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Morten Breinholt Søvsø,1 Rasmine Birch Haurum,2 Trine Hagelskær Ebbesen,2 Ann Øster Rasmussen,2 Logan Morgan Ward,3 Mads Lause Mogensen,3 Erika Frischknecht Christensen,1 Tim Alex Lindskou1 1Centre for Prehospital and Emergency Research at Danish Centre for Health Services Research; Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Gistrup, Denmark; 2Department of Health, Science and Technology, Aalborg University, Gistrup, Denmark; 3Treat Systems ApS, Aalborg, DenmarkCorrespondence: Tim Alex Lindskou, Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, Gistrup, 9260, Denmark, Tel +45 23274523, Email tim.l@rn.dkIntroduction: Ambulance requests by general practitioners for primary care patients (GP-requested) are often omitted in studies on increased demand within emergency care but may comprise a substantial patient group. We aimed to assess acute severity, intensive care unit (ICU) admission, and diagnostic pattern, including comorbidity, and mortality among GP-requested ambulance patients, compared to emergency call ambulance patients. Our hypothesis was that emergency call patients had more severe health issues than GP-requested ambulance patients.Methods: Historic population-based cohort study of ambulance patients in the North Denmark Region, 2016– 2020. Hospital contact data including diagnoses, ambulance data, vital signs and vital status was linked using each patient’s unique identification number. Primary outcome measure was mortality within 1, 7, and 30 days. Secondary outcomes were disease severity expressed as modified National Early Warning Score (NEWS2), and ICU admission. Admission status and hospital diagnostic pattern, including comorbidity were described and compared.Results: We included 255,487 patients. GP-requested patients (N = 119,361, 46.7%) were older (median years [IQR] 73 [58– 83] versus 61 [37– 76]) and more had moderate/severe comorbidity (11.9%, N = 13,806 versus 4.9%, N = 6145) than the emergency call patients. Prehospital mNEWS2 median scores were lower for GP-requested patients. For both groups, mNEWS2 was highest among patients aged 66+. GP-requested patients had higher 30-day mortality (9.0% (95% CI: 8.8– 9.2), N = 8996) than emergency call patients (5.2% (95% CI: 5.1– 5.4), N = 6727). Circulatory (12.0%, 11,695/97,112) and respiratory diseases (11.6%, 11,219/97,112) were more frequent among GP-requested patients than emergency call patients ((10.7%, 12,640/118,102) and (5.8%, 6858/118,102)). The highest number of deaths was found for health issues ‘circulatory diseases’ in the emergency call group and ‘other factors’ followed by “respiratory diseases” in the GP-requested group.Conclusion: GP-requested patients constituted nearly half of the EMS volume, they were older, with more comorbidity, had serious conditions with substantial acute severity, and a higher 30-day mortality than emergency call patients.Keywords: emergency medical services, mortality, diagnoses, early warning scores, after-hours care, primary healthcare, general practitioners

Theo Walter Jensen,1,2 Stig Nikolaj Blomberg,1,2 Fredrik Folke,1– 3 Søren Mikkelsen,4,5 Martin Rostgaard-Knudsen,6 Palle Juelsgaard,7 Erika Frishknecht Christensen,6,8 Christian Torp-Pedersen,9,10 Freddy Lippert,1,2 Helle Collatz Christensen1,2,11,12 1Research, Copenhagen Emergency Medical Services, Copenhagen, Denmark; 2Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; 3Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark; 4Emergency Medical Services, The Region of Southern Denmark, Odense, Denmark; 5Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; 6Emergency Medical Services, North Region of Denmark, Aalborg, Denmark; 7Emergency Medical Services, Central Denmark Region, Viborg, Denmark; 8Center for Prehospital and Emergency Research, Aalborg University Hospital and Aalborg University, Aalborg, Denmark; 9Department of Cardiology and Clinical Investigation, Nordsjaellands Hospital, Hillerød, Denmark; 10Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; 11Emergency Medical Services, Naestved, Region Zealand, Denmark; 12Danish Clinical Quality Program (RKKP) ▪ National Clinical Registries, Copenhagen, DenmarkCorrespondence: Helle Collatz Christensen, Email helle.collatz.christensen.02@regionh.dkAim of the Database: The aim of the Danish Cardiac Arrest Registry is to monitor the quality of prehospital cardiac arrest treatment, evaluate initiatives regarding prehospital treatment of cardiac arrest, and facilitate research.Study Population: All patients with prehospital cardiac arrest in Denmark treated by the emergency medical services in whom resuscitation or defibrillation has been attempted.Main Variables: The Danish Cardiac Arrest Register records descriptive and qualitative variables as outlined in the “Utstein” template for reporting out-of-hospital-cardiac arrest. Main variables include whether the case was witnessed, whether the cardiac arrest was electrocardiographically monitored, the timing of cardiopulmonary resuscitation, and the timing of the first analysis of the cardiac rhythm. The outcome measures are the status of the patient at handover to the hospital, return of spontaneous circulation, and 30-day survival after event.Database Status: The Danish Cardiac Arrest Registry was established in June 2001, and all Danish emergency medical services are reporting to the database.Conclusion: The Danish Cardiac Arrest Registry is among the oldest Danish national clinical registries, with a high quality of clinical data and coverage. This registry provides the prerequisite for all research on out-of-hospital cardiac arrest research in Denmark and is essential for monitoring and improving the quality of care for patients suffering from out-of-hospital cardiac arrest.Keywords: cardiac arrest, OHCA, cardiopulmonary resuscitation, Denmark, quality, survival

Juliane Frydenlund,1 Julie Mackenhauer,1 Erika F Christensen,2– 4 Helle Collatz Christensen,5 Ulla Væggemose,6,7 Jacob Steinmetz,8,9 Søren Paaske Johnsen1 1Department of Clinical Medicine, Aalborg University, Aalborg East, 9220, Denmark; 2Department of Clinical Medicine, Aalborg University, Aalborg, 9000, Denmark; 3Clinic for Internal and Emergency Medicine, Aalborg University Hospital, Aalborg, 9000, Denmark; 4Emergency Medical Services, North Denmark Region, Aalborg, 9000, Denmark; 5Danish Clinical Quality Program, National Clinical Registries, Copenhagen, Denmark; 6Department of Research & Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark; 7Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; 8Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark; 9Danish Air Ambulance, Aarhus, DenmarkCorrespondence: Juliane Frydenlund, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, Aalborg East, 9220, Denmark, Tel +45 24671465, Email j.frydenlund@rn.dkBackground: Differences related to socioeconomic status (SES) in use of prehospital emergency medical services (EMS) have been reported. However, detailed data on potential disparities in the quality of the EMS according to SES are lacking.Methods: A nationwide cohort study of medical emergency calls made to the Danish emergency number 1-1-2 in the period 2016– 2017. To measure quality of care, performance indicators from the Danish Quality Registry for Prehospital Emergency Medical Services were used. SES was based on income, education and adherence to workforce. Poisson regression was used to measure relative risk (RR).Results: We included 388,378 medical 1-1-2 calls, of which 261,771 were unique individuals; 42% of the calls concerned patients with low education, 5% concerned patients living in relative poverty and 23% concerned patients receiving social subsidy. There were no significant differences between the SES regarding time span for arrival of first EMS units. However, patients receiving social subsidy and retired people were more likely to be released at scene and to call again within 24 hours: Adjusted RRs were 2.79 [2.20; 3.54] and 2.08 [1.58; 2.75], respectively, compared with patients having a job. In addition, patients receiving social subsidy and retired people were more likely to call again within 24 hours after receiving telephone advice only: Adjusted RRs 2.35 [1.95; 2.82] and 1.88 [1.51; 2.35], respectively compared with patients having a job. Adjusted RRs for unplanned hospital contact after being treated and released at scene were higher for patients receiving social subsidy and retired people, respectively, relative to patients having a job.Conclusion: Patients with low SES were significantly more likely to contact the hospital or EMS again after their first call or after treatment and release at scene compared with patients with high SES. This indicates that callers with low SES did not receive the appropriate help.Keywords: socioeconomic, prehospital, EMS, register study, Denmark

