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Abstract Healthcare is awash with numbers, and figuring out what knowledge these numbers might hold is worthwhile in order to improve patient care. Numbers allow for objective mathematical analysis of the information at hand, but while mathematics is objective by design, our choice of mathematical approach in a given situation is not. In prehospital and critical care, numbers stem from a wide range of different sources and situations, be it experimental setups, observational data or data registries, and what constitutes a “good” statistical analysis can be unclear. A well-crafted statistical analysis can help us see things our eyes cannot, and find patterns where our brains come short, ultimately contributing to changing clinical practice and improving patient outcome. With increasingly more advanced research questions and research designs, traditional statistical approaches are often inadequate, and being able to properly merge statistical competence with clinical knowhow is essential in order to arrive at not only correct, but also valuable and usable research results. By marrying clinical knowhow with rigorous statistical analysis we can accelerate the field of prehospital and critical care.

Background. In situ simulation-based team training of non-technical skills is considered an important initiative for preventing adverse events caused by poor teamwork among healthcare personnel. This study aimed to assess the non-technical skills of anaesthesia personnel before and after in situ simulation-based team training in a clinical setting. Methods. The study was conducted from October 2020 to June 2021 using a quasiexperimental before and after design based on video-recorded observations and ratings of anaesthesia teams’ non-technical skills during anaesthesia induction in the operating room before and shortly after in situ simulation-based team training. Anaesthesia personnel were divided into 20 teams and video recorded during anaesthesia induction. The Anaesthetists’ Non-technical Skills (ANTS) system was used to score the teams’ non-technical skills. A paired-sample t-test was used to assess the impact of the intervention on the anaesthesia teams’ scores on the various ANTS categories. Interrater agreement between the two ANTS raters was assessed using weighted kappa. Results. At the category level, the overall scores had a statistically significant increase in performance after simulation-based team training (3.48 vs. 3.71; p

Abstract Background Training prehospital personnel in identifying patients with acute stroke is key to providing rapid treatment. This study aimed to investigate whether game-based digital simulation training is a feasible alternative to standard in-person simulation training. Methods Second-year paramedic bachelor students at Oslo Metropolitan University in Norway were invited to participate in a study to compare game-based digital simulation (intervention) to standard in-person training (control). For 2 months, students were encouraged to practice the NIHSS, and both groups logged their simulations. Then, they performed a clinical proficiency test, and their results were assessed using a Bland-Altman plot with corresponding 95% limits of agreement (LoA). Results Fifty students participated in the study. Individuals in the game group (n = 23) spent an average (SD) of 42:36 min (36) on gaming and performed 14.4 (13) simulations on average, whereas the control group (n = 27) spent 9:28 min (8) simulating and performed 2.5 (1) simulations. Comparing time variables collected during the intervention period, the mean time for each simulated assessment was significantly shorter in the game group (2:57 min vs. 3:50 min, p = 0.004). In the final clinical proficiency test, the mean difference from the true NIHSS score was 0.64 (LoA: − 1.38 to 2.67) in the game group and 0.69 (LoA: − 1.65 to 3.02) in the control group. Conclusion Game-based digital simulation training is a feasible alternative to standard in-person simulation training to acquire competence in NIHSS assessment. Gamification seemed to give an incentive to simulate considerably more and to perform the assessment faster, with equal accuracy. Trial registration The study was approved by the Norwegian Centre for Research Data (reference no. 543238).

BackgroundVideos have been an important medium for providing health and risk communication to the public during the COVID-19 pandemic. Public health officials, health care professionals, and policy makers have used videos to communicate pandemic-related content to large parts of the population. Evidence regarding the outcomes of such communication, along with their determinants, is however limited. ObjectiveThe aim of this study was to test the impact of nonvisual information factors of video communication on 4 outcomes: trust, comprehension, intentions, and behavior. MethodsTwelve short health communication videos related to pandemics were produced and shown to a large sample of participants, applying a randomized controlled between-subjects design. Three factors were included in the creation of the videos: the topic (exponential growth, handwashing, and burden of pandemics on the health care system), the source (expert and nonexpert), and a call to action (present or absent). Participants were randomly assigned to 1 video intervention, and 1194 valid replies were collected. The data were analyzed using factorial ANOVA. ResultsThe 3 pandemic-related topics did not affect trust, comprehension, intentions, or behavior. Trust was positively influenced by an expert source (2.5%), whereas a nonexpert source instead had a positive effect on the proxy for behavior (5.7%) compared with the expert source. The inclusion of a call to action had a positive effect on both trust (4.1%) and comprehension (15%). ConclusionsTrust and comprehension in pandemic-related video communication can be enhanced by using expert sources and by including a call to action, irrespective of the topic being communicated. Intentions and behavior appear to be affected to a small extent by the 3 factors tested in this study. International Registered Report Identifier (IRRID)RR2-10.2196/34275

Objective The objective of this systematic review was to examine how the record linkage process is reported in multimorbidity research.Methods A systematic search was conducted in Medline, Web of Science and Embase using predefined search terms, and inclusion and exclusion criteria. Published studies from 2010 to 2020 using linked routinely collected data for multimorbidity research were included. Information was extracted on how the linkage process was reported, which conditions were studied together, which data sources were used, as well as challenges encountered during the linkage process or with the linked dataset.Results Twenty studies were included. Fourteen studies received the linked dataset from a trusted third party. Eight studies reported variables used for the data linkage, while only two studies reported conducting prelinkage checks. The quality of the linkage was only reported by three studies, where two reported linkage rate and one raw linkage figures. Only one study checked for bias by comparing patient characteristics of linked and non-linked records.Conclusions The linkage process was poorly reported in multimorbidity research, even though this might introduce bias and potentially lead to inaccurate inferences drawn from the results. There is therefore a need for increased awareness of linkage bias and transparency of the linkage processes, which could be achieved through better adherence to reporting guidelines.PROSPERO registration number CRD42021243188.

