfusion therapy (adjusted odds ratio, 1.57, 95% CI: 1.09, 2.27). CONCLUSION: Patients with stroke who use ambulances arrived faster and were more likely to receive reperfusion therapy compared to those using personal transport. Further public education about using ambulance services at all times, instead of personal transport when stroke is suspected is needed to optimise access to time critical care.

Air pollutants play a crucial role in human health and disease. Emergency ambulance dispatch data have excellent potential for public and environmental health research. This study aimed at investigating the impact of short-term exposure to air pollutants on the emergency ambulance dispatches. We used data on emergency ambulance dispatches in Shanghai Municipality, China, from April 1, 2016 to December 31, 2017. The association of the daily emergency ambulance dispatches with air pollutants including PM2.5 (particles ≤ 2.5 μm in aerodynamic diameter), PM10, O3, NO2 and SO2 was analyzed with the use of time-series analyses. A total of 310,825 emergency ambulance dispatches for acute illness occurred in Shanghai during the study period. An increase in PM2.5 by 10 μg/m3 at lag1 and lag2 was shown to increase the risk of emergency ambulance dispatches (RR for lag1 = 1.05, 95% CI 1.00–1.11, RR for lag2 = 1.07, 95% CI 1.01–1.12). PM10, NO2, and SO2 also showed significant associations with emergency ambulance dispatches in single-pollutant models. Cause-specific analyses showed an elevation in PM2.5 by 10 μg/m3 was associated with an increased risk of emergency ambulance dispatches related to respiratory diseases on the current day (lag0, RR 1.17, 95% CI 1.01–1.33), while the impact on emergency ambulance dispatches related to other diseases presented 1–3 days later. The other pollutants have the similar trend. Our findings show a strong relationship between ambient air pollutants and emergency ambulance dispatches. Our study contributes to the growing body of evidence describing the adverse health effects of ambient air pollution and will benefit ambulance services for early warning and effective ambulatory planning.

Background many patients brought to emergency departments (EDs) following an emergency medical services (EMS) call have non-urgent needs that could be treated elsewhere. Older people are particularly vulnerable to adverse events while attending the ED. Alternative care pathway models can reduce ED crowding and improve outcomes. Internationally, there is no consensus on which model is recommended. Aim the aim of this study is to investigate the impact of the Pathfinder model on ED conveyance rates and patient safety. Methods the Pathfinder service is a collaboration between the National Ambulance Service and Beaumont Hospital Occupational Therapy and Physiotherapy Departments. It is supported by the Government of Ireland’s Sláintecare Integration fund. This is a retrospective cohort study of the Pathfinder service over a 5-month period. Results one-hundred and seventy-eight patients were responded to by the Pathfinder ‘Rapid Response Team’. Average age was 79.6 years (standard deviation 7.6), median clinical frailty score was 6 (interquartile range: 5–6). Sixty-four percent remained at home following initial review. None re-presented to the ED within 24 hours, and 10% re-presented within 7 days. The majority (67%) of patients required follow-up by the Pathfinder ‘Follow-Up Team’ and/or another community-based service. Feedback demonstrates 99% patient satisfaction with the service. Conclusion the Pathfinder service is a safe alternative to ED conveyance for older people following an EMS call. It is the first model of this kind to be evaluated in Ireland. The overwhelmingly positive feedback confirms that older people want this service. This model could expand, with local adaptation, nationally and internationally.

Introduction:Early police transport (PT) of penetrating trauma patients has the potential to improve survival rates for trauma patients. There are no well-established guidelines for the transport of blunt trauma patients by PT currently.Study Objective:This study examines the association between the survival rate of blunt trauma patients and the transport modality (police versus ground ambulance).Methods:A retrospective, matched cohort study was conducted using the National Trauma Data Bank (NTDB). All blunt trauma patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by ground Emergency Medical Services (EMS) for analysis. Descriptive analysis was carried out. This was followed by comparing all patients’ characteristics and their survival rates in terms of the mode of transportation.Results:Out of the 2,469 patients with blunt injuries, EMS transported 1,846 patients and police transported 623 patients. Most patients were 16-64 years of age (86.2%) with a male predominance (82.5%). Fall (38.4%) was the most common mechanism of injury with majority of injuries involving the head and neck body part (64.8%). Fractures were the most common nature of injury (62.1%). The overall survival rate of adult blunt trauma patients was similar for both methods of transportation (99.2%; P = 1.000).Conclusion:In this study, adult blunt trauma patients transported by police had similar outcomes to those transported by EMS. As such, PT in trauma should be encouraged and protocolized to improve resource utilization and outcomes further.

Background/aims Despite epistaxis being a common presentation to emergency departments there is a lack of guidelines, both nationally and internationally, for its management. The authors reviewed the current management of epistaxis and then introduced a new pathway for management to see if care could be improved. The aims were to evaluate the impact of the pathway on reduction of emergency department breaches, emergency ambulance transfers and hospital admissions. Methods The study was an interrupted time series analysis over 29 months and included 903 participants. A pathway for the management of adults with non-traumatic epistaxis was designed and implemented in a university teaching hospital with an emergency department annual attendance rate of 105 495 in 2019–20. Results The pathway led to a 14-minute longer stay in the emergency department, a 5% increase in emergency department breaches, an 8.2% reduction in admissions, a 3.6% reduction in emergency ambulance transfers, a 14.1% increase in nasal cautery and a 3.2% reduction in nasal packing. Conclusions The authors calculate that these results equate to roughly 56 hospital bed days saved, providing better care closer to home for patients, in addition to beneficial knock-on effects for other emergency department and admitted patients.

To compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time.A retrospective analysis was performed using data from Florida's Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks.In 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005).This study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.

