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Objective: Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future. Methods: A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017–2021) and Wellington Free Ambulance (2018–2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described. Results: There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population‐years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min. Conclusions: A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care. [ABSTRACT FROM AUTHOR]

Background: Emergency service workers (ESW) are known to be at increased risk of mental disorders but population-level and longitudinal data regarding their risk of suicide are lacking. Method: Suicide data for 2001–2017 were extracted from the Australian National Coronial Information Service (NCIS) for two occupational groups: ESW (ambulance personnel, fire-fighters and emergency workers, police officers) and individuals employed in all other occupations. Age-standardised suicide rates were calculated and risk of suicide compared using negative binomial regression modelling. Results: 13 800 suicide cases were identified among employed adults (20–69 years) over the study period. The age-standardised suicide rate across all ESW was 14.3 per 100 000 (95% CI 11.0–17.7) compared to 9.8 per 100 000 (95% CI 9.6–9.9) for other occupations. Significant occupational differences in the method of suicide were identified (p < 0.001). There was no evidence for increased risk of suicide among ESW compared to other occupations once age, gender and year of death were accounted for (RR = 0.99, 95% CI 0.84–1.17; p = 0.95). In contrast, there was a trend for ambulance personnel to be at elevated risk of suicide (RR = 1.41, 95% CI 1.00–2.00, p = 0.053). Conclusion: Whilst age-standardised suicide rates among ESW are higher than other occupations, emergency service work was not independently associated with an increased risk of suicide, with the exception of an observed trend in ambulance personnel. Despite an increased focus on ESW mental health and wellbeing over the last two decades, there was no evidence that rates of suicide among ESW are changing over time. [ABSTRACT FROM AUTHOR]

Paramedics play an essential and distinct role as providers of care to the dying, deceased and bereaved in Aotearoa, New Zealand and around the world. In this paper, we highlight what is known about the features, barriers and facilitators of quality end-of-life care by emergency ambulance personnel. We also identify priorities for future policy and practice, education and research in this area. Paramedics provide urgent and after-hours support to those with known life-limiting illness and their caregivers, but also attend sudden deaths, from unexpected or unknown causes. Paramedic care at the end of life may involve attempted resuscitation; challenging decision-making and communication; symptom relief; recognition of irreversible dying; provision of compassionate, culturally responsive support for co-responders, bystanders and the bereaved. There is an insufficient acknowledgement of the critical and unique role of paramedics, as providers of urgent care to the dying deceased and bereaved. Ambulance personnel around the world want better preparation and support for end-of-life care. Future research should aim to evaluate and improve this vital care, explore the needs and experiences of those who call an ambulance in the context of death, dying or bereavement and address equity and cultural responsiveness. [ABSTRACT FROM AUTHOR]

Background: For those patients who receive fibrinolysis in the treatment of ST-elevation myocardial infarction (STEMI), early treatment, i.e., within 2 hours of symptom onset, confers the greatest clinical benefit. This rationale underpins paramedic-delivered fibrinolysis in the prehospital setting. However, the current New Zealand approach requiring paramedics to first gain physician authorization, has proved inefficient and time consuming, particularly due to technological failings. Therefore, this study aimed to trial a new autonomous paramedic-delivered fibrinolysis model, examining the impact on time-to-treatment, paramedic diagnostic accuracy and patient outcomes. Methods: Utilizing a prospective observational approach, over a 24-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI, and initiated fibrinolysis. These patients were compared to a historic cohort who received fibrinolysis by paramedics within the same regions but following physician authorization. The main outcome measures were pain-to-needle (PTN) time and accuracy of paramedic diagnosis. A secondary end-point was 30-day and 6-month mortality and hospital length of stay (LOS). Results: A total of 174 patients received fibrinolysis (mean age, 64 years, SD ± 11.2). Median PTN time was 87 minutes (IQR = 58) for the historic cohort (n = 96), versus 65 minutes (IQR = 31) for the experimental cohort (n = 78), (p = 0.007). Autonomous paramedic diagnosis showed a sensitivity of 96% (95% CI 89–99) and specificity of 91% (95% CI 76–98). A significant reduction in both 30-day mortality and hospital LOS was observed among the experimental cohort (p = 0.04 and <0.001, respectively). No significant difference was observed between groups in terms of 6-month mortality. Conclusions: Prehospital fibrinolysis provided autonomously by paramedics without direct physician oversight is safe and feasible. Moreover, this independent approach can significantly improve time-to-treatment, resulting in short term mortality benefit and reduced hospital LOS. [ABSTRACT FROM AUTHOR]