Morten Breinholt Søvsø,1,2 Bodil Hammer Bech,3 Helle Collatz Christensen,4 Linda Huibers,2 Erika Frischknecht Christensen,1 Morten Bondo Christensen2 1Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark; 2Research Unit for General Practice, Aarhus, Denmark; 3Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark; 4Emergency Medical Services, Copenhagen, University of Copenhagen, Copenhagen, DenmarkCorrespondence: Morten Breinholt SøvsøCentre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Søndre Skovvej 15, Aalborg 9000, DenmarkTel +45 9764 4446Email morten.soevsoe@rn.dkBackground: Out-of-hours (OOH) health care services are often divided into emergency medical services (EMS) and OOH primary care (OOH-PC). EMS and many OOH-PC use telephone triage, yet the patient still makes the initial choice of contacting a service and which service. Sociodemographic characteristics are associated with help-seeking. Yet, differences in characteristics for EMS and OOH-PC patients have not been investigated in any large-scale cohort studies. Such knowledge may contribute to organizing OOH services to match patient needs. Thus, in this study we aimed to explore which sociodemographic patient characteristics were associated with utilizing OOH health care and to explore which sociodemographic characteristics were associated with EMS or OOH-PC contact.Methods: A population-based observational cohort study of inhabitants in two regions (North Denmark Region and Capital Region of Copenhagen) with or without contact to OOH services during 2016 was conducted. Associations between sociodemographic characteristics and OOH contacts (and EMS versus OOH-PC contact) were evaluated by regression analyses.Results: We identified 619,857 patients with OOH contact. Female sex (IRR=1.16 (95% CI: 1.16– 1.17)), non-western ethnicity (IRR=1.02 (95% CI: 1.01– 1.02)), living alone (IRR=1.08 (95% CI: 1.08– 1.09)), age groups ≥ 81 years (IRR=2.00 (95% CI: 1.98– 2.02)) and 0– 18 years (IRR=1.66 (95% CI: 1.66– 1.67)) and low income (IRR=1.41 (95% CI: 1.40– 1.42)) were more likely to contact OOH health care compared to males, Danish ethnicity, citizens cohabitating, age 31– 65 years and high income. Disability pensioners more often contacted OOH care (IRR=1.79 (95% CI: 1.77– 1.81) compared to employees. Old age (≥ 81 years) (OR=3.21 (95% CI: 3.13– 3.30)), receiving cash benefits (OR=2.45 (95% CI: 2.36– 2.54)), low income (OR=1.76 (95% CI: 1.72– 1.81)) and living alone (OR=1.40 (95% CI: 1.37– 1.42)) were all associated with EMS contacts rather than OOH-PC contacts.Conclusion: Several sociodemographic factors were associated with contacting a health care service outside office hours and with contacting EMS rather than OOH-PC. Old age, low income, low education and low socioeconomic status were of greatest importance.Keywords: out-of-hours health care, delivery of health care, Denmark, telephone hotline, telephone triage

Objectives: As a part of the chain of survival, the emergency medical communication centre (EMCC) and the emergency medical dispatcher (EMD) has an important role in early identification of out-of-hospital cardiac arrests (OHCA). The EMD may provide instructions to the caller and thereby initiate cardiopulmonary resuscitation in a substantial number of subjects and thus contribute to increased survival. The EMCC provides a response with first responders, ambulances, physician manned units and potentially other health care providers. EMCC in many cases initiates the communication with experts in the referral hospital and provide added value to the post resuscitation care by providing advanced transport, logistics and follow up. In research there is a growing focus on the EMCC/EMDs impact on survival in OHCA. The lack of standards in reporting results from medical dispatching is an obstacle for thorough evaluation of results in this area and comparison of data. The objective for this paper is to introduce a framework for uniform reporting of the dispatching process for quality improvement, collecting and reporting data and exchanging information regarding OHCA. [ABSTRACT FROM AUTHOR]

Background: Out-of-hospital cardiac arrest is a leading cause of death worldwide. Establishing vascular access is critical for administering guideline-recommended drugs during cardiopulmonary resuscitation. Both the intraosseous route and the intravenous route are used routinely, but their comparative effectiveness remains unclear., Methods: We conducted a randomized clinical trial to compare the effectiveness of initial attempts at intraosseous or intravenous vascular access in adults who had nontraumatic out-of-hospital cardiac arrest. The primary outcome was a sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability)., Results: Among 1506 patients who underwent randomization, 1479 were included in the primary analysis (731 in the intraosseous-access group and 748 in the intravenous-access group). The successful establishment of vascular access within two attempts occurred in 669 patients (92%) assigned to the intraosseous-access group and in 595 patients (80%) assigned to the intravenous-access group. Sustained return of spontaneous circulation occurred in 221 patients (30%) in the intraosseous-access group and in 214 patients (29%) in the intravenous-access group (risk ratio, 1.06; 95% confidence interval [CI], 0.90 to 1.24; P = 0.49). At 30 days, 85 patients (12%) in the intraosseous-access group and 75 patients (10%) in the intravenous-access group were alive (risk ratio, 1.16; 95% CI, 0.87 to 1.56); a favorable neurologic outcome at 30 days occurred in 67 patients (9%) and 59 patients (8%), respectively (risk ratio, 1.16; 95% CI, 0.83 to 1.62). Prespecified adverse events were uncommon., Conclusions: There was no significant difference in sustained return of spontaneous circulation between initial intraosseous and intravenous vascular access in adults who had out-of-hospital cardiac arrest. (Funded by the Novo Nordisk Foundation and others; IVIO EU Clinical Trials Register number, 2022-500744-38-00; ClinicalTrials.gov number, NCT05205031.)., (Copyright © 2024 Massachusetts Medical Society.)