Objective: Study objectives were to (i) develop and test a whole-of-system method for identifying patients who meet a major trauma by-pass guideline definition; (ii) apply this method to assess conformance to the current 2006 guideline for a road trauma cohort; and (iii) leverage relevant findings to propose improvements to the guideline. Methods: Retrospective analysis of existing, routinely collected data relating to Queensland road trauma patients July 2015 to June 2017. Data from ambulance, aero-medical retrievals, ED, hospital and death registers were linked and used for analysis. Processes of care measured included: frequency of pre-hospital triage criteria, distribution of destination (trauma service level), compliance with guideline (recommended vs actual destination), trauma service level by threat to life (injury severity) (all modes of transport and aero-medical in particular), proportion of patients requiring only ED, transport pathway (direct vs inter-hospital transfer). Results: 3847 cases were identified from data as meeting criteria for major trauma by-pass. The top five most frequently used criteria for qualifying patients as meeting the major trauma by-pass guideline were pulse rate, vehicle rollover, possible spinal cord injury, respiration rate and entrapment. The study demonstrates a 65% conformance to the clinical guideline. Over-triaged patients (transported to higher trauma service than recommended) generally reveal International Classification of Disease Injury Severity Score representing a high threat to life. Conclusion: Overall, the present study found good conformance, with over-triage rate as expected by clinicians. It is recommended to include data values to capture paramedics assessment of trauma level to enable more accurate assessment of conformance to guideline and future revision of the thresholds.

Background: San Francisco (California USA) is a relatively compact city with a population of 884,000 and nine stroke centers within a 47 square mile area. Emergency Medical Services (EMS) transport distances and times are short and there are currently no Mobile Stroke Units (MSUs). Methods: This study evaluated EMS activation to computed tomography (CT [EMS-CT]) and EMS activation to thrombolysis (EMS-TPA) times for acute stroke in the first two years after implementation of an emergency department (ED) focused, direct EMS-to-CT protocol entitled “Mission Protocol” (MP) at a safety net hospital in San Francisco and compared performance to published reports from MSUs. The EMS times were abstracted from ambulance records. Geometric means were calculated for MP data and pooled means were similarly calculated from published MSU data. Results: From July 2017 through June 2019, a total of 423 patients with suspected stroke were evaluated under the MP, and 166 of these patients were either ultimately diagnosed with ischemic stroke or were treated as a stroke but later diagnosed as a stroke mimic. The EMS and treatment time data were available for 134 of these patients with 61 patients (45.5%) receiving thrombolysis, with mean EMS-CT and EMS-TPA times of 41 minutes (95% CI, 39-43) and 63 minutes (95% CI, 57-70), respectively. The pooled estimates for MSUs suggested a mean EMS-CT time of 35 minutes (95% CI, 27-45) and a mean EMS-TPA time of 48 minutes (95% CI, 39-60). The MSUs achieved faster EMS-CT and EMS-TPA times (P Conclusions: In a moderate-sized, urban setting with high population density, MP was able to achieve EMS activation to treatment times for stroke thrombolysis that were approximately 15 minutes slower than the published performance of MSUs.

BACKGROUND In Japan, 44.3% of neonates are delivered in private clinics without an attending pediatrician. Obstetricians in the clinics must resuscitate asphyxiated neonates in unstable condition, such as respiratory failure, and they are frequently transferred to tertiary perinatal medical centers. There has been no study comparing the physiological status and prognosis of neonates transported by ambulance with those transported by helicopter. METHODS Medical and transport records were used to compare the physiological status of neonates transported to Kagoshima City Hospital by land and those transported by air between January 1, 2013, and December 31, 2017. RESULTS Data from 425 neonates transferred by land and 143 by air were analyzed. There were no significant differences between the two groups in mean gestational age, mean birthweight, fetal blood pH, Apgar score, or the Score for Neonatal Acute Physiology with Perinatal Extension-II (SNAPPE-II) on arrival to the tertiary center (16.3 ± 15.4 [95% confidence interval (CI): 13.2-17.7] vs 16.4 ± 15.4 [95% CI: 13.9-19.0], respectively; P = 0.999); both groups had SNAPPE-II score 10-19, indicating no difference in mortality risk. The times to starting first aid and to admission to the intensive care unit were significantly reduced in neonates transported by air than by land. In subgroup analysis of patients of a gestational age ≤28 weeks, all cases of severe intraventricular hemorrhage (IVH) were observed in the land transportation group. CONCLUSIONS Neonatal transportation by air is as safe as land transportation, and time to first aid and intensive care are significantly reduced by transportation by air than by land. Air transport could also contribute to the prevention of IVH in neonatal transportation.

The time it takes to begin treatment in life-threatening situations is critical. Ambulance transport to the hospital in such situations ensures quick and effective treatment but is not always readily available in nonurban areas, or not preferred by the public, for various reasons. The purpose of this qualitative study was to examine the factors that deter or encourage ambulance use in life-threatening situations in the geographic periphery from clients' perspectives. We conducted interviews with 71 patients in 3 medical centers who had arrived by ambulance or by private transport, and with the 3 emergency department directors. The findings revealed that awareness of the clinical situation and health literacy, accessibility of emergency services, geographical conditions, and social and economic factors are central in the decision to utilize this service. We detail research recommendations for strengthening public health literacy and access to services.

ObjectivesTo understand the effect of COVID-19 lockdown measures on severity of illness and mortality in non-COVID-19 acute medical admissions.DesignA prospective observational study.Setting3 large acute medical receiving units in NHS Lothian, Scotland.ParticipantsNon-COVID-19 acute admissions (n=1682) were examined over the first 31 days after the implementation of the COVID-19 lockdown policy in the UK on 23 March 2019. Patients admitted over a matched interval in the previous 5 years were used as a comparator cohort (n=14 954).Main outcome measuresPatient demography, biochemical markers of clinical acuity and 7-day hospital inpatient mortality.ResultsNon-COVID-19 acute medical admissions reduced by 44.9% across all three sites in comparison with the mean of the preceding 5 years (pConclusionsThese data demonstrate a significant reduction in non-COVID-19 acute medical admissions during the early weeks of lockdown. Patients admitted during this period were of higher clinical acuity with a higher incidence of early inpatient mortality.

Objectives. This study aimed to investigate whether Swedish ambulance personnel differ in the extent of suffering from health problems compared to other occupational groups. Methods. Two cohorts of ambulance personnel from 2001 and 2008, with 1778 and 2753 individuals, respectively, were followed regarding assignment of diagnostic coding (International Classification of Diseases codes) until 2016. These two cohorts represent all who were employed as ambulance personnel by public employers during these years. Two comparison groups were added: other healthcare workers and other professions. All data were retrieved from national registers. The chi (2) test was were used for statistical calculation. Results. Swedish ambulance personnel are at a significantly higher risk of being affected by 'Paroxysmal tachycardia, atrial fibrillation and flutter, other cardiac arrhythmias', by 'Other intervertebral disc disorders' and by 'Arthropathies', when compared to both comparison groups in both cohorts. Almost similar results were seen for 'Gonarthrosis' and for 'Dorsopathies'. Conclusions. Swedish ambulance personnel run the risk of being affected by certain diseases and injuries to a greater extent compared to other professions.