Abstract Background A worldwide pandemic of a new and unknown virus is characterised by scientific uncertainty. However, despite this uncertainty, health authorities must still communicate complex health risk information to the public. The mental models approach to risk communication describes how people perceive and make decisions about complex risks, with the aim of identifying decision-relevant information that can be incorporated into risk communication interventions. This study explored how people use mental models to make sense of scientific information and apply it to their lives and behaviour in the context of COVID-19. Methods This qualitative study enrolled 15 male and female participants of different ages, with different levels of education and occupational backgrounds and from different geographical regions of Norway. The participants were interviewed individually, and the interview data were subjected to thematic analysis. The interview data were compared to a expert model of COVID-19 health risk communication based on online information from the Norwegian Institute of Public Health. Materials in the interview data not represented by expert model codes were coded inductively. The participants’ perceptions of and behaviours related to health risk information were analysed across three themes: virus transmission, risk mitigation and consequences of COVID-19. Results The results indicate that people placed different meanings on the medical and scientific words used by experts to explain the pandemic (e.g., virus transmission and the reproduction number). While some people wanted to understand why certain behaviour and activities were considered high risk, others preferred simple, clear messages explaining what to do and how to protect themselves. Similarly, information about health consequences produced panic in some interviewees and awareness in others. Conclusion There is no one-size-fits-all approach to public health risk communication. Empowering people with decision-relevant information necessitates targeted and balanced risk communication.

Abstract Background Less than 50% of stroke patients in Norway reach hospital within 4 h of symptom onset. Early prehospital identification of stroke and triage to the right level of care may result in more patients receiving acute treatment. Quality of communication between paramedics and the stroke centre directly affects prehospital on-scene time, emphasising this as a key factor to reduce prehospital delay. Prehospital stroke scales are developed for quick and easy identification of stroke, but have poor sensitivity and specificity compared to an in-hospital assessment with the National Institutes of Health Stroke Scale (NIHSS). The aim of the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) is to assess whether a structured learning program, prehospital NIHSS and a mobile application facilitating communication with the stroke physician may improve triage of acute stroke patients. Methods A stepped wedge cluster randomised controlled intervention design will be used in this trial in Oslo, Norway. Paramedics at five ambulance stations will enrol adult patients with suspected stroke within 24 h of symptom onset. All paramedics will begin in a control phase with standard procedures. Through an e-learning program and practical training, a random and sequential switch to the intervention phase takes place. A mobile application for NIHSS scoring, including vital patient information for treatment decisions, transferring data from paramedics to the on-call stroke physician at the Stroke Unit at Oslo University Hospital, will be provided for the intervention. The primary outcome measure is positive predictive value (PPV) for prehospital identification of patients with acute stroke defined as the proportion of patients accepted for stroke evaluation and discharged with a final stroke diagnosis. One thousand three hundred patients provide a 50% surplus to the 808 patients needed for 80% power to detect a 10% increase in PPV. Discussion Structured and digital communication using a common scale like NIHSS may result in increased probability for better identification of stroke patients and less stroke mimics delivered to a stroke team for acute diagnostics and treatment in our population. Trial registration ClinicalTrials.gov NCT04137874 . Registered on October 24, 2019.

ObjectivesHelicopter Emergency Medical Services (HEMS) throughout Europe are generally on scene within 10-15 minutes. In Norway, however, with its 13 HEMS bases, only 75% of the population can currently be reached within half an hour. We estimate the number of HEMS bases needed to reach the full Norwegian population within 10-15 minutes, and discuss implications regarding cost effectiveness.MethodsUsing geographic location and population characteristics from Norway's 428 municipalities as input to the Maximal Covering Location Problem-a mathematical location optimization model-we estimate the number of HEMS bases required along with accompanying personnel and healthcare costs. We estimate the minimum number of lives that would have to be saved to achieve a net social benefit of zero.ResultsTo reach 99% or 100% of the Norwegian population by HEMS within 15 minutes 78 or 104 bases are needed, respectively. The incremental need for personnel going from 20 to 15 minutes for 99/100% of the population is 602/728, with an accompanying incremental cost of 228/276 million EURO per year. A yearly total of 280/339 additional lives would have to be saved to obtain a net social benefit of zero. Then, the HEMS-system as a whole would be cost effective although the least efficient bases still would not be.ConclusionsReducing Norwegian HEMS response times to 10-15 minutes requires a drastic increase in the number of HEMS bases needed. Choice of ethical philosophy (utilitarianism or egalitarianism) determines when the expansion might be considered cost effective.

BackgroundHumans struggle to grasp the extent of exponential growth, which is essential to comprehend the spread of an infectious disease. Exponential growth bias is the tendency to linearize exponential functions when assessing them intuitively. Effective public health communication about the nonlinear nature of infectious diseases has strong implications for the public’s compliance with strict restrictions. However, there is a lack of synthesized knowledge on the communication of the exponential growth of infectious diseases and on the outcomes of exponential growth bias. ObjectiveThis systematic review identifies, evaluates, and synthesizes the findings of empirical studies on exponential growth bias of infectious diseases. MethodsA systematic review will be conducted using the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 statement. Eligibility criteria include empirical studies of exponential growth bias of infectious diseases regardless of methodology. We include studies both with and without interventions/strategies. For information sources, we include the following five bibliographic databases: MEDLINE, Embase, Cochrane Library, PsychINFO, and Web of Science Core Collection. The risk of bias will be assessed using RoB 2 (Risk of Bias 2) and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Data synthesis will be achieved through a narrative synthesis. ResultsBy February 2022, we included 11 experimental studies and 1 cross-sectional survey study. Preliminary themes identified are the presence of exponential growth bias, the effect of exponential growth bias, and communication strategies to mitigate exponential growth bias. Data extraction, narrative synthesis, and the risk of bias assessment are to be completed by February 2023. ConclusionsWe anticipate that this systematic review will draw some lines related to how people comprehend and misperceive exponential growth and its consequences for infectious disease mitigation and communication. Furthermore, the study will conclude with the limitations of the research and suggestions for future research. International Registered Report Identifier (IRRID)DERR1-10.2196/37441