Background: The guidelines for Advanced Life Support issued by the European Resuscitation Council recommend considering drug delivery through intraosseous access if intravenous access to the vascular bed is not feasible or unsuccessful. Emergency prehospital intraosseous cannulation may theoretically lead to an increased risk of long-term complications such as osteomyelitis, osteonecrosis, or compartment syndrome. Such complications have previously been reported in case reports or small sample case series. We systematically investigated long-term complications potentially associated with intraosseous cannulation using validated Danish health registries., Methods: Data sources were the nationwide electronic Prehospital Patient Record system, the Danish National Patient Registry, and the Danish Civil Personal Registry. We investigated all patients who were subjected to prehospital intraosseous cannulation in Denmark from January 2016 through December 2019. During a follow-up period of 180 days from the index date we extracted information concerning mortality status and potential long-term complications defined as osteomyelitis, osteonecrosis, or compartment syndrome from the day of prehospital intraosseous cannulation., Results: Of the 5,387 patients receiving intraosseous access, 375 were unidentified and lost to follow-up. Of the 5012 remaining patients, 4,775 were adults, and 237 were children. No children and "less than five" adults had long-term complications. No osteonecrosis, osteomyelitis or compartment syndrome appeared later than 175 days after an intraosseous cannulation., Conclusions: Long-term complications such as osteomyelitis, osteonecrosis, or compartment syndrome following prehospital intraosseous cannulation and drug delivery occurred in less than 0.1% of the cases. Our findings indicate that prehospital intraosseous cannulation may be safe across age groups., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Arterial blood gas (ABG) values are important in the assessment of critically ill patients. However, arterial puncture may be challenging to perform in these patients. The venous-to-arterial conversion method (v-TAC) is used to convert venous blood gas values to calculated values meant to resemble arterial values. Calculated pH and partial pressure of carbon dioxide (PCO 2 ) values have shown good agreement with arterial values in stable patients, but performance of the method in patients with severe acid-base disturbances is unknown. We aim to evaluate venous and calculated blood gas value congruency with arterial values in critically ill patients., Methods: Critically ill adult patients with abnormal arterial pH (<7.35 or >7.45) admitted to an intensive care unit were included in this study. Patients were divided in groups based on arterial pH (alkalemia, moderate acidaemia and severe acidaemia). ABG samples were obtained from arterial catheters and venous samples simultaneously from peripheral or central venous catheters. Venous blood gas values were converted to calculated values using the v-TAC software. Both venous and calculated values of pH, PCO 2 and partial pressure of oxygen (PO 2 ) were compared to arterial values in scatterplots and using the Spearman's Rank Correlation., Results: Arterial and venous sample pairs were obtained from 28 patients, and 24 venous values were converted using the v-TAC method. Scatterplots showed similar congruency of venous and calculated pH and PCO 2 values to arterial values. However, one patient in the severe acidaemia group had arterial pH 7.07 and venous pH 7.04, but calculated pH 7.42. Spearman's Rank Correlation rho showed no correlation of venous and calculated PO 2 values compared to arterial values (p = .989 and p = .361)., Conclusion: Venous and calculated pH and PCO 2 values showed similar congruency with arterial values in patients with alkalemia and moderate acidaemia, while the method was unreliable in a patient suspected of severe metabolic acidaemia., (© 2024 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: The prehospital use of blood lactate measurements is increasing. However, the test's benefits have not been methodically evaluated in non-trauma patients. This study had three aims: (1) To assess the evidence of prehospital blood lactate measurements' prognostic value in non-trauma patients, (2) to investigate to what extent the test changed early patient treatment, and (3) to evaluate the healthcare personnel's attitude towards the test., Methods: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were systematically searched until Aug 26, 2023. Cohort and randomized controlled trials assessing ≥ 20 acute non-trauma patients with prehospital lactate measurements were included if they reported (1) prognostic outcomes such as short-term mortality or (2) changes in early patient treatments. All study designs were included to assess (3) the healthcare personnel's opinion on prehospital lactate measurements. The risks of bias were assessed using the QUIPS tool, the Newcastle-Ottawa Scale, and the RoB-2. Study registration number CRD42020167169 (PROSPERO)., Results: We screened 6028 study reports. We included 15 studies on (1) the prognostic value of prehospital lactate measurements. Elevated blood lactate levels were correlated to a higher short-term mortality risk in most of the studies but not in studies with out-of-hospital cardiac arrest (OHCA) patients. The 15 prognostic studies were all cohort studies with moderate or high risks of bias. Four studies investigated (2) early treatment changes. They found that the prehospital lactate measurement may have changed early treatment in sepsis patients. However, all four studies on treatment changes were at high risk of bias. Four studies were included on (3) the healthcare personnel's attitude towards the lactate measurement. Evidence of the healthcare personnel's opinion on prehospital lactate measurements was scarce., Conclusion: Most acute non-trauma patients with elevated prehospital lactate levels had increased risks of short-term mortality, except OHCA patients. Few studies suggested that measuring prehospital lactate levels could change early patient care, particularly in patients with suspected sepsis. The certainty of the evidence is low in this systematic review. The included studies were heterogeneous, and many had high risks of bias. Further studies are needed to investigate the impact of prehospital lactate measurements on patient care., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: LHW was funded by the sources stated under ‘Funding’. All remaining authors declare that they have no competing interests., (© 2024. The Author(s).)

Background: During the COVID-19 pandemic, disturbing images of ambulances unable to respond to the demands for prehospital assistance appeared from several parts of the world. In Denmark, however, a notion occurred that the demands for emergency medical assistance declined. The purpose of this study was to compare the patients' use of the Danish Emergency Medical Services (EMS) before and during the COVID-19 pandemic. Furthermore, we investigated the overall mortality of the ambulance population, the main reason for calling the emergency medical dispatch centre, and the diagnosis assigned to the admitted patients., Methods: The study was a nationwide registry-based cohort study based on the national prehospital medical records and the Danish National Patient Registry. The primary outcome was the requested number of ambulances. Secondary outcomes included the primary reason for contact with the dispatch centre (reflected by the dispatch criteria), patient mortality, and the diagnoses assigned to the patients transported to the hospital by ambulance during the COVID-19 pandemic in Denmark in March-December 2020. Comparisons were made using a similar period in 2019 before the pandemic., Results: In comparison with the baseline values before the pandemic, the total number of patients treated by the EMS was reduced by 4.5% during the COVID-19 pandemic. The number of patients transported to the hospital during the pandemic was similarly reduced by 3.5%. Compared with baseline values, fewer were patients hospitalised with respiratory diseases during the pandemic (a reduction of 53.3% from April 2019 to April 2020). Compared to the baseline period, there were significant increases in both the 48-h mortality (from 1.4% to 1.5%) and the 30-day mortality (from 4.9% to 5.4%) (p < 0.03 and p < 0.001, respectively), in patients hospitalised during the pandemic., Conclusion: During the first wave of the COVID-19 pandemic, the Danish EMS experienced an overall reduction in the requests for and the use of ambulances and, especially, in the number of patients admitted to hospitals for respiratory diseases. Despite the overall reduction in EMS requests, the mortality of the ambulance population increased, indicating that despite the reduced ambulance use, the prehospital population was more severely ill during the pandemic., (© 2024. The Author(s).)