Background Patient with dizziness are challenging in prehospital care. The aim was to describe final diagnosis among patients assessed by EMS as suffering from dizziness with focus on time-critical conditions. Methods Consecutive patients assessed by an EMS clinician during 12 months in a single large EMS system in Gothenburg, Sweden (660,000 inhabitants), were assessed. The study comprised patients given ESS code 11 dizziness. The main end-point was the final diagnosis (ICD code). Results There were 58,575 primary missions, of which 2,048 (3.5%) were assessed as ESS code 11 (dizziness). Of these, 161 (8%) were excluded. Among the remaining 1887 cases, there were 230 different ICD codes and 96 (5%) had a time-critical condition. The majority (88%) had a cerebrovascular disease. The most typical symptoms among time-critical conditions were an acute onset (63%) and nausea, vomiting (61%). When compared with non-time-critical conditions, those with time-critical conditions were older and had a higher median systolic blood pressure at EMS arrival. Conclusion Among primary missions by the EMS, 3.5% had dizziness. Of these, 5% had a time-critical condition and the majority had a cerebrovascular disease. Instruments to identify time-critical conditions among patients seen by EMS due to dizziness are required.

Background Sudden cardiac death remains a leading cause of mortality in Canada, resulting in more than 35,000 deaths annually. Most cardiac arrest victims collapse in their own home (85% of the time) and 50% are witnessed by a family member or bystander. Survivors have a quality of life similar to the general population, but the overall survival rate for out-of-hospital cardiac arrest (OHCA) rarely exceeds 8%. Victims are almost four times more likely to survive when receiving bystander CPR, but bystander CPR rates have remained low in Canada over the past decade, not exceeding 15–25% until recently. Telecommunication-assisted CPR instructions have been shown to significantly increase bystander CPR rates, but agonal breathing may be misinterpreted as a sign of life by 9–1-1 callers and telecommunicators, and is responsible for as much as 50% of missed OHCA diagnoses. We sought to improve the ability and speed with which ambulance telecommunicators can recognize OHCA over the phone, initiate timely CPR instructions, and improve survival. Methods In this multi-center national study, we will implement and evaluate an educational program developed for ambulance telecommunicators using a multiple baseline interrupted time-series design. We will compare outcomes 12 months before and after the implementation of a 20-min theory-based educational video addressing barriers to recognition of OHCA while in the presence of agonal breathing. Participating Canadian sites demonstrated prior ability to collect standardized data on OHCA. Data will be collected from eligible 9–1-1 recordings, paramedic documentation and hospital medical records. Eligible cases will include suspected or confirmed OHCA of presumed cardiac origin in patients of any age with attempted resuscitation. Discussion The ability of telecommunication-assisted CPR instructions to improve bystander CPR and survival rates for OHCA victims is undeniable. The ability of telecommunicators to recognize OHCA over the phone is unequivocally impeded by relative lack of training on agonal breathing, and reluctance to initiate CPR instructions when in doubt. Our pilot data suggests the potential impact of this project will be to increase absolute OHCA recognition and bystander CPR rates by at least 10%, and absolute out-of-hospital cardiac arrest survival by 5% or more. Trial registration Prospectively registered on March 28, 2019 at ClinicalTrials.gov identifier: NCT03894059.

Background: Time delays to reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) still remain a considerable drawback in many healthcare systems. Emergency medical service (EMS) has a critical role in the early management of STEMI. Under investigation herein, was whether the use of physician-staffed ambulances leads to shorter pre-hospital delays in STEMI patients. Methods: This was an observational and retrospective study, using data from the registry of the Silesian regional EMS system in Katowice, Poland and the Polish Registry on Acute Coronary Syndromes (PL-ACS) for a study period of January 1, 2013 to December 31, 2016. The study population (n = 717) was divided into two groups: group 1 (n = 546 patients) — physician-staffed ambulances and group 2 (n = 171 patients) — paramedic-staffed ambulances. Results: Responses during the day and night shifts were similar. Paramedic-led ambulances more often transmitted 12-lead electrocardiogram (ECG) to the percutaneous coronary intervention centers. All EMS time intervals were similar in both groups. The type of EMS dispatched to patients (physicianstaffed vs. paramedic/nurse-only staffed ambulance) was adjusted for ECG transmission, sex had no impact on in-hospital mortality (odds ratio [OR] 1.41; 95% confidence interval [CI] 0.79–1.95; p = 0.4). However, service time exceeding 42 min was an independent predictor of in-hospital mortality (OR 4.19; 95% CI 1.27–13.89; p = 0.019). In-hospital mortality rate was higher in the two upper quartiles of service time in the entire study population. Conclusions: These findings suggest that both physician-led and paramedic-led ambulances meet the criteria set out by the Polish and European authorities. All EMS time intervals are similar regardless of the type of EMS unit dispatched. A physician being present on board did not have a prognostic impact on outcomes.

Objective This paper presents the first Naturalistic Decision Making model of prehospital resuscitation decision-making, which has clear implications for education, practice and support. Methods A mixed-methods exploratory sequential research design consisting of interviews with ambulance personnel (study 1), focus groups with ambulance educators, managers and peer supporters (study 2), and an online survey of graduating paramedic students (study 3). This paper reports the model developed from integrated findings, across all three studies. All research was undertaken in New Zealand and underpinned by a critical realist worldview. Results The Prehospital Resuscitation Decision Making model identifies key processes, challenges and facilitators before, during and after ambulance personnel attend a cardiac arrest event. It is the only descriptive model of resuscitation decision making which acknowledges the decision-maker, non-prognostic factors and the importance of adequate preparation and support. Conclusions This research project is the first to comprehensively explore and model ambulance personnel perspectives on decisions to start, continue or stop resuscitation. The decision-making process is complex and difficult to simply formularise. Education and supports must assist ambulance personnel in navigating this complexity. Where resuscitation is withheld or terminated, ambulance personnel need to feel confident that they can effectively provide after-death care.