Objectives The objective for this systematic review was to examine how the record linkage process was reported and to understand challenges related to accessing, linking, and analysing linked routinely collected data used for multimorbidity research. Approach A systematic search for relevant studies was conducted in three online databases (Medline, Web of Science and Embase) in May 2021 using predefined search terms, and inclusion and exclusion criteria. Studies using linked routinely collected data for multimorbidity research were included. Information was extracted on how the linkage process was reported, which conditions were studied together, which data sources were used, as well as challenges encountered during the linkage process or with the linked dataset. The findings from this study will feed into further guidance to understand and minimise bias due to linkage error in medical research. Results Twenty studies were included, of which seventeen looked at the relationship between two specified long-term conditions. Fourteen studies received the linked dataset from an external data linkage provider. Hospital Episode Statistics was the most common source of data (n=5). Eight studies reported variables used for the data linkage, while only two studies reported pre-linkage checks. The quality of the linkage was assessed by three studies, of which two reported linkage rate and one reported raw linkage figures. Only one study checked for bias by comparing patient characteristics of linked and non-linked records. Conclusions The linkage process was poorly reported in multimorbidity research, even though this might introduce bias and potentially lead to inaccurate inferences drawn from the results. There is therefore a need for increased awareness of linkage bias and transparency of the linkage processes, which could be achieved through better adherence to reporting guidelines.

Abstract Background Responses from the H1N1 swine flu pandemic and the recent COVID-19 coronavirus pandemic provide an opportunity for insight into the role of health authorities’ ways of communicating health risk information to the public. We aimed to synthesise the existing evidence regarding different modes of communication used by health authorities in health risk communication with the public during a pandemic. Methods We conducted a rapid scoping review. MEDLINE and EMBASE were searched for publications in English from January 2009 through October 2020, covering both the full H1N1 pandemic and the response phase during the COVID-19 pandemic. The search resulted in 1440 records, of which 48 studies met our eligibility criteria. Results The present review identified studies across a broad interdisciplinary field of health risk communication. The majority focused on the H1N1 pandemic and the COVID-19 pandemic. A content analysis of the studies identified three categories for modes of communication: i) communication channels, ii) source credibility and iii) how the message is communicated. The identified studies on social media focused mainly on content and engagement, while studies on the effect of the use of social media and self-protective behaviour were lacking. Studies on the modes of communication that take the diversity of receivers in the field into account are lacking. A limited number of studies of health authorities’ use of graphic and audio-visual means were identified, yet these did not consider/evaluate creative communication choices. Conclusion Experimental studies that investigate the effect of health authorities’ videos and messages on social media platforms and self-protective behaviour are needed. More studies are needed across the fields of health risk communication and media studies, including visual communication, web design, video and digital marketing, at a time when online digital communication is central to reaching the public.

Pandemic video communication aimed at the general public often lacks creativity and fails to reach large audiences. Yet, the scientific content should not be compromised by attempts to improve the creativity or reach. This study explores the processes utilised by various health experts and professional communicators when creating communication, to identify similarities and differences, and how pandemic video communication thus can be improved through an interdisciplinary approach. We interviewed 12 individuals from 6 different professional domains: health, public health, film/science communication, video journalism, advertising, and social media/YouTube. Semi-structured individual interviews were conducted using the same interview guide. The interview data were subjected to thematic analysis with both deductive and inductive coding, and the results were visualised in a bubble chart. Our study has highlighted both similarities and differences between health professionals and creative communicators relating to their creative processes and their approaches to pandemic video communication. We found that participants from health domains assigned great importance to and efforts on the content, but were unsure or lacked experience in how content is translated through form and creativity. Creative communicators, on the other hand, emphasise and specialise in form, yet depend on health professionals, experts, and scientists to provide and validate content. The key to improving pandemic-related video communication appears to lie in striking the right balance between high-quality and evidence-based content and creativity. This study found that both health professionals and creative communicators play crucial roles in reaching a solid end result, and we suggest a fusion model approach to interdisciplinary collaboration.

Abstract Background Complement activation is a central mechanism in systemic inflammation and remote organ dysfunction following major trauma. Data on temporal changes of complement activation early after injury is largely missing. We aimed to describe in detail the kinetics of complement activation in individual trauma patients from admission to 10 days after injury, and the association with trauma characteristics and outcome. Methods In a prospective cohort of 136 trauma patients, plasma samples obtained with high time resolution (admission, 2, 4, 6, 8 h, and thereafter daily) were assessed for terminal complement complex (TCC). We studied individual TCC concentration curves and calculated a summary measure to obtain the accumulated TCC response 3 to 6 h after injury (TCC-AUC3–6). Correlation analyses and multivariable linear regression analyses were used to explore associations between individual patients’ admission TCC, TCC-AUC3–6, daily TCC during the intensive care unit stay, trauma characteristics, and predefined outcome measures. Results TCC concentration curves showed great variability in temporal shapes between individuals. However, the highest values were generally seen within the first 6 h after injury, before they subsided and remained elevated throughout the intensive care unit stay. Both admission TCC and TCC-AUC3–6 correlated positively with New Injury Severity Score (Spearman’s rho, p-value 0.31, 0.0003 and 0.21, 0.02) and negatively with admission Base Excess (− 0.21, 0.02 and − 0.30, 0.001). Multivariable analyses confirmed that deranged physiology was an important predictor of complement activation. For patients without major head injury, admission TCC and TCC-AUC3–6 were negatively associated with ventilator-free days. TCC-AUC3–6 outperformed admission TCC as a predictor of Sequential Organ Failure Assessment score at day 0 and 4. Conclusions Complement activation 3 to 6 h after injury was a better predictor of prolonged mechanical ventilation and multiple organ dysfunction syndrome than admission TCC. Our data suggest that the greatest surge of complement activation is found within the first 6 h after injury, and we argue that this time period should be in focus in the design of future experimental studies and clinical trials using complement inhibitors.