Purpose: To compare patients with and without a history of mental illness on process and outcome measures in relation to prehospital and emergency surgical care for patients with perforated ulcer., Methods: A nationwide registry-based cohort study of patients undergoing emergency surgery for perforated ulcer. We used data from the Danish Prehospital Database 2016-2017 and the Danish Emergency Surgery Registry 2004-2018 combined with data from other Danish databases. Patients were categorized according to severity of mental health history., Results: We identified 4.767 patients undergoing emergency surgery for perforated ulcer. Among patients calling the EMS with no history of mental illness, 51% were identified with abdominal pain when calling the EMS compared to 31% and 25% among patients with a history of moderate and major mental illness, respectively. Median time from hospital arrival to surgery was 6.0 h (IQR: 3.6;10.7). Adjusting for age, sex and comorbidity, patients with a history of major mental illness underwent surgery 46 min (95% CI: 4;88) later compared to patients with no history of mental illness. Median number of days-alive-and-out-of-hospital at 90-day follow-up was 67 days (IQR: 0;83). Adjusting for age, sex and comorbidity, patients with a history of major mental illness had 9 days (95% CI: 4;14) less alive and out-of-hospital at 90-day follow-up., Conclusion: One-third of the population had a history of mental illness or vulnerability. Patients with a history of major mental illness were less likely to be identified with abdominal pain if calling the EMS prior to arrival. They had longer delays from hospital arrival to surgery and higher mortality., (© 2024. The Author(s).)

Introduction: The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care., Methods: A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions., Results: Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome., Conclusion: The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Life-threatening conditions are infrequent in children. Current literature in paediatric prehospital research is centred around trauma and paediatric out-of-hospital cardiac arrests (POHCA). The aims of this study were to (1) outline the distribution of trauma, POHCA or other medical symptoms among survivors and non-survivors after paediatric emergency calls, and (2) to investigate these clinical presentations' association with mortality in children with and without pre-existing comorbidity, respectively., Methods: Nationwide population-based cohort study including ground and helicopter emergency medical services in Denmark for six consecutive years (2016-2021). The study included all calls to the emergency number 1-1-2 regarding children ≤ 15 years (N = 121,230). Interhospital transfers were excluded, and 1,143 patients were lost to follow-up. Cox regressions were performed with trauma or medical symptoms as exposure and 7-day mortality as the outcome, stratified by 'Comorbidity', 'Severe chronic comorbidity' and 'None' based on previous healthcare visits., Results: Mortality analysis included 76,956 unique patients (median age 5 (1-12) years). Annual all-cause mortality rate was 7 per 100,000 children ≤ 15 years. For non-survivors without any pre-existing comorbidity (n = 121), reasons for emergency calls were trauma 18.2%, POHCA 46.3% or other medical symptoms 28.9%, whereas the distribution among the 134 non-survivors with any comorbidity was 7.5%, 27.6% and 55.2%, respectively. Compared to trauma patients, age- and sex-adjusted hazard ratio for patients with calls regarding medical symptoms besides POHCA was 0.8 [0.4;1.3] for patients without comorbidity, 1.1 [0.5;2.2] for patients with comorbidity and 6.1 [0.8;44.7] for patients with severe chronic comorbidity., Conclusion: In both non-survivors with and without comorbidity, a considerable proportion of emergency calls had been made because of various medical symptoms, not because of trauma or POHCA. This outline of diagnoses and mortality following paediatric emergency calls can be used for directing paediatric in-service training in emergency medical services., (© 2024. The Author(s).)

Background: Emergency patients are frequently assigned nonspecific diagnoses. Nonspecific diagnoses describe observations or symptoms and are found in chapters R and Z of the International Classification of Diseases, 10 th edition (ICD-10). Patients with such diagnoses have relatively low mortality, but due to patient volume, the absolute number of deaths is substantial. However, information on cause of short-term mortality is limited., Objectives: To investigate whether death could be expected for ambulance patients brought to the emergency department (ED) after a 1-1-2 call, released with a nonspecific ICD-10 diagnosis within 24 h, and who subsequently died within 30 days., Methods: Retrospective medical record review of adult 1-1-2 emergency ambulance patients brought to an ED in the North Denmark Region during 2017-2021. Patients were divided into three categories: unexpected death, expected death (terminal illness), and miscellaneous. Charlson Comorbidity Index (CCI) was assessed., Results: We included 492 patients. Mortality was distributed as follows: Unexpected death 59.2% (n = 291), expected death (terminal illness) 25.8% (n = 127), and miscellaneous 15.0% (n = 74). Patients who died unexpectedly were old (median age of 82 years) and had CCI 1-2 (58.1%); 43.0% used at least five daily prescription drugs, and they were severely acutely ill upon arrival (24.7% with red triage, 60.1% died within 24 h)., Conclusions: More than half of ambulance patients released within 24 h from the ED with nonspecific diagnoses, and who subsequently died within 30 days, died unexpectedly. One-fourth died from a pre-existing terminal illness. Patients dying unexpectedly were old, treated with polypharmacy, and often life-threateningly sick at arrival., Competing Interests: Declaration of competing interest None., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Mobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability., Method: Following a pilot study, we developed a 4-level prehospital mobility score based of the question"How much help did the patient need to be mobilized to the ambulance trolley". Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020-May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics., Results: We included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1). Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86)., Conclusion: We developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers., (© 2024. The Author(s).)

Background: Patients dead before arrival of the ambulance or before arrival at hospital may be in- or excluded in mortality analyses, making comparison of mortality difficult. Often only physicians are allowed to declare death, thereby impeding uniform registration of prehospital death. Many studies do not report detailed definitions of prehospital mortality. Our aim was to define criteria to identify and categorize prehospital patients' vital status, and to estimate the proportion of these groups, primarily the proportion of patients dead on ambulance arrival., Methods: Prehospital medical records review for patients receiving an ambulance in the North Denmark Region from 2019 to 2021 and registered dead on the same or the following day. We defined three vital status categories: (1) Dead on Ambulance Arrival (DOAA), (2) Out-of-Hospital Cardiac Arrest (OHCA) divided into OHCA Basic Life Support (OHCA BLS) and OHCA Advanced treatment, and 3) Alive on Ambulance Arrival., Results: Among 3 174 dead patients, DOAA constituted 28.8%, OHCA BLS 13.4%, OHCA Advanced treatment 31.3%, and Alive on Ambulance Arrival 26.6%., Conclusion: We defined exhaustive and mutually exclusive criteria to define vital status, DOAA, OHCA, and Alive on Ambulance Arrival based on prehospital medical records. More than one out of four patients receiving an ambulance and registered dead on the same or the following day were dead already at ambulance arrival. Adding OHCA BLS where resuscitation was terminated without defibrillation or other treatment, increased the proportion of patients dead on ambulance arrival to 42%. We recommend reporting similar categories of vital status to improve valid comparisons of prehospital mortality rates., (© 2023. The Author(s).)