New Zealand (NZ) has an ethnically diverse population. International studies have demonstrated significant differences in health equity by ethnicity; however, there is limited evidence in the context of out-of-hospital cardiac arrest in NZ. We investigated whether heath disparities in incidence and outcome of out-of-hospital cardiac arrest exist between NZ ethnic groups. A retrospective observational study was conducted using NZ cardiac arrest registry data for a 2-year period. Ethnic cohorts investigated were the indigenous Māori population, Pacific Peoples and European/Others. Incidence rates, population characteristics and outcomes (Return of Spontaneous Circulation sustained to hospital handover and thirty-day survival) were compared. Age-adjusted incidence rates per 100,000 person-years were higher in Māori (144.4) and Pacific Peoples (113.5) compared to European/Others (93.8). Return of spontaneous circulation sustained to hospital handover was significantly lower in Māori (adjusted OR 0.74, 95% CI 0.64–0.87, p < 0.001). Survival to thirty-days was lower for both Māori (adjusted OR 0.61, 95% CI 0.48–0.78, p < 0.001) and Pacific Peoples (adjusted OR 0.52, 95% CI 0.37–0.72, p < 0.001). A higher proportion of events occurred in all age groups below 65 years old in Māori and Pacific Peoples (p < 0.001), and a higher proportion of events occurred among women in Māori and Pacific Peoples (p < 0.001). There are significant differences in health equity by ethnicity. Both Māori and Pacific Peoples have higher incidence of out-of-hospital cardiac arrest and at a younger age. Māori and Pacific Peoples have lower rates of survival to thirty-days. Our results provide impetus for targeted health strategies for at-risk ethnic populations. [ABSTRACT FROM AUTHOR]

It is widely accepted that survival from OHCA may be improved through direct transfer of patients to hospitals with percutaneous coronary intervention (PCI) capability. However, within the New Zealand healthcare system there is limited evidence available to support this. We aimed to compare patient characteristics and outcomes following an out-of-hospital cardiac arrest between those patients transported to hospitals with or without PCI-capability within New Zealand. A retrospective cohort study was conducted using data from the St John New Zealand OHCA registry for adults treated for an out-of-hospital cardiac arrest of presumed cardiac aetiology between 1 October 2013 and 31 October 2018. Population characteristics were investigated using a Chi-Square analysis. Binary logistic regression modelling was used to investigate outcome differences in survival at 30 days post-event according to receiving hospital PCI-capability. The study included 1750 patients who were transported to hospital following an OHCA. A significantly lower proportion of patients over 65 years (49.9%) were conveyed to hospitals with PCI-capability compared to younger aged patients (15–44 years (52.1%) and 45–64 years (59.7%) (p < 0.001). When ethnic groups were compared, Māori (32.9%) had the lowest proportion transported to PCI-capable hospitals, followed by European (55.6%) then Pacific Peoples (86.2%) (p < 0.001). A lower proportion of patients located rurally (34.7%) were transported to hospitals with PCI-capability compared to patients in an urban location (59.1%) (p < 0.001). Thirty-day survival was higher in patients transported to hospitals with PCI-capability (adjusted OR 1.285, 95%CI (1.01–1.63), p = 0.04). Patient characteristic differences indicate that inequities in healthcare may exist in New Zealand related to age, ethnic group, and rurality. Thirty-day survival was significantly increased in patients conveyed directly to a hospital with PCI-capability. [ABSTRACT FROM AUTHOR]