Abstract Background A primary task of the Norwegian helicopter emergency medical services (HEMS) is to provide advanced medical care to the critical ill and injured outside of hospitals. Where HEMS bases are located, directly influences who in the population can be reached within a given response time threshold and who cannot. When studying the locations of bases, the focus is often on efficiency, that is, maximizing the total number of people that can be reached within a given set time. This approach is known to benefit people living in densely populated areas, such as cities, over people living in remote areas. The most efficient solution is thus typically not necessarily a fair one. This study aims to incorporate fairness in finding optimal air ambulance base locations. Methods We solve multiple advanced mathematical optimization models to determine optimal helicopter base locations, with different optimization criteria related to the level of aversion to inequality, including the utilitarian, Bernoulli-Nash and iso-elastic social welfare functions. This is the first study to use the latter social welfare function for HEMS. Results Focusing on efficiency, a utilitarian objective function focuses on covering the larger cities in Norway, leaving parts of Norway largely uncovered. Including fairness by rather using an iso-elastic social welfare function in the optimization avoids leaving whole areas uncovered and in particular increases service levels in the north of Norway. Conclusions Including fairness in determining optimal HEMS base locations has great impact on population coverage, in particular when the number of base locations is not enough to give full coverage of the country. As results differ depending on the mathematical objective, the work shows the importance of not only looking for optimal solutions, but also raising the essential question of ‘optimal with respect to what’.

Abstract Background Organizational changes in out-of-hour (OOH) services may have unintended consequences for other prehospital services. Reports indicate an increased use of helicopter emergency medical services (HEMS) after changes in OOH services in Norway due to greater geographical distances for the on-call doctors. We investigated whether HEMS dispatches increased when nine municipalities in Sogn og Fjordane County merged into one large inter-municipal OOH district. Methods All primary dispatches of the HEMS in the county between 2004 and 2013 were included. We applied interrupted time series regression to monthly aggregated data to evaluate the impact of the organizational change 1 April 2009. The nine target municipalities were compared to the rest of the municipalities in the county, which served as a control group. A quasipoisson model adjusted for seasonality was found to be most applicable. Results We included 8,751 dispatches, 5,009 (57.2%) of which were completed with a patient encounter. Overall, we found no alteration in requests for HEMS after 2009 (p = 0.251). Separate analyses of the target municipalities and control group revealed no significant increase after 2009 (p = 0.400 and p = 0.056, respectively). When categorizing the municipalities into urban or rural, we found a general increase in HEMS dispatches for the rural group over the 10-year span (p = 0.045) but no added increase after 2009 (p = 0.502). The urban subgroup showed no change. Distance from the OOH service in regards to travel increased within the nine municipalities after 2009, median [quartiles] (5.0[3.0, 6.2] km vs 26.5[5.0, 62.2] km, p

BackgroundThe nonlinear nature of contagious diseases and the potential for exponential growth can be difficult to grasp for the general public. This has strong implications for public health communication, which needs to be both easily accessible and efficient. A pandemic is an extreme situation, and the accompanying strict societal measures are generally easier to accept if one understands the underlying reasoning behind them. Bringing about informed attitude change and achieving compliance to strict restrictions requires explanations of scientific concepts and terminologies that laypersons can understand. ObjectiveThe aim of the project is to develop effective, evidence-based modes of video communication for translating complex, but important, health messages about pandemics to both the general population and decision makers. The study uses COVID-19 as a case to learn and prepare society for handling the ongoing and future pandemics, as well as to provide evidence-based tools for the science communication toolbox. MethodsThe project applies a mixed methods design, combining qualitative methods (eg, interviews, observational studies, literature reviews) and quantitative methods (eg, randomized controlled trials [RCTs]). The project brings together researchers from a wide range of academic fields, as well as communication industry professionals. ResultsThis study has received funding from the Trond Mohn Foundation through the Research Council of Norway’s “COVID-19 Emergency Call for Proposals” March 2020. Recruitment and data collection for the exploratory first phase of the project ran from February 2021 to March 2021. Creative communication work started in May 2021, and the production of videos for use in the RCTs in the final phase of the project started in September 2021. ConclusionsThe COVCOM project will take on several grand challenges within the field of communicating science and provide evidence-based tools to the science communication toolbox. A long-term goal of the project is to contribute to the creation of a more resilient health care system by developing communication responses tailormade for different audiences, preparing society for any future pandemic. International Registered Report Identifier (IRRID)DERR1-10.2196/34275