Background: The prehospital patients treated by ambulances and mobile emergency care units (MECU) are potentially critically ill or injured. Knowing the risks of serious outcomes in these patients is important for guiding their treatment. Some settings allow for prehospital arterial blood gas analyses. This study aimed to assess the outcomes of prehospital patients in relation to their prehospitally measured lactate, pH, and CO 2 levels. The primary outcome was 7-day mortality., Methods: This register-based cohort study included patients with one or more prehospital blood gas analyses during their prehospital treatment by a physician-manned MECU, from January 2015 to December 2018. The blood samples were analyzed on an ABL90 Flex analyzer. Absolute values with percentages and odds ratios (OR) with 95% confidence intervals (CI) were calculated for the primary and secondary outcomes within prespecified subgroups., Results: The study included 745 patients, with an overall 7-day mortality rate of 20.0%., Lactate Level: The 7-day mortality rates were 11.5% in patients with normal lactate levels (< 2.0 mmol/L), 14.4% with intermediate lactate levels (2.0-3.9 mmol/L), and 33.0% with high lactate levels (≥ 4.0 mmol/L). This corresponded to an OR of 1.30 (95% CI: 0.75-2.24) in the intermediate lactate group (2.0-3.9 mmol/L) and an OR of 3.77 (95% CI: 2.44-5.85) in the high lactate group (≥ 4.0 mmol/L), compared to the reference group with normal lactate., Ph Level: The ORs of 7-day mortality rates were 4.82 (95% CI: 3.00-7.75) in patients with blood pH of < 7.35 and 1.33 (95% CI: 0.65-2.72) in patients with blood pH > 7.45, compared to the reference group with normal pH (7.35-7.45). CO2 LEVEL : The ORs of 7-day mortality rates were 2.54 (95% CI: 1.45-4.46) in patients with blood CO 2 of < 4.3 kPa and 2.62 (95% CI: 1.70-4.03) in patients with blood CO 2  > 6.0 kPa, compared to the reference group with normal CO 2 (4.3-6.0 kPa)., Conclusions: This study found a strong correlation between increasing 7-day mortality rates and high blood lactate levels, low levels of pH, and abnormal CO 2 blood levels, in prehospital patients undergoing prehospital blood analysis., (© 2023. The Author(s).)

Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery., (© 2023. The Author(s).)

Ineffective use of the early warning score (EWS) can compromise recognition and response to patients' deteriorating condition. This study explores nurses' and physicians' ideas on initiatives for supporting the effective use of the EWS in a hospital setting. Participatory workshops were conducted, and data were analyzed using content analysis. Ideas generated for integrating new functions into the EWS protocol to facilitate effective use are described. Also recommended was that all users receive training and an update on how to use the EWS score to support acceptance and confidence using the protocol and thereby increase adherence to the EWS. Further research is needed on the efficiency of incorporating nurses' clinical judgment in the EWS protocol within different specialties and the effect on adherence to the tool., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: One third of ambulance patients receive non-specific diagnoses in hospital. Mortality is 3-4%, however due to the high patient volume this group accounts for 20% of all deaths at day 30. Non-specific diagnoses do not provide much information on causes for death. Vital signs at first contact with ambulance personnel can act as a proxy for the patient's condition. Thus, we aimed to describe the prevalence of abnormal vital signs, as determined by a modified NEWS2, in ambulance patients who received a non-specific hospital diagnosis. Secondly, we examined the association between vital signs, NEWS2 scores, type of non-specific diagnosis, and mortality among these patients., Methods: Register-based historic cohort study of ambulance patients aged 16+ in the North Denmark Region during 2012-2016, who received a non-specific diagnosis (ICD-10 chapters R or Z) at hospital. We used NEWS2 scores to determine if first vital signs were normal or deviating (including critical). Mortality was estimated with the Kaplan-Meier estimator. Association between vital signs and mortality was evaluated by logistic regression., Results: We included 41,539 patients, 20.9% (N = 8,691) had normal vital signs, 16.3% (N = 6,766) had incomplete vital sign registration, 62.8% (N = 26,082) had deviating vital signs, and of these 6.8% (N = 1,779) were critical. If vital signs were incompletely registered or deviating, mortality was higher compared to normal vital signs. Patients with critical vital signs displayed the highest crude 48-hour and 30-day mortality (7.0% (5.9-8.3) and 13.4% (11.9-15.1)). Adjusting for age, sex, and comorbidity did not change that pattern. Across all vital sign groups, despite severity, the most frequent diagnosis assigned was Z039 observation for suspected disease or condition unspecified., Conclusions: Most ambulance patients with non-specific diagnoses had normal or non-critical deviating vital signs and low mortality. Around 4% had critical vital signs and high mortality, not explained by age or comorbidity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Sørensen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Importance: Early warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services., Objective: To validate EWSs' ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances., Design, Setting, and Participants: This prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023., Main Outcomes and Measures: The primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC)., Results: There were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores < .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission., Conclusions and Relevance: This study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.

Background: Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA., Methods: We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis., Results: All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values., Conclusion: This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making., Competing Interests: The authors have declared that no competing interests exist, (Copyright: © 2023 Milling et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: During the first weeks of the outbreak of the coronavirus disease 2019 (COVID-19), the North Denmark emergency medical services authorised paramedics to assess patients suspected of COVID-19 at home, and then decide if conveyance to a hospital was required. The aim of this study was to describe the cohort of patients who were assessed at home and their outcomes in terms of subsequent hospital visits and short-term mortality., Methods: This was a historical cohort study in the North Denmark Region with consecutive inclusion of patients suspected of COVID-19 who were referred to a paramedic's assessment visit by their general practitioner or an out-of-hours general practitioner. The study was conducted from 16 March to 20 May 2020. The outcomes were the proportion of non-conveyed patients who subsequently visited a hospital within 72 hours of the paramedic's assessment visit and mortality at 3, 7 and 30 days. Mortality was estimated using a Poisson regression model with robust variance estimation., Results: During the study period, 587 patients with a median age of 75 (IQR 59-84) years were referred to a paramedic's assessment visit. Three of four patients (76.5%, 95% CI 72.8;79.9) were non-conveyed, and 13.1% (95% CI 10.2;16.6) of the non-conveyed patients were subsequently referred to a hospital within 72 hours of the paramedic's assessment visit. Within 30 days from the paramedic's assessment visit, mortality was 11.1% [95% CI 6.9;17.9] among patients directly conveyed to a hospital and 5.8% [95% CI 4.0;8.5] among non-conveyed patients. Medical record review revealed that deaths in the non-conveyed group had happened among patients with 'do-not-resuscitate' orders, palliative care plans, severe comorbidities, age ≥ 90 years or nursing home residents., Conclusions: The majority (87%) of the non-conveyed patients did not visit a hospital for the following three days after a paramedic's assessment visit. The study implies that this newly established prehospital arrangement served as a kind of gatekeeper for the region's hospitals in regard to patients suspected of COVID-19. The study also demonstrates that implementation of non-conveyance protocols should be accompanied by careful and regular evaluation to ensure patient safety., (© 2023. The Author(s).)