Heart failure is the main cause of hospitalization, which burdens the healthcare system. Although many hospitalizations for heart failure follow ambulance use, it is unknown whether ambulance use increases hospitalization costs. Using the Diagnosis Procedure Combination database in Japan, we examined all hospitalizations of patients with heart failure from April 2014 to March 2015. Patients were divided into those with and those without ambulance use. We performed a multiple regression analysis to examine the association between ambulance use and total hospitalization costs, adjusting for age, sex, length of day, and activities of daily living. We identified 126,067 hospitalizations for heart failure. The percentages of ambulance use were 29%, 27%, 30%, and 50% among patients with NYHA Functional Classification I, II, III, and IV, respectively. For patients categorized as NYHA I (n = 9,700), multiple linear regression analysis revealed that ambulance use was significantly associated with higher hospitalization cost (coefficient 723 USD; 95% confidence interval 109-1337; p = 0.021). Even for heart failure patients with NYHA I, ambulances were frequently used. Ambulance use was independently associated with increased hospital costs. Future research is needed on transitional care to limit unnecessary ambulance use.

Resumo O objetivo deste artigo é analisar a evolução e o cenário de cobertura da atenção pré-hospitalar no Brasil entre 2015 e 2019, sob as dimensões de eficiência e suficiência, na totalidade dos municípios, segundo macrorregiões, população coberta, situação e estratégia de cobertura, área geográfica coberta, modalidades disponíveis e recursos móveis distribuídos. Estudo censitário, observacional, de abordagem quantitativa, descritiva e exploratória, realizado com dados disponibilizados pelo Ministério da Saúde, complementados com dados do Instituto Brasileiro de Geografia e Estatística. A eficiência na cobertura pré-hospitalar foi analisada segundo 17 indicadores relacionados a população coberta, distribuição dos recursos móveis e configuração de equipes por modalidade. A suficiência foi analisada segundo variações nestes indicadores entre municípios nas diferentes macrorregiões do país. Em 5 anos, a cobertura cresceu 5,4%, alcançou 85,0% dos cidadãos e 3750 municípios, com predomínio da modalidade de Suporte Básico de Vida. A exígua expansão da atenção pré-hospitalar e a persistência de municípios descobertos, denotam a ineficiência da cobertura, o que, associada à desigualdade na distribuição de recursos e modalidades, corrompe as diretrizes de integralidade e igualdade no acesso à saúde (suficiência). Abstract The scope of this article is to analyze the evolution and coverage of pre-hospital care in Brazil between 2015 and 2019 based on efficiency and sufficiency in all municipalities, according to macro-regions, population covered, situation and coverage strategy, geographic area covered, available modalities and mobile resources distributed. It is an observational, quantitative, descriptive, and exploratory census, conducted with data provided by the Ministry of Health, complemented with data from the Brazilian Institute of Geography and Statistics. Efficiency in pre-hospital coverage was analyzed according to 17 indicators linked to the population covered, distribution of mobile resources and configuration of teams by modality. Sufficiency was analyzed according to variations in these indicators between municipalities in different macro-regions of the country. In 5 years, coverage rose by 5.4%, attaining 85% of citizens and 3750 municipalities, with a predominance of the Basic Life Support modality. The meager expansion of pre-hospital care and the persistence of uncovered municipalities denote the inefficiency of coverage which, associated with the inequality in the distribution of resources and modalities, corrupts the guidelines of integrality and equality in access to health (sufficiency).

BackgroundEmergency Medical Services (EMS) have experienced surges in demand as the COVID-19 pandemic has progressed with ambulances services in the UK declaring major incidents due to the risk of care being compromised. COVID-19 specific EMS telephone triage tools have been introduced to help manage demand. There has been no previous evaluation of the accuracy of EMS telephone triage in identifying patients with suspected COVID-19 at risk of serious adverse outcome.We aimed to assess accuracy of EMS telephone triage in identifying patients who need an EMS response and identify factors which affect triage accuracy.MethodPatients who made an emergency call to Yorkshire Ambulance Service between 2nd April and 29th June 2020 and were assessed using an AMPDS pandemic pathway for suspected COVID-19 were linked to Office for National Statistics death registration data, hospital and general practice electronic health care data collected by NHS Digital.Accuracy of decision to dispatch an ambulance was assessed in terms of death or need for organ support at 30 days from the first 999 call. Multivariable logistic regression was used to identify factors associated with false negative and false positive triage.ResultsOf 12, 653 callers included in the study population, 11.1% experienced the primary composite adverse outcome. Using the triage pathway, 16% of callers did not receive an emergency response and they had a lower risk (3.5%) of the primary outcome. Ambulances were dispatched to 4, 230 callers (33.4%) who were not subsequently conveyed to hospital and did not experience the primary outcome (false positive triage). Multivariable modelling found older age and presence of pre-existing respiratory disease were significant predictors of false positive triage.ConclusionEMS telephone triage avoided 16% of calls receiving an emergency ambulance, of whom 3.5% died or needed organ support by 30 days. Telephone triage can therefore reduce the burden of EMS responses but with the cost of a small proportion of patients who do not receive an initial emergency response deteriorating. Research is needed to identify the appropriate balance between over- and under-triage

We aimed to evaluate the knowledge of 112 ambulance service staffers (doctors, nurses, emergency medical technicians [EMTs], and paramedics [PMs]) who were the first intervention to pediatric patients with burn injuries regarding first intervention and patient transfer.The study included 373 personnel working in 112 ambulance services in Ankara province. Participants were asked 17 questions to measure their knowledge of burns in children. Statistical analysis was performed with the Statistical Package for Social Sciences 21.0.Of the participants, 26 (7%) were doctors, 25 (6.7%) nurses, 180 (48.3%) EMTs, and 142 (35.3%) PMs. Of the participants, 118 stated that they always calculate the burn surface area, while only five (1.3%) marked the correct choice of the Lund Browder scheme to the question by which method they calculated. One hundred twenty one personnel (32.4%) use the Parkland formula to calculate the amount of fluid to be given during transfer while only 7 (1.9%) use the Galveston formula, which is more suitable for chil-dren. Of the participants, 56 (15%) answered as lactated Ringer's solution which is the correct fluid to the question of which fluid do you give at the scene and during the transfer. One hundred fifty-three participants (41%) responded correctly to the scenario question expected to recognize inhalation damage while only 138 (37%) responded correctly as 'I do immediately intubate' to the inhalation injury described scenario question. One out of 373 (0.3%) participants marked the appropriate procedure for a patient who had a 50% scald burn during the first intervention and transfer. The rate of topical lidocaine use of participants was high (70.8%). Of the 373 participants, only 33 (8.8%) thought themselves competent for first aid and transfer of children with burns. If training on the subject was held, 333 personnel (89.3%) wanted to participate.It is expected that the knowledge of 112 ambulance services who see pediatric burn patients first, perform the first intervention, and provide transfer would be suitable. However, our questionnaire shows that these personnel have insufficient knowledge and need to be trained.