Abstract Background Individualized treatment is a common principle in hospitals. Treatment decisions are made based on the patient’s condition, including comorbidities. This principle is equally relevant out-of-hospital. Furthermore, comorbidity is an important risk-adjustment factor when evaluating pre-hospital interventions and may aid therapeutic decisions and triage. The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is included in templates for reporting data in physician-staffed pre-hospital emergency medical services (p-EMS) but whether an adequate full pre-event ASA-PS can be assessed by pre-hospital physicians remains unknown. We aimed to explore whether pre-hospital physicians can score an adequate pre-event ASA-PS with the information available on-scene. Methods The study was an inter-rater reliability study consisting of two steps. Pre-event ASA-PS scores made by pre- and in-hospital physicians were compared. Pre-hospital physicians did not have access to patient records and scores were based on information obtainable on-scene. In-hospital physicians used the complete patient record (Step 1). To assess inter-rater reliability between pre- and in-hospital physicians when given equal amounts of information, pre-hospital physicians also assigned pre-event ASA-PS for 20 of the included patients by using the complete patient records (Step 2). Inter-rater reliability was analyzed using quadratic weighted Cohen’s kappa (κw). Results For most scores (82%) inter-rater reliability between pre-and in-hospital physicians were moderate to substantial (κw 0,47-0,89). Inter-rater reliability was higher among the in-hospital physicians (κw 0,77 to 0.85). When all physicians had access to the same information, κw increased (κw 0,65 to 0,93). Conclusions Pre-hospital physicians can score an adequate pre-event ASA-PS on-scene for most patients. To further increase inter-rater reliability, we recommend access to the full patient journal on-scene. We recommend application of the full ASA-PS classification system for reporting of comorbidity in p-EMS.

Abstract Simulation-based training of emergency teams offers a safe learning environment in which training in the management of the critically ill patient can be planned and practiced without harming the patient. We developed a concept for in situ simulation that can be carried out during on-call time. The aim of this study is to investigate the feasibility of introducing in situ, simulation-based training for the on-call team on a busy helicopter emergency medical service (HEMS) base. We carried out a one-year prospective study on simulation training during active duty at a busy Norwegian HEMS base, which has two helicopter crews on call 24/7. Training was conducted as low fidelity in situ simulation while the teams were on call. The training took place on or near the HEMS base. Eight scenarios were developed with learning objectives related to the mission profile of the base which includes primary missions for both medical and trauma patients of all ages, and interhospital transport of adults, children, and neonates. All scenarios included learning objectives for non-technical skills. A total of 44 simulations were carried out. Total median (quartiles) time consumption for on-call HEMS crew was 65 (59-73) min. Time for preparation of scenarios was 10 (5-11) min, time for simulations was 20 (19-26) min, cleaning up 7 (6-10) min, and debrief 35 (30-40) min. For all items on the questionnaire, the majority of respondents replied with the two most positive categories on the Likert scale. Our results demonstrate that in situ simulation training for on-call crews on a busy HEMS base is feasible with judicious investment of time and money. The participants were very positive about their experience and the impact of this type of training.

BackgroundScience communication can provide people with more accurate information on pandemic health risks by translating complex scientific topics into language that helps people make more informed choices on how to protect themselves and others. During pandemics, experts in medicine, science, public health, and communication are important sources of knowledge for science communication. This study uses the COVID-19 pandemic to explore these experts' opinions and knowledge of what to communicate to the public during a pandemic. The research question is: What are the key topics to communicate to the public about health risks during a pandemic?MethodWe purposively sampled 13 experts in medicine, science, public health, and communication for individual interviews, with a range of different types of knowledge of COVID-19 risk and communication at the national, regional and hospital levels in Norway. The interview transcripts were coded and analysed inductively in a qualitative thematic analysis.ResultsThe study's findings emphasise three central topics pertaining to communication about pandemic health risk during the first year of the COVID-19 pandemic in Norway: 1) how the virus enters the human body and generates disease; 2) how to protect oneself and others from being infected; and 3) pandemic health risk for the individual and the society.ConclusionThe key topics emerging from the expert interviews relate to concepts originating from multiple disciplinary fields, and can inform frameworks for interprofessional communication about health risks during a pandemic. The study highlights the complexity of communicating pandemic messages, due to scientific uncertainty, fear of risk amplification, and heterogeneity in public health and scientific literacy. The study contributes with insight into the complex communication processes of pandemic health risk communication.

BackgroundThe importance of effective communication during public health emergencies has been highlighted by the World Health Organization, and it has published guidelines for effective communication in such situations. With video being a popular medium, video communication has been a growing area of study over the past decades and is increasingly used across different sectors and disciplines, including health. Health-related video communication gained momentum during the SARS-CoV-2 pandemic, and video was among the most frequently used modes of communication worldwide. However, although much research has been done regarding different characteristics of video content (the message) and its delivery (the messenger), there is a lack of knowledge about the role played by the characteristics of the recipients for the creation of effective communication. ObjectiveThe aim of this review is to identify how health video communication outcomes are shaped by recipient characteristics, as such characteristics might affect the effectiveness of communication. The main research question of the study is as follows: do the characteristics of the recipients of health videos affect the outcomes of the communication? MethodsA scoping review describing the existing knowledge within the field was conducted. We searched for literature in 3 databases (PubMed, Scopus, and Embase) and defined eligibility criteria based on the relevance to the research question. Recipient characteristics and health video communication outcomes were identified and classified. ResultsOf the 1040 documents initially identified, 128 (12.31%) met the criteria for full-text assessment, and 39 (3.75%) met the inclusion criteria. The included studies reported 56 recipient characteristics and 42 communication outcomes. The reported associations between characteristics and outcomes were identified, and the potential research opportunities were discussed. Contributions were made to theory development by amending the existing framework of the Integrated-Change model, which is an integrated model of motivational and behavioral change. ConclusionsAlthough several recipient characteristics and health video communication outcomes were identified, there is a lack of robust empirical evidence on the association between them. Further research is needed to understand how the preceding characteristics of the recipients might affect the various outcomes of health video communication.