Introduction: Throughout recent years the demand for prehospital emergency care has increased significantly. Non-traumatic chest pain is one of the most frequent complaints. Our aim was to investigate the trend in frequency of the most urgent ambulance patients with chest pain, subsequent acute myocardial infarction (AMI) diagnoses, and 48-hour and 30-day mortality of both groups., Methods: Population-based historic cohort study in the North Denmark Region during 2012-2018 including chest pain patients transported to hospital by highest urgency level ambulance following a 1-1-2 emergency call. Primary diagnoses (ICD-10) were retrieved from the regional Patient Administrative System, and descriptive statistics (distribution, frequency) performed. We evaluated time trends using linear regression, and mortality (48 hours and 30 days) was assessed by the Kaplan Meier estimator., Results: We included 18,971 chest pain patients, 33.9% (n = 6,430) were diagnosed with"Diseases of the circulatory system" followed by the non-specific R- (n = 5,288, 27.8%) and Z-diagnoses (n = 3,634; 19.2%). AMI was diagnosed in 1,967 patients (10.4%), most were non-ST-elevation AMI (39.7%). Frequency of chest pain patients and AMI increased 255 and 22 patients per year respectively, whereas the AMI proportion remained statistically stable, with a tendency towards a decrease in the last years. Mortality at 48 hours and day 30 in chest pain patients was 0.7% (95% CI 0.5% to 0.8%) and 2.4% (95% CI 2.1% to 2.6%)., Conclusions: The frequency of chest pain patients brought to hospital during 2012-2018 increased. One-tenth were diagnosed with AMI, and the proportion of AMI patients was stable. Almost 1 in of 4 high urgency level ambulances was sent to chest pain patients. Only 1 of 10 patients with chest pain had AMI, and overall mortality was low. Thus, monitoring the number of chest pain patients and AMI diagnoses should be considered to evaluate ambulance utilisation and triage., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lindskou et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Prehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives., Methods: Prospective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region., Results: In North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3-11 months (7.4%), 1-2 years (18.8%), 3-7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3-7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference - 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period., Conclusions: Mandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases., (© 2023. The Author(s).)

Background: Patients calling for an emergency ambulance and assessed as presenting with 'unclear problem' account for a considerable part of all emergency calls. Previous studies have demonstrated that these patients are at increased risk for unfavourable outcomes. A deeper insight into the underlying diagnoses and outcomes is essential to improve prehospital treatment. We aimed to investigate which of these diagnoses contributed most to the total burden of diseases in terms of numbers of deaths together with 1- and 30-day mortality., Methods: A historic regional population-based observational cohort study from the years 2016 to 2018. Diagnoses were classified according to the World Health Organisation ICD-10 System (International Statistical Classification of Diseases and Related Health Problems, 10th edition). The ICD-10 chapters, R ('symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified)' and Z ('factors influencing health status and contact with health services") were combined and designated "non-specific diagnoses". Poisson regression with robust variance estimation was used to estimate proportions of mortality in percentages with 95% confidence intervals, crude and adjusted for age, sex and comorbidities., Results: Diagnoses were widespread among the ICD-10 chapters, and the most were 'non-specific diagnoses' (40.4%), 'circulatory diseases' (9.6%), 'injuries and poisonings' (9.4%) and 'respiratory diseases' (6.9%). The diagnoses contributing most to the total burden of deaths (n = 554) within 30 days were 'circulatory diseases' (n = 148, 26%) followed by 'non-specific diagnoses' (n = 88, 16%) 'respiratory diseases' (n = 85, 15%), 'infections' (n = 54, 10%) and 'digestive disease' (n = 39, 7%). Overall mortality was 2.3% (1-day) and 7.1% (30-days). The risk of mortality was highly associated with age., Conclusion: This study found that almost half of the patients brought to the hospital after calling 112 with an 'unclear problem' were discharged with a 'non-specific diagnosis' which might seem trivial but should be explored more as these contributed the second-highest to the total number of deaths after 30 days only exceeded by 'circulatory diseases'., (© 2022. The Author(s).)

Point-of-care blood lactate is a promising prognostic biomarker of short-term mortality risk. Portable lactate meters need validation in the prehospital setting before widespread implementation and it is unknown whether the mode of sampling (arterial, capillary or venous) matters. This study aims to compare the StatStrip Xpress Lactate Meter's (SSX) accuracy to a validated blood gas analyser, ABL90 FLEX (ABL90), in arterial samples in the prehospital environment and to determine if lactate levels measured in venous and capillary blood samples are sufficiently accurate compared to arterial lactate levels. Patients with arterial samples drawn by the prehospital anaesthesiologist for any reason were eligible for inclusion. Simultaneously, three blood samples (arterial, capillary and venous) were analysed on SSX and arterial blood on ABL90. Measurements of agreements were evaluated by Lin's concordance correlations coefficient (CCC) and Bland-Altman Plots. One-hundred-and-eleven patients were included. SSX showed good accuracy compared to ABL90 in arterial samples with a CCC of 0.92 (95% CI 0.90-0.94). Compared to the arterial samples measured on ABL90, venous samples analysed on SSX showed higher agreement than capillary samples analysed on SSX with CCCs of 0.88 (95% CI 0.85-0.91) and 0.79 (95% CI 0.72-0.85), respectively. Bland-Altman plots showed that SSX lactate measurements in arterial, venous and capillary blood samples all had systematically negative biases compared to ABL90. We conclude that the SSX is accurate in our prehospital setting. Venous samples should be preferred over capillary samples, when arterial samples cannot be obtained., (© 2022. The Author(s).)