The purpose of this article is to summarize existing literature about healthcare-associated infection (HAI) in the medical transport environment and to define the term medical transport–associated infection (MTAI) to unify all previous work under a single umbrella with the objective of providing a standardized definition for future research. A review of the literature yielded 34 relevant articles. These studies show that there are pathogens in the ambulance environment, that emergency medical services (EMS) personnel do not regularly comply with hygiene practices, and that patients are potentially affected by HAI as a direct result of ambulance exposure. Prospective studies must be conducted to truly understand the impact that ambulance exposure has on HAIs. MTAI is a subset of HAI and is defined as any infection acquired as a direct effect of exposure in a medical transport setting.

BACKGROUND: The United States is currently facing 2 epidemics: sustained morbidity and mortality from substance use and the more recent COVID-19 pandemic. We tested the hypothesis that the pandemic has disproportionately affected individuals with substance use disorder by evaluating average daily 9-1-1 ambulance calls for substance use-related issues compared with all other calls. METHODS: This was a retrospective cross-sectional analysis of 9-1-1 ambulance calls before and after the start of COVID-19 in Massachusetts. We used consecutive samples of 9-1-1 ambulance calls, categorized into those which were substance-related or not. An interrupted time series analysis was performed to determine if there were changes in numbers of daily calls before a statewide declaration of emergency for COVID-19 (February 15–March 9, 2020), from the emergency declaration until a stay-at-home advisory (March 10–March 22, 2020) and following the stay-at-home advisory (March 23–May 15, 2020). RESULTS: Compared with prior to the statewide emergency, the post-statewide emergency average of daily ambulance calls decreased from 2,453.2 to 1,969.6, a 19.7% decrease. Similarly, calls for substance-related reasons decreased by 16.4% compared with prior to the statewide emergency. However, despite an initial decrease in calls, after the stay-at-home advisory calls for substance use began increasing by 0.7 (95% confidence interval (CI) 0.4–1.1) calls/day, while calls for other reasons did not significantly change (+1.2 (95% CI −0.8 to 3.1) calls/day). Refusal of transport for substance-related calls increased from 5.0% before the statewide emergency to 7.5% after the declaration (p < 0.001). CONCLUSIONS: After an initial decline in substance-related ambulance calls following a statewide declaration of emergency, calls for substance use increased to pre-COVID-19 levels, while those for other reasons remained at a lower rate. The results suggest that COVID-19 is disproportionately affecting individuals with substance use disorder.

Aim of the study For out-of-hospital-cardiac-arrest (OHCA) due to ventricular fibrillation (VF) guidelines recommend early defibrillation followed by chest compressions for two minutes before analyzing shock success. If rhythm analysis reveals VF again, it is obscure whether VF persisted or reoccurred within the two-minutes-cycle of chest compressions after successful defibrillation. We investigated the time of VF-recurrence in OHCA. Methods We examined all cases of OHCA presenting with initial VF rhythm at arrival of ALS-ambulance (Marburg-Biedenkopf-County, 246.648 inhabitants) from January 2014 to March 2018. Three independent investigators analyzed corpuls3® ECG-recordings. We included ECG-data from CPR-beginning until four minutes after the third shock. VF termination was defined as the absence of a VF-waveform within 5 s of shock delivery. VF recurrence was defined as the presence of a VF-waveform in the interval 5 s post shock delivery. Results We included 185 shocks in 82 patients. 74.1% (n = 137) of all shocks terminated VF, but VF recurred in 81% (n = 111). The median (IQR) time of VF-recurrences was 27 s (13.5 s/80.5 s) after shock. 51.4% (n = 57) of VF-recurrence occurred 5–30 s after shock, 13.5% (n = 15) VF-recurrence occurred 31−60 s after shock, 21.6% (n = 24) of VF-recurrence occurred 61–120 s after shock, 13.5% (n = 15) of VF-recurrence occurred 121–240 s after shock. Conclusions Although VF was terminated by defibrillation in 74.1%, VF recurred in 81% subsequent to the chest compression interval. Thus, VF reappears frequently and early. It is unclear to which extend chest compressions influence VF-relapse. Further studies need to re-evaluate the algorithm, timing of antiarrhythmic therapy or novel defibrillation strategies to minimize refibrillation during shockable OHCA.

Aims and objectives: To obtain the current perception of the knowledge and competence of pre-hospital emergency specialist nurses (ambulance) in attending patients with psychiatric symptoms. Background: Psychiatric illnesses have increased throughout the population. Consequently, pre-hospital emergency services frequently attend individuals with suspected or known mental illnesses. Design: We employed a set of quantitative and qualitative methods to gain a deeper understanding of ambulance nurses' self-evaluated knowledge. Methods: Seven ambulance nurses received and completed a survey questionnaire prior commencing employment in November 2019. Then, we conducted interviews to explore ambulance nurses' perceptions of their own knowledge and competence when attending individuals with mental disorders. The surveys were analysed with descriptive statistics, followed by content analysis. Results: Three topics emerged: the encounter of patients with mental illness; the awareness of lacking knowledge about mental illnesses; and the expectations for future Prehospital Emergency Psychiatric Response Teams. Although ambulance nurses already possessed basic knowledge regarding psychiatric illnesses, it was insufficient, based on their perception of appropriate care. Ambulance nurses considered that combining pre-hospital and psychiatric expertise in the pre-hospital emergency unit would increase their in-depth knowledge about various psychiatric illnesses, the treatment options and the alternatives regarding where to deliver patients for continued care. (Less)

Prescription medicine misuse is a significant problem in many areas of the world. Understanding the acute and chronic harms related to misuse of prescription medicines allows healthcare professionals, drug addiction treatment services and legislative authorities to determine what interventions may be beneficial to reduce these harms and protect individuals and society. However, it is difficult to obtain systematic data on the harms associated with prescription medicine misuse because of how patient visits to clinics and hospitals are recorded and coded in regional or national databases. In this review, we discuss how regional, national and international sources of information can help develop a greater understanding of the prevalence and pattern of acute harms related to prescription medicine misuse using data from ambulance attendances, emergency department presentations and poisons information services.

The optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality.Using the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates.A total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P.0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P.0001).Helicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.

Traumatic brain injury (TBI) is the most common neurosurgical condition globally. In Cameroon, there are 572 cases of TBI per 100,000 people, but40% of Cameroonians live within 4 hours of a neurosurgical facility. We sought to understand the clinical outcomes at a neurosurgical center in Central Cameroon.This cross-sectional study was conducted at the largest neurosurgical center of Cameroon, the Yaounde Central Hospital. Data included 100 consecutive patients undergoing an intervention 72 hours after their injury from February 1, 2015 to February 1, 2019. Patients with missing data or undergoing surgery72 hours after injury were excluded. Analyses of covariance were performed, and a P value0.05 was considered significant. A Kaplan-Meier survival curve was computed.The patients had a mean age of 31.3 ± 17.4 years, with a male predominance of 91.0%, and the principal mechanism of injury was road traffic accidents (68.0%). Only 11% arrived via ambulance, and 36.0% were admitted3 hours after the traumatic event. The postoperative mortality was 15.0%, mean survival was 25.0 postoperative days (95% confidence interval, 23.42-26.52), and the mean Glasgow Outcome Scale score at 28 days was 3.9 ± 1.4.Most patients with TBI undergoing neurosurgery 72 hours after injury in Cameroon arrive at the hospital late and have a high mortality risk during the first postoperative week. Investments in prehospital care should be made to improve surgical outcomes.

Supplemental Digital Content is available in the text., Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P

Introduction:The effect and subjective perception of audiovisual consults (AVCs) by paramedics with a distant physician in prehospital emergency care (PHEC) remain unexplained, especially in low-urgency calls.Objectives:The primary objective of the study was to evaluate the effect of AVCs by paramedics with a base physician on the rate of patients treated on site without the need of hospital transfer. The co-primary safety outcome was the frequency of repeated ambulance trips within 48 hours to the same patient. Secondary objective was the qualitative analysis of perception of the AVCs.Methods:During a six-week period, the dispatching center of Karlovy Vary Emergency Medical Service (EMS) randomized low-urgency events from a rural area (n = 791) to receive either a mandatory phone-call consult (PHONE), AVC (VIDEO), or performed by the paramedic crew in a routine manner, when phone-call consultation is for paramedic crew optional (CONTROL). Secondarily, the qualitative analysis of subjective perception of AVCs compared to consultation over the phone by the paramedic and consulting physician was performed.Results:Per-protocol analysis (PPA) was performed (CONTROL, n = 258; PHONE, n = 193; and VIDEO, n = 192) in addition to the intention-to-treat (ITT) analysis. Patients (PPA) in both mandatory consulted groups were twice as likely to be treated and left on site compared to the CONTROL (PHONE: OR = 2.07; 95% CI, 1.19 to 3.58; P = 0.01 or VIDEO: OR = 2.01; 95% CI, 1.15 to 3.49; P = .01). Repeated trips to patients treated and left on site in 48 hours occurred in three (8.6%) of 35 cases in the PHONE group and in eight (23.5%) of 34 cases in the VIDEO group.Conclusions:The AVCs of the emergency physician by paramedics was not superior to the mandatory conventional phone call in increasing the proportion of patients treated and left at home after a low-urgency call. The AVC improved the subjective feelings of safety by physicians, but not the satisfaction of patients or paramedics, and may lead to an increased need of repeated trips.

Medical services in WWI had to face enormous new problems: masses of wounded, most with devastating wounds from artillery splinters, often involving body cavities, and always contaminated. Tetanus, gas gangrene, wound infections were common and often fatal. Abdominal wounds were especially a problem: upon entering the war the commanders of all medical services ordered to avoid surgery, based on dismal experiences of previous wars. Surgical community divided into non-operative and operative treatment supporters. The problem seemed mainly organizational, as the wounded were rescued after many hours and treated by non-specialist doctors, in inadequate frontline settings or evacuated back with further delay of treatment. During initial neutrality, Italian Academics closely followed the debate, with different positions. Many courses and publications on war surgery flourished. Among the interventionists, Baldo Rossi, to provide a setting adequate to major operations close to the frontline, with trained surgeons and adequate instruments, realized for the Milano Red Cross three fully equipped, mobile surgical hospitals mounted on trucks, with an operating cabin-tent, with warming, illumination and sterilizing devices, post-operative tents and a radiological unit. Chiefs of the army approved the project and implemented seven similar units, called army surgical ambulances, each run by a distinguished surgeon. Epic history and challenges of the mobile units at the frontline, brilliant results achieved on war wounds and epidemics are described. After the war they were considered among the most significant novelties of military medical services. Parallels with present scenarios in war and peace are outlined.

Integration in operations between 1990 Suwa Seriya ambulance service and A&E services of hospitals in Sri Lanka was assessed qualitatively using the Mini Focus Group Discussion (Mini-FGD) technique and applying a Likert scale survey. Agreed group-perceived satisfaction of the A&E staff was recorded based on identified thematic areas. The technique of patient handling, reliability of vital sign recording, providing random blood sugar reading, and professional relationship with hospital staff of Suwa Seriya emergency ambulance service were the thematic areas that recorded positive agreed group-perceived satisfaction indicating a potential to broaden the integration process with the A&E operations of the country. Quality of providing clinical history, administration of medication, and awareness of A&E operations of emergency ambulance service indicated least agreed group-perceived satisfaction. Moreover, providing clinical notes and investigation records such as electrocardiogram, sharing feedback about the patient, prehospital triaging, and pre-alert system were found to be non-operational. The health-care policymakers of Sri Lanka should exploit the positives and explore the negatives of the A&E staff perception on 1990 Suwa Seriya ambulance service, focusing on widening the integration process.