Video communication has played a key role in relaying important and complex information on the COVID-19 pandemic to the general public. The aim of the present study is to compare Norwegian health authorities’ and WHO’s use of video communication during the COVID-19 pandemic to the most viewed COVID-19 videos on YouTube, in order to identify how videos created by health authorities measure up to contemporary video content, both creatively and in reaching video consumers. Through structured search on YouTube we found that Norwegian health authorities have published 26 videos, and the WHO 29 videos on the platform. Press briefings, live videos, news reports, and videos recreated/translated into other languages than English or Norwegian, were not included. A content analysis comparing the 55 videos by the health authorities to the 27 most viewed videos on COVID-19 on YouTube demonstrates poor reach of health authorities’ videos in terms of views and it elucidates a clear creative gap. While the videos created by various YouTube creators communicate using a wide range of creative presentation means (such as professional presenters, contextual backgrounds, advanced graphic animations, and humour), videos created by the health authorities are significantly more homogenous in style often using field experts or public figures, plain backgrounds or PowerPoint style animations. We suggest that further studies into various creative presentation means and their influence on reach, recall, and on different groups of the population, are carried out in the future to evaluate specific factors of this creative gap.

Abstract Background Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template. Methods The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher’s Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties. Results All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method. Conclusions We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Background: Knowledge of how to improve consumer satisfaction with the outcome of co-production in services with high levels of interaction is important for achieving and maintaining a competitive advantage in the service industry. Objectives: The aim of this paper is to review and meta-analyse research on the relationship between aspects of feedback to customers in interaction-intense encounters and the customer's satisfaction with the outcome. Methods: We followed recommendations of the Cochrane Handbook for Systematic Review and Interventions to do a review and meta-analysis of relevant empirical research. From January 2018 to July 2018, we systematically searched PsycINFO, Business Source Complete, Science Direct and Web of Science for relevant studies. Results: A total of six articles – consisting of 22 RCTs – were identified and included in the meta-analysis. Results indicate that feedback valence, with an effect size of 0.61 (0.43, 0.78), and feedback style, with an effect size of 0.82 (0.08, 1.57), have an impact on customers’ satisfaction with the outcome of co-production. For feedback interventions, effect size -0.29 (-0.69, 0.11), and feedback medium, effect size 0.43 (-0.00, 0.86), the results are inconclusive. Conclusions: The present study suggest that there is a significant relationship between satisfaction with the outcome of co-production and feedback style and valence. To satisfy customers, service providers should offer positive feedback. In order to extend our knowledge, more studies on the effect of different feedback styles on customers' satisfaction with the outcome of co-production are needed.

Abstract Background Helicopter emergency medical services are important in many health care systems. Norway has a nationwide physician manned air ambulance service servicing a country with large geographical variations in population density and incident frequencies. The aim of the study was to compare optimal air ambulance base locations using both population and incident data. Methods We used municipality population and incident data for Norway from 2015. The 428 municipalities had a median (5–95 percentile) of 4675 (940–36,264) inhabitants and 10 (2–38) incidents. Optimal helicopter base locations were estimated using the Maximal Covering Location Problem (MCLP) optimization model, exploring the number and location of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, in green field scenarios and conditioned on the existing base structure. Results The existing bases covered 96.90% of the population and 91.86% of the incidents for time threshold 45 min. Correlation between municipality population and incident frequencies was −0.0027, and optimal base locations varied markedly between the two data types, particularly when lowering the target time. The optimal solution using population density data put focus on the greater Oslo area, where one third of Norwegians live, while using incident data put focus on low population high incident areas, such as northern Norway and winter sport resorts. Conclusion Using population density data as a proxy for incident frequency is not recommended, as the two data types lead to different optimal base locations. Lowering the target time increases the sensitivity to choice of data.

Abstract Background Endotracheal intubation of patients with massive regurgitation represents a challenge in emergency airway management. Gastric contents tend to block suction catheters, and few treatment alternatives exist. Based on a technique that was successfully applied in our district, we wanted to examine if endotracheal intubation would be easier and quicker to perform when the patient is turned over to a semiprone position, as compared to the supine position. Methods In a randomized crossover simulation trial, a child manikin with on-going regurgitation was intubated both in the supine and semiprone positions. Endpoints were experienced difficulty with the procedure and time to intubation, as well as visually confirmed intubation and first-pass success rate. Results Intubation in the semiprone position was significantly easier and faster compared to the supine position; the median experienced difficulty on a visual analogue scale was 27 and 65, respectively (p = 0.004), and the median time to intubation was 26 and 45 s, respectively (p = 0.001). There were no significant differences in frequency of visually confirmed intubation (16 and 18, p = 0.490) of first-pass success rate (17 and 18, p = 1.000). Conclusion In this experiment, endotracheal intubation during massive regurgitation with the patient in the semiprone position was significantly easier and quicker to perform than in the supine position. Endotracheal intubation in the semiprone position can provide a quick rescue method in situations where airway management is hindered by massive regurgitation, and it represents a possible supplement to current airway management training.

Abstract Background The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS. Methods Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran–Mantel–Haenszel methods and mixed-effects models. Results Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4–5.4). Conclusions Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients. Trial registration Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.