Aim: The primary aim was to investigate the association between alarm acceptance compared to no-acceptance by volunteer responders, bystander intervention, and survival in out-of-hospital cardiac arrest., Materials and Methods: This retrospective observational study included all suspected out-of-hospital cardiac arrests (OHCAs) with activation of volunteer responders in the Capital Region of Denmark (1 November 2018 to 14 May 2019), the Central Denmark Region (1 November 2018 to 31 December 2020), and the Northern Denmark Region (14 February 2020 to 31 December 2020). All OHCAs unwitnessed by Emergency Medical Services (EMS) were analyzed on the basis on alarm acceptance and arrival before EMS. The primary outcomes were bystander cardio-pulmonary resuscitation (CPR), bystander defibrillation and secondary outcome was 30-day survival. A questionnaire sent to all volunteer responders was used with respect to their arrival status., Results: We identified 1,877 OHCAs with volunteer responder activation eligible for inclusion and 1,725 (91.9%) of these had at least one volunteer responder accepting the alarm (accepted). Of these, 1,355 (79%) reported arrival status whereof 883 (65%) arrived before EMS. When volunteer responders accepted the alarm and arrived before EMS, we found increased proportions and adjusted odds ratio for bystander CPR {94 vs. 83%, 4.31 [95% CI (2.43-7.67)] and bystander defibrillation [13 vs. 9%, 3.16 (1.60-6.25)]} compared to cases where no volunteer responders accepted the alarm., Conclusion: We observed a fourfold increased odds ratio for bystander CPR and a threefold increased odds ratio for bystander defibrillation when volunteer responders accepted the alarm and arrived before EMS., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Nielsen, Folke, Andelius, Hansen, Væggemose, Christensen, Torp-Pedersen, Ersbøll and Gregers.)

Introduction: Severe exacerbations in chronic obstructive pulmonary disease (COPD) may require acute medical attention by calling the emergency medical services (EMS) for an ambulance. The 30-day mortality for EMS patients with respiratory diseases appears to have stagnated, which may be due to changes in age, comorbidity or disease severity. We examined trends of occurrence, severity and mortality for EMS patients with COPD., Methods: A historical population-based cohort study was conducted encompassing patients with COPD who requested an ambulance in the North Denmark Region in the 2007-2018 period. We described acute severity by oxygen saturation and respiratory rate at the arrival of the ambulance along with comorbidity and duration of hospitalisation., Results: A total of 5,969 EMS patients with COPD were identified and the figure nearly doubled from 2007 to 2018. Age and comorbidity were higher in the last part of the period. Furthermore, the initial respiratory rate was higher, oxygen saturation was lower and the duration of hospitalisation was lower in the last part of the period. The 30-day mortality rose from 12.6% to 15.4%, but the odds ratio was not statistically higher and decreased after adjustment., Conclusions: COPD constituted increasing proportions of those admitted to hospital after calling the EMS. The mortality among EMS patients with COPD may be due to patients being older, having more comorbidities or being more severely acutely ill. The mortality suggests that COPD patients requesting an ambulance should be considered severely ill., Funding: none., Trial Registration: not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Study Objective: To examine the diagnostic pattern, level of severity of illness or injuries, and mortality among children for whom a physician-staffed helicopter emergency medical service (HEMS) was dispatched., Methods: Population-based cohort study including patients aged less than 16 years treated by the Danish national HEMS from October 1, 2014, to September 30, 2018. Diagnoses were retrieved from inhospital medical records, and the severity of illness or injuries was assessed by a severity score on scene, administration of advanced out-of-hospital care, need for intensive care in a hospital, and mortality., Results: In total, 651 HEMS missions included pediatric patients aged less than 1 year (9.2%), 1 to 2 years (29.0%), 3 to 7 years (28.3%), and 8 to 15 years (33.5%). A third of the patients had critical emergencies (29.6%), and for 20.1% of the patients, 1 or more out-of-hospital interventions were performed: intubation, mechanical chest compressions, intraosseous vascular access, blood transfusion, chest tube insertion, and/or ultrasound examination. Among the 525 patients with hospital follow-up, the most frequent hospital diagnoses were injuries (32.2%), burns (11.2%), and respiratory diseases (7.8%). Within 24 hours of the mission, 18.1% of patients required intensive care. Twenty-nine patients (5.1%, 95% confidence interval [CI] 3.6 to 7.3) died either on or within 1 day of the mission, and the cumulative 30-day mortality was 35 of 565 (6.2%, 95% CI 4.5 to 8.5) (N=565 first-time missions)., Conclusion: On Danish physician-staffed HEMS missions, 1 in 5 pediatric patients required advanced out-of-hospital care. Among hospitalized patients, nearly one-fifth of the patients required immediate intensive care and 6.2% died within 30 days of the mission., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: Prehospital treatment and release of patients may reduce unnecessary transports to the hospital and may improve patient satisfaction. However, the safety of patients should be paramount., Objective: To determine the extent of unplanned emergency department (ED) contacts, short-term mortality, and diagnostic patterns in patients treated and released by a prehospital anesthesiologist supervising a mobile emergency care unit (MECU)., Design, Setting, and Participants: This retrospective cohort study used a manual review of prehospital and in-hospital medical records to investigate all living patients who were treated and released by an MECU in Odense, Denmark, between January 1, 2011, and December 31, 2020. Patients were followed up for 30 days after initial contact with the prehospital service., Main Outcomes and Measures: Primary outcome measures included unplanned contacts with the emergency department less than 48 hours after prehospital treatment and prehospital assigned diagnosis. Secondary outcomes consisted of mortality at 48 hours and 7 and 30 days., Results: A total of 3141 patients were identified; 384 were excluded and 2757 were included in the analysis. The median patient age was 40 (IQR, 14-66) years; 1296 (47.0%) were female and 1461 (53.0%) were male. Two hundred thirty-nine patients (8.7% [95% CI, 7.6%-9.8%]) had unplanned contact with the ED within 48 hours; this rate was doubled for patients with respiratory diseases (37 of 248 [14.9% (95% CI, 10.7%-20.0%)]). Fifty-nine of 60 patients who died within 48 hours of release had terminal illness. Excluding these patients, the mortality rates were 0.04% at 48 hours, 0.8% at 7 days, and 2.4% at 30 days. Two thousand sixty-one patients (74.8%) had primarily nondefinitive observational diagnoses., Conclusions and Relevance: The findings of this cohort study suggest that prehospital treatment and subsequent release at the scene is safe. One patient in 12 attended the ED within the ensuing 48 hours. However, for patients with respiratory diseases, this rate was doubled. Hospital admission could be avoided for some patients in the end stage of a terminal illness.