Emergency Medical Services (EMS) often respond to 911 calls using red lights and sirens (RLS). RLS is associated with increased collisions and increased injuries to EMS personnel. While some patients might benefit from time savings, there is little evidence to guide targeted RLS response strategies. To describe the frequency and nature of 911 calls that result in potentially life-saving interventions (PLSI) during the call. Using data from ESO (Austin, Texas, USA), a national provider of EMS electronic health records, we analyzed all 911 calls in 2018. We abstracted the use of RLS, call nature, and interventions performed. A liberal definition of PLSI was developed a priori through a consensus process and included both interventions, medications, and critical hospital notifications. We calculated the proportion of calls with RLS response and with PLSI performed, both overall and stratified by call nature. There were 5,977,612 calls from 1,187 agencies included in the analysis. The majority (85.8%) of calls utilized RLS, yet few (6.9%) resulted in PLSI. When stratified by call nature, cardiac arrest calls had the highest frequency PLSI (45.0%); followed by diabetic problems (37.0%). Glucose was the most frequently given PLSI, n = 69,036. When including multiple administrations to the same patient, epinephrine was given most commonly PLSI, n = 157,282 administrations). In this large national dataset, RLS responses were very common (86%) yet potentially life-saving interventions were infrequent (6.9%). These data suggest a methodology to help EMS leaders craft targeted RLS response strategies.

BackgroundSyndromic surveillance can supplement conventional health surveillance by analyzing less-specific, near-real-time data for an indication of disease occurrence. Emergency medical call centre dispatch and ambulance data are examples of routinely and efficiently collected syndromic data that might assist in infectious disease surveillance. Scientific literature on the subject is scarce and an overview of results is lacking.MethodsA scoping review including (i) review of the peer-reviewed literature, (ii) review of grey literature and (iii) interviews with key informants.ResultsForty-four records were selected: 20 peer reviewed and 24 grey publications describing 44 studies and systems. Most publications focused on detecting respiratory illnesses or on outbreak detection at mass gatherings. Most used retrospective data; some described outcomes of temporary systems; only two described continuously active dispatch- and ambulance-based syndromic surveillance. Key informants interviewed valued dispatch- and ambulance-based syndromic surveillance as a potentially useful addition to infectious disease surveillance. Perceived benefits were its potential timeliness, standardization of data and clinical value of the data.ConclusionsVarious dispatch- and ambulance-based syndromic surveillance systems for infectious diseases have been reported, although only roughly half are documented in peer-reviewed literature and most concerned retrospective research instead of continuously active surveillance systems. Dispatch- and ambulance-based syndromic data were mostly assessed in relation to respiratory illnesses; reported use for other infectious disease syndromes is limited. They are perceived by experts in the field of emergency surveillance to achieve time gains in detection of infectious disease outbreaks and to provide a useful addition to traditional surveillance efforts.

Introduction Public access defibrillation is a key component of the early links in the chain of survival. Despite growing numbers of PADs in the community, actual use remains poor, partly because of the difficulties in locating the nearest PAD. We aimed to establish the cover that would be provided if PADs were located in any given building type, which would enable the public to know where the nearest PAD was located. Methods Mapping software was used to classify each and every building type in the South Central Ambulance Service region. The 52 commonest building types were then mapped to all cardiac arrest calls in the same geographical area from Jan 2014 - July 2018. The walking distance from each cardiac arrest to each nearest building type was calculated. Results A total of 22,382 cardiac arrests were mapped to a total of 24,155 buildings considered suitable for potential PAD location. Post boxes ranked first in both urban and rural areas, covering 11.7% of cardiac arrests at 100 m and 85.6% of cardiac arrests at 500 m. In urban areas, bus shelters and telephone boxes also provided good coverage (9.7%, 9.5% @ 100 m; 69.2%, 71.9% @ 500 m respectively). In rural areas, good coverage was provided by nursing/care homes and pubs/bars (4.9%, 4.6% @ 100 m; 15.2%, 31.8% @ 500 m respectively). Conclusion Locating PADs at all post boxes would provide the most effective geographical coverage in both urban and rural areas according to building type. This may be an effective strategy to improve rapid PAD locating.

OBJECTIVE Administration of unfractionated heparin to STEMI patients by the ambulance service is an established practice in Scotland, but the efficacy is unknown. We studied the effects of unfractionated heparin in STEMI patients treated by primary percutaneous coronary intervention, on infarct artery patency and mortality. METHODS AND RESULTS Consecutive patients (n = 1000) admitted to Ninewells Hospital, Dundee, from 2010 to 2014 for primary percutaneous coronary intervention were allocated to 2 groups: 437 (44%) prehospital heparin (PHH) administered by paramedics, and 563 (56%) in-hospital heparin. A trained medical student assessed coronary flow at presentation and collected the data. Mortality status was ascertained at 30 days and 5 years. Cox proportional hazards regression models were generated. The patient groups were similar, although PHH had shorter symptom onset-treatment time (187 vs. 251 minutes, P < 0.001) and less cardiogenic shock (3.9% vs. 8.0%, P = 0.008). Initial coronary flow was not different between the groups. Thirty day mortality in PHH was 2.5% versus 8.3%, P < 0.001. Independent predictors of 30-day mortality were age (odds ratio 1.07, 95% CI 1.04-1.09), cardiogenic shock (5.97, 3.33-10.69), radial access (0.53, 0.28-0.98), and PHH (0.33, 0.17-0.66). Five-year mortality in PHH was 13.0% versus 21.6%, P < 0.001. Significant predictors of long-term mortality were age (1.07, 1.06-1.09), cardiogenic shock (3.40, 2.23-5.17), and PHH (0.68, 0.49-0.96). CONCLUSIONS PHH was associated with reduced short- and long-term mortality after adjusting for important potential confounders.

Motor vehicle crashes (MVCs) comprise a significant component of emergency medical service workload. Due to the potential for life-threatening injuries, ambulances are often dispatched at the highest priority to MVCs. However, previous research has shown that only a small proportion of high-priority ambulance responses to MVCs encounter high acuity patients. Alternative methods for triaging patients over the phone are required to reduce the burden of over-triage. One method is to use information readily available at the scene (e.g. whether a person was a motorcyclist, ejection status or whether an airbag deployed) as potential predictors of high acuity.