Abstract Background Labor that progresses faster than anticipated may lead to unplanned out-of-hospital births. With the aim to improve planning of transportation to birthing institutions, this study investigated predictors of time to completion for the first stage of labor conditional on cervical opening (conditional time) in multiparous women at term. Methods We performed a retrospective analysis of partograms for women in Robson’s group 3 who delivered at one hospital from 2003 to 2013. A generalized additive mixed model was fitted, accounting for possible non-linear relationships between the predictor variables and outcome, e.g. the time from each cervical measurement to full dilation, using multiple measurements for each woman. The following predictors were included: cervical dilation (cm), parity (1, 2, or ≥3 previous vaginal births), oxytocin infusion (no/yes), epidural (no/yes), maternal age (years), maternal height (cm), body mass index (BMI, kg/m2), birthweight (kg), spontaneous rupture of membranes (no/yes). A modified regression model with gestational age (days) instead of birthweight was used to predict conditional time to full cervical dilation for combinations of the most relevant predictors. Results A total of 1753 partograms were included in the analysis. The strongest predictors were birthweight, epidural and oxytocin use, and spontaneous rupture of membranes, along with cervical measurements. For birthweight, there was an almost 40% increase in time to full cervical dilation for each 1-kg increment. Conditional time was on average 23% longer in cases with epidural use and 53% longer in cases requiring oxytocin augmentation. Spontaneous rupture of the membranes shortened conditional time by 31%. Maternal age was not associated with the outcome, while increasing BMI and parity modestly reduced conditional time. Conclusions Higher parity, lower fetal weight (gestational age), and spontaneous rupture of the membranes are associated with more rapid labor.

PURPOSE:Respiratory variations in pulse pressure (dPP) and photoplethysmographic waveform amplitude (dPOP) are used for evaluation of volume status in mechanically ventilated patients. Amplification of intrathoracic pressure changes may enable their use also during spontaneous breathing. We investigated the association between the degree of hypovolemia and dPP and dPOP at different levels of two commonly applied clinical interventions; positive expiratory pressure (PEP) and continuous positive airway pressure (CPAP). METHODS:20 healthy volunteers were exposed to progressive hypovolemia by lower body negative pressure (LBNP). PEP of 0 (baseline), 5 and 10 cmH2O was applied by an expiratory resistor and CPAP of 0 (baseline), 5 and 10 cmH2O by a facemask. dPP was obtained non-invasively with the volume clamp method and dPOP from a pulse oximeter. Central venous pressure was measured in 10 subjects. Associations between changes were examined using linear mixed-effects regression models. RESULTS:dPP increased with progressive LBNP at all levels of PEP and CPAP. The LBNP-induced increase in dPP was amplified by PEP 10 cmH20. dPOP increased with progressive LBNP during PEP 5 and PEP 10, and during all levels of CPAP. There was no additional effect of the level of PEP or CPAP on dPOP. Progressive hypovolemia and increasing levels of PEP were reflected by increasing respiratory variations in CVP. CONCLUSION:dPP and dPOP reflected progressive hypovolemia in spontaneously breathing healthy volunteers during PEP and CPAP. An increase in PEP from baseline to 10 cmH2O augmented the increase in dPP, but not in dPOP.

BackgroundAmbulance services play a crucial role in providing pre-hospital emergency care. In order to ensure quick responses, the location of the bases, and the distribution of available ambulances among these bases, should be optimized. In mixed urban-rural areas, this optimization typically involves a trade-off between backup coverage in high-demand urban areas and single coverage in rural low-demand areas. The aim of this study was to find the optimal distribution of bases and ambulances in the Vestfold region of Norway in order to optimize ambulance coverage.MethodThe optimal location of bases and distribution of ambulances was estimated using the Maximum Expected Covering Location Model. A wide range of parameter settings were fitted, with the number of ambulances ranging from 1 to 15, and an average ambulance utilization of 0, 15, 35 and 50%, corresponding to the empirical numbers for night, afternoon and day, respectively. We performed the analysis both conditioned on the current base structure, and in a fully greenfield scenario.ResultsFour of the five current bases are located close to the mathematical optimum, with the exception of the northernmost base, in the rural part of the region. Moving this base, along with minor changes to the location of the four other bases, coverage can be increased from 93.46% to 97.51%. While the location of the bases is insensitive to the workload of the system, the distribution of the ambulances is not. The northernmost base should only be used if enough ambulances are available, and this required minimum number increases significantly with increasing system workload.ConclusionAs the load of the system increases, focus of the model shifts from providing single coverage in low-demand areas to backup coverage in high-demand areas. The classification rule for urban and rural areas significantly affects results and must be evaluated accordingly.

Objectives: Missing data is a recurrent issue in many fields of medical research, particularly in questionnaires. The aim of this article is to describe and compare six conceptually different multiple imputation methods, alongside the commonly used complete case analysis, and to explore whether the choice of methodology for handling missing data might impact clinical conclusions drawn from a regression model when data are categorical. Methods: In addition to the commonly used complete case analysis, we tested the following six imputation methods: multiple imputation using expectation–maximization with bootstrapping, multiple imputation using multiple correspondence analysis, multiple imputation using latent class analysis, multiple hot deck imputation and multivariate imputation by chained equations with two different model specifications: logistic regression and random forests. The methods are tested on real data from a questionnaire-based study in the Norwegian opioid maintenance treatment programme. Results: All methods performed relatively well when the sample size was large (n = 1000). For a smaller sample size (n = 200), the regression estimates depend heavily on the level of missing. When the amount of missing was ⩾20%, in particular, complete case analysis, hot deck and random forests had biased estimates with too low coverage. Multiple imputation using multiple correspondence analysis had the best performance all over. Conclusion: The choice of missing handling methodology has a significant impact on the clinical interpretation of the accompanying statistical analyses. With missing data, the choice of whether to impute or not, and choice of imputation method, can influence clinical conclusion drawn from a regression model and should therefore be given sufficient consideration.