Approximately 7% of all dispatched ambulances in Denmark are for patients for whom breathing difficulties are the main cause for using ambulance services. Objective measurements are routinely carried out in the ambulances, but little is known of the patients' subjective experience of dyspnea. The purpose of this study was to investigate how patients with acute dyspnea, transported to hospital by ambulance, experience their situation, along with their experience of the use of a dyspnea scale. The study was carried out in the North Denmark Region. Transcribed patient interviews and field notes were analyzed and interpreted with inspiration from Paul Ricoeur. For interviews, we included 12 patients with dyspnea who were transported to the hospital by ambulance: six women and six men all aged 60 years or above. Observations were made over six ambulance transports related to dyspnea. Three themes emerged: "anxiety", "reassurance in the ambulance" and "acceptance of the dyspnea measurements in the ambulance". Several patients expressed anxiety due to their dyspnea, which was substantiated by observations in the ambulance. The patients expressed different perspectives on what improved the situation (treatment, reassurance by ambulance professionals). The patients and the ambulance personnel were, in general, in favor of the dyspnea scale.

Background: Emergency departments (EDs) experience an increasing number of patients. High patient flow are incentives for short duration of ED stay which may pose a challenge for patient diagnostics and care implying risk of ED revisits or increased mortality. Four hours are often used as a target time to decide whether to admit or discharge a patient., Objective: To investigate and compare the diagnostic pattern, risk of revisits and short-term mortality for ED patients with a length of stay of less than 4 h (visits) with 4-24 h stay (short stay visits)., Methods: Population-based cohort study of patients contacting three EDs in the North Denmark Region during 2014-2016, excluding injured patients. Main diagnoses, number of revisits within 72 h of the initial contact and mortality were outcomes. Data on age, sex, mortality, time of admission and ICD-10 diagnostic chapter were obtained from the Danish Civil Registration System and the regional patient administrative system. Descriptive statistics were applied and Kaplan Meier mortality estimates with 95% CI were calculated., Results: Seventy-nine thousand three hundred forty-one short-term ED contacts were included, visits constituted 60%. Non-specific diagnoses (i.e. symptoms and signs and other factors) were the most frequent diagnoses among both visits and short stay visits groups (67% vs 49%). Revisits were more frequent for visits compared to short stay visits (5.8% vs 4.2%). Circulatory diseases displayed the highest 0-48-h mortality within the visits and infections in the short stay visits (11.8% (95%CI: 10.4-13.5) and (3.5% (95%CI: 2.6-4.7)). 30-day mortality were 1.3% (95%CI: 1.2-1.5) for visits and 1.8% (95%CI: 1.7-2.0) for short stay visits. The 30-day mortality of the ED revisits with an initial visit was 1.0% (0.8-1.3), vs 0.7% (0.7-0.8) for no revisits, while 30-day mortality nearly doubled for ED revisits with an initial short stay visit (2.5% (1.9-3.2))., Conclusions: Most patients were within the visit group. Non-specific diagnoses constituted the majority of diagnoses given. Mortality was higher among patients with short stay visits but increased for both groups with ED revisits. This suggest that diagnostics are challenged by short time targets., (© 2022. The Author(s).)

Timely reperfusion in ST-elevation myocardial infarction (STEMI) is essential. This study aimed to evaluate the reduction in system delay (time from emergency medical service [EMS] call to primary percutaneous coronary intervention [PPCI]) in patients with STEMI when using helicopter EMS (HEMS) rather than ground-based EMS (GEMS). This was a retrospective, nationwide cohort study of consecutive patients with STEMI treated with PPCI at 5 PPCI centers in Denmark. Polynomial spline curves were constructed to describe the association between system delay and distance to the PPCI center stratified by transportation mode. A total of 26,433 patients with STEMI were treated with PPCI between January 1, 1999, and December 31, 2016. In 16,436 patients field triaged directly to the PPCI center, the proportion treated within 120 minutes of the EMS call was 75% for those living 0 to 25 km from the PPCI center compared with 65% for all patients transported by GEMS (median transport distance 50 km [interquartile range 23 to 90]) and 64% for all patients transported by HEMS (median transport distance 119 km [interquartile range 99 to 142]). The estimated reduction in system delay owed to using HEMS rather than GEMS was 14, 16, 20, and 29 minutes for patients living 75, 100, 125, and 170 km from a PPCI center. In conclusion, this study confirmed that using HEMS ensures that most patients with STEMI, living up to 170 km from a PPCI center, can be treated within 120 minutes of their EMS call provided they are field triaged directly to the PPCI center., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Desaturation on exercise has been suggested as a predictive feature for deterioration in COVID-19. The objective of this paper was to determine the feasibility and validity for the 40-steps desaturation test.A prospective observational cohort study was undertaken in patients assessed in hospital prior to discharge. One-hundred and fifty-two participants were screened between November 2020 and February 2021, and 64 were recruited to perform a 40-steps desaturation test. Patients who were able to perform the test were younger and less frail. Four patients were readmitted to hospital and one patient deteriorated within 30 days but no patient died.The majority of patients showed little change in saturations during the test, even with pre-existing respiratory pathology. Change in saturations, respiratory rate, heart rate and breathlessness were not predictive of death or readmission to hospital within 30 days. Of 13 patients who had a desaturation of 3% or more during exercise, none was readmitted to hospital within 30 days.Not enough patients with COVID-19 could be recruited to the study to provide evidence for the safety of the test in this patient group.The 40-steps desaturation test requires further evaluation to assess clinical utility., (© Royal College of Physicians 2022. All rights reserved.)

Aim: This study describes and explores the influences in registered nurses' use of early warning scores to support clinical decisions in a hospital setting., Design: A focussed ethnography allowed for the investigation of registered nurses' clinical practices in two wards in a Danish University Hospital. The study adhered to the 'Standards for Reporting Qualitative Research'., Methods: Participant observation and ethnographic interviews were conducted from March 2019 to August 2019. Ten registered nurses were observed and interviewed, and four physicians were interviewed. Data were analysed using LeCompte and Schensul's ethnographic analysis., Findings: The findings show the registered nurses' ambivalence towards the early warning score as a decision support system. Early warning score monitoring created a space for registered nurses to identify and initiate optimized care. However, when early warning scores contradicted registered nurses' clinical judgments, the latter were given priority in decisions even though elevated scores were not always accounted for in the situation. Moreover, we found unspoken expectations in the collaboration between physicians and registered nurses, which influenced the registered nurses' workloads and decisions regarding early warning scores., Conclusion: Registered nurses' clinical judgment is essential to clinical decisions on the care and safety of patients if used combined with the early warning score. Interprofessional collaboration between registered nurses and physicians about the early warning score is challenged. Future research may address this challenge to explore how it should be operated as a collaboration tool., Impact: The study adds knowledge to the evidence base of registered nurses' use of early warning score and the advantages and challenges associated with the use of these scoring systems. The study may provide valuable knowledge for the future development of policies or implementation strategies., (© 2021 John Wiley & Sons Ltd.)

Aim: This systematic review explored how non-medical factors influence the prehospital resuscitation providers' decisions whether or not to resuscitate adult patients with cardiac arrest., Methods: We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings., Results: We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient's characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers' characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers' had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests., Conclusions: Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest., (© 2022. The Author(s).)