To investigate the extent to which long-term care facilities used ambulances for low-acuity conditions. A large number of instances of ambulance use for low-acuity conditions corresponded to long-term care facilities. Intervention in long-term care facilities may reduce ambulance use for low-acuity conditions, which will help facilitate the timely transportation of patients. Increased ambulance calls affect the timely transportation of patients. Recently, ambulance uses from long-term care facilities (LTCFs) for older adults has been increasing. The aim of this study was to investigate to what extent LTCFs used ambulances for low-acuity conditions. Ambulance records from the fire department of Misato City were used. The participants were patients aged 65 years or older transported from all types of LTCFs (including public nursing homes, geriatric health services facilities, private nursing homes, and group homes) and homes. The proportions of ambulance use for low-acuity conditions and their 95% confidence intervals (CI) were calculated and compared by time (daytime and night-time) and day (weekdays and holidays) of ambulance use for each type of residence. Of 12,494 participants, 1336 (11%) were transported from LTCFs, and 326 (2.6%) for low-acuity conditions. Of 326 patients with low-acuity conditions, 69% were transported from LTCFs. The proportion of low-acuity conditions was 17% among those transported from LTCFs, while it was only 1% among those from homes. The proportion of low-acuity conditions was significantly greater during night-time than daytime among those from public nursing homes, geriatric health services facilities, and group homes, while this proportion was greater on weekdays than holidays among those from geriatric health services facilities. This study found a large number of instances of ambulance use for low-acuity conditions by LTCFs. To reduce unnecessary ambulance use for low-acuity conditions efficiently, LTCFs should be assisted in making proper assessments of both patients’ conditions and appropriate ambulance use.

ObjectivePatients in the last year of life experience medical emergencies which may lead to an emergency attendance by ambulance clinicians and some patients having a transfer to hospital even when this is unwanted by patients, carers or professionals. Here we report the patient characteristics and outcomes of a 24-hour hospice nursing telephone advice service to support an ambulance service.MethodAn evaluation of the outcomes of ambulance calls to a nursing telephone advice service for people living in northwest London, UK, attended at home during a 6-month period by the London Ambulance Service, whose clinicians then sought advice from the hospice’s 24 hours’ telephone line.ResultsForty-five attendances of 44 acutely ill people with palliative care needs resulted in a telephone call. Thirteen patients (30%) were male and the median age was over 80 years. Thirty-two attendances (71%) were managed without a transfer to hospital, with telephone advice from the hospice and in some cases arrangements for another clinician to visit. Seven attendances (16%) resulted in a transfer to hospital, of which at least five led to an admission. Six attendances (13%) resulted in a notification of the patient’s death.ConclusionsThis preliminary study shows the feasibility, outcomes and acceptability of telephone advice to support ambulance clinicians attending patients with palliative care needs. The service was associated with low rates of subsequent transfer to hospital. Further controlled research is needed to assess the clinical and cost-effectiveness of the service.

Objective: Use of point-of-care (POC) troponin (cTn) testing in the Emergency Department (ED) is well established. However, data examining POC cTn measurement in the prehospital setting, during amb...

Background and Purpose— Mobile stroke units (MSUs) are increasingly used worldwide to provide prehospital triage and treatment. The benefits of MSUs in giving earlier thrombolysis have been well established, but the impacts of MSUs on endovascular thrombectomy (EVT) and effect on disability avoidance are largely unknown. We aimed to determine the clinical impact and disability reduction for reperfusion therapies in the first operational year of the Melbourne MSU. Methods— Treatment time metrics for MSU patients receiving reperfusion therapy were compared with control patients presenting to metropolitan Melbourne stroke units via standard ambulance within MSU operating hours. The primary outcome was median time difference in first ambulance dispatch to treatment modeled using quantile regression analysis. Time savings were subsequently converted to disability-adjusted life years avoided using published estimates. Results— In the first 365-day operation of the Melbourne MSU, prehospital thrombolysis was administered to 100 patients (mean age, 73.8 years; 62% men). The median time savings per MSU patient, compared with the control cohort, was 26 minutes ( P P P P =0.001) for EVT hospital arrival to arterial puncture for MSU patients. Estimated median disability-adjusted life years saved through earlier provision of reperfusion therapies were 20.9 for thrombolysis and 24.6 for EVT. Conclusions— The Melbourne MSU substantially reduced time to reperfusion therapies, with the greatest estimated disability avoidance driven by the more powerful impact of earlier EVT. These findings highlight the benefits of prehospital notification and direct triage to EVT centers with facilitated workflow on arrival by the MSU.

Background: Stroke has been found to have a seasonally varying incidence; blood pressure, one of its risk factors, is influenced by humidity and temperature. The relationship between the incidence of stroke and meteorological parameters remains controversial. Objective: We investigated whether meteorological conditions are significant risk factors for stroke, focusing on the fluctuation of weather elements that triggers the onset of stroke. Methods: We collected ambulance transportation data recorded by emergency personnel from Gifu Prefecture. We included cases where the cause of the transportation was stroke and excluded cases of trauma. We combined these data with meteorological data as well as data on average temperature, average air pressure, and humidity provided publicly by the Japan Meteorological Agency. Our target period was from January 2012 to December 2016. Results: In the 5-year target period, there were 5,501 occurrences of ambulance transportation due to stroke. A seasonal tendency was confirmed, since ambulance transportation for stroke occurred more frequently at low temperatures (p < 0.001). Temperature (odds ratio: 0.91; p < 0.001) and humidity change (odds ratio: 1.50; p = 0.016) were identified as risk factors for ambulance transportation due to stroke. An increase in temperature incurs a lower risk than a decrease (odds ratio: 0.58; p = 0.09), although there is no statistically significant difference. Conclusions: Meteorological effects on the frequency of ambulance transportation due to stroke were studied. A lower temperature and radical humidity change were identified as risk factors for ambulance transportation due to stroke, and a decrease in temperature was also associated. We speculate on the possibilities of using meteorological data to optimize the assignment of limited medical resources in medical economics.