Abstract Background Wastewater-based epidemiology (WBE) is a novel approach in drug use epidemiology which aims to monitor the extent of use of various drugs in a community. In this study, we investigate functional principal component analysis (FPCA) as a tool for analysing WBE data and compare it to traditional principal component analysis (PCA) and to wavelet principal component analysis (WPCA) which is more flexible temporally. Methods We analysed temporal wastewater data from 42 European cities collected daily over one week in March 2013. The main temporal features of ecstasy (MDMA) were extracted using FPCA using both Fourier and B-spline basis functions with three different smoothing parameters, along with PCA and WPCA with different mother wavelets and shrinkage rules. The stability of FPCA was explored through bootstrapping and analysis of sensitivity to missing data. Results The first three principal components (PCs), functional principal components (FPCs) and wavelet principal components (WPCs) explained 87.5-99.6 % of the temporal variation between cities, depending on the choice of basis and smoothing. The extracted temporal features from PCA, FPCA and WPCA were consistent. FPCA using Fourier basis and common-optimal smoothing was the most stable and least sensitive to missing data. Conclusion FPCA is a flexible and analytically tractable method for analysing temporal changes in wastewater data, and is robust to missing data. WPCA did not reveal any rapid temporal changes in the data not captured by FPCA. Overall the results suggest FPCA with Fourier basis functions and common-optimal smoothing parameter as the most accurate approach when analysing WBE data.

Trauma is a leading global cause of death, and predicting the burden of trauma admissions is vital for good planning of trauma care. Seasonality in trauma admissions has been found in several studies. Seasonal fluctuations in daylight hours, temperature and weather affect social and cultural practices but also individual neuroendocrine rhythms that may ultimately modify behaviour and potentially predispose to trauma. The aim of the present study was to explore to what extent the observed seasonality in daily trauma admissions could be explained by changes in daylight and weather variables throughout the year.Retrospective registry study on trauma admissions in the 10-year period 2001-2010 at Oslo University Hospital, Ullevål, Norway, where the amount of daylight varies from less than 6 hours to almost 19 hours per day throughout the year. Daily number of admissions was analysed by fitting non-linear Poisson time series regression models, simultaneously adjusting for several layers of temporal patterns, including a non-linear long-term trend and both seasonal and weekly cyclic effects. Five daylight and weather variables were explored, including hours of daylight and amount of precipitation. Models were compared using Akaike's Information Criterion (AIC).A regression model including daylight and weather variables significantly outperformed a traditional seasonality model in terms of AIC. A cyclic week effect was significant in all models.Daylight and weather variables are better predictors of seasonality in daily trauma admissions than mere information on day-of-year.

Wastewater-based epidemiology (WBE) is a new methodology for estimating the drug load in a population. Simple summary statistics and specification tests have typically been used to analyze WBE data, comparing differences between weekday and weekend loads. Such standard statistical methods may, however, overlook important nuanced information in the data. In this study, we apply functional data analysis (FDA) to WBE data and compare the results to those obtained from more traditional summary measures.We analysed temporal WBE data from 42 European cities, using sewage samples collected daily for one week in March 2013. For each city, the main temporal features of two selected drugs were extracted using functional principal component (FPC) analysis, along with simpler measures such as the area under the curve (AUC). The individual cities' scores on each of the temporal FPCs were then used as outcome variables in multiple linear regression analysis with various city and country characteristics as predictors. The results were compared to those of functional analysis of variance (FANOVA).The three first FPCs explained more than 99% of the temporal variation. The first component (FPC1) represented the level of the drug load, while the second and third temporal components represented the level and the timing of a weekend peak. AUC was highly correlated with FPC1, but other temporal characteristic were not captured by the simple summary measures. FANOVA was less flexible than the FPCA-based regression, and even showed concordance results. Geographical location was the main predictor for the general level of the drug load.FDA of WBE data extracts more detailed information about drug load patterns during the week which are not identified by more traditional statistical methods. Results also suggest that regression based on FPC results is a valuable addition to FANOVA for estimating associations between temporal patterns and covariate information.

ObjectiveTo use multilevel functional principal component analysis to exploit the information inherent in the shape of longitudinally sampled glucose curves during pregnancy, and to analyse the impact of glucose curve characteristics on neonatal birth weight, percentage fat and cord blood C-peptide.Study design and settingA cohort study of healthy, pregnant women (n = 884). They underwent two oral glucose tolerance tests (gestational weeks 14-16 and 30-32), which gave two glucose curves per woman.ResultsGlucose values were higher, and peaked later in third trimester than in early pregnancy. The curve characteristic "general glucose level" accounted for 91% of the variation across visits, and 72% within visits. The curve characteristics "timing of postprandial peak", and "oscillating glucose levels" accounted for a larger part of the variation within visits (15% and 8%), than across visits (7% and ConclusionShape information in entire OGTT curves provides significant physiological information of importance for several outcomes, and may contribute to the understanding of the metabolic changes during pregnancy.

Background. Correct volume management is essential in patients with respiratory failure. We investigated the ability of respiratory variations in noninvasive pulse pressure (ΔPP), photoplethysmographic waveform amplitude (ΔPOP), and pleth variability index (PVI) to reflect hypovolemia during noninvasive positive pressure ventilation by inducing hypovolemia with progressive lower body negative pressure (LBNP). Methods. Fourteen volunteers underwent LBNP of 0, −20, −40, −60, and −80 mmHg for 4.5 min at each level or until presyncope. The procedure was repeated with noninvasive positive pressure ventilation. We measured stroke volume (suprasternal Doppler), ΔPP (Finapres), ΔPOP, and PVI and assessed their association with LBNP-level using linear mixed model regression analyses. Results. Stroke volume decreased with each pressure level (−11.2 mL, 95% CI −11.8, −9.6, P