Around the world, many paramedics are authorised to withhold or terminate resuscitation. Research indicates this can be a challenging part of their role. Little is known about graduating paramedic student confidence, concerns and learning in this area. An online cross-sectional survey of students nearing completion of a paramedic degree in New Zealand, including piloting of a newly-developed confidence scale. Seventy-two participants reported varying exposure to termination of resuscitation and patient death. Participants felt most confident providing technical procedurally-based care and least confident with non-technical skills. Participants' greatest concerns included making 'the right call', supporting grieving family, controlling emotions and encountering conflict. Clinical exposure with supportive mentoring, clinical simulation, peer reflection and resolved personal experience with death, were considered most useful for professional development. Exposure to termination of resuscitation and management of the scene of a patient death is variable amongst graduating paramedics. Novice paramedics may benefit from opportunities to observe and rehearse non-technical skills including delivering death notification and communicating with bystanders and bereaved family. The Confidence with Resuscitation Decision-Making and Patient Death Scale has favourable psychometric properties and utility as an outcome measure for future research in this area. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To describe the incidence and outcomes from out‐of‐hospital cardiac arrest (OHCA) in the New Zealand population served by the St John Ambulance Service. Methods: A retrospective observational study was conducted using data from the St John New Zealand OHCA registry, which serves a population of around 4 million. The incidence and outcomes of adult patients who were treated for an OHCA between 1 October 2013 and 30 September 2015 are reported. Results: A total of 7996 adult OHCA cases were attended, resuscitation was attempted in 3862 cases (60 per 100 000 person‐years). The median response time was 9 min (interquartile range 7–12), the median age was 66 (interquartile range 53–77) and 69% were men. Most events occurred in the home (67%), bystanders witnessed 53%, EMS witnessed 16% and 31% were unwitnessed. Bystander CPR was administered in 62% of cases and 8% were defibrillated prior to EMS arrival. Most events had a presumed cardiac aetiology (77%) and 38% presented in a shockable rhythm. Of those who had attempted resuscitation, a return of spontaneous circulation sustained to hospital handover occurred in 30% of events and 15% survived to 30 days. Adjusted survival outcomes demonstrated differences according to ethnicity. Conclusion: This is the first study to describe the epidemiology and outcomes of OHCA in New Zealand. Our findings provide important baseline data to monitor temporal trends, investigate the impact of changes in the management of OHCA and demonstrate that there are opportunities for improvement across the system of care. [ABSTRACT FROM AUTHOR]

Objective The present study aimed to describe and examine similarities and differences in the current service provision and resuscitation protocols of the ambulance services participating in the Aus- ROC Australian and New Zealand out-of-hospital cardiac arrest ( OHCA) Epistry. Understanding these similarities and differences is important in identifying ambulance service factors that might explain regional variation in survival of OHCA in the Aus- ROC Epistry. Methods A structured questionnaire was completed by each of the ambulance services participating in the Aus- ROC Epistry. These ambulance services were SA Ambulance Service, Ambulance Victoria, St John Ambulance Western Australia, Queensland Ambulance Service, St John Ambulance NT, St John New Zealand and Wellington Free Ambulance. The survey aimed to describe ambulance service and dispatch characteristics, resuscitation protocols and details of cardiac arrest registries. Results We observed similarities between services with respect to the treatment of OHCA and dispatch systems. Differences between services were observed in the serviced population; the proportion of paramedics with basic life support, advanced life support or intensive care training skills; the number of OHCA cases attended; guidelines related to withholding or terminating resuscitation attempts; and the variables that might be used to define 'attempted resuscitation'. All seven participating ambulance services were noted to have existing OHCA registries. Conclusion There is marked variation between ambulance services currently participating in the Aus- ROC Australian and New Zealand OHCA Epistry with respect to workforce characteristics and key variable definitions. This variation between ambulance services might account for a proportion of the regional variation in survival of OHCA. [ABSTRACT FROM AUTHOR]

Objective The present study aims to determine the agreement between paramedic and ED or hospital working diagnosis in dyspnoeic patients. Methods Non-consecutive written patient report forms were retrospectively audited for patients suffering from dyspnoea, who were transported to a tertiary hospital ED by ambulance paramedics. Accuracy of the paramedic working diagnosis was assessed by comparing agreement with either the primary or secondary ED diagnoses or hospital discharge diagnosis. Results The study cohort was 293 patients. Exact agreement between paramedic versus ED or hospital diagnosis was 64%, 95% CI 58-69, k = 0.58, 95% CI 0.52-0.64. Only 226 (77%) had a 'clearly documented' paramedic diagnosis. Among these, agreement with either ED or hospital diagnosis was 79%, and there was a trend towards more agreement as paramedic level of practice increased (74%, 78% and 87% for Basic, Intermediate and ALS paramedics, respectively, P = 0.07). Conversely, ALS paramedics were less likely to document a working diagnosis (30/98, 31%) compared with Intermediate (22/102, 23%) and BLS paramedics (15/93, 16%), P = 0.008. Diagnostic agreement varied according to medical condition, from anaphylaxis (100%) and asthma (86%) to acute pulmonary oedema (46%). Conclusions There was moderate agreement between paramedic and ED or hospital diagnosis. The number of cases with no clearly documented working diagnosis suggested that a singular working diagnosis may not always serve the complexity of presentation of some dyspnoea patients: more open descriptors such as 'mixed disease' or 'atypical features' should be encouraged. [ABSTRACT FROM AUTHOR]