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Objectives: The paramedics’ role is pivotal in ensuring eligible stroke patients reach the hospital within 4.5 hours, as this increases the chance of patients being treated with recombinant tissue plasminogen activator (rTPA) and improves their outcome. The lack of reviews on interventions done on paramedic services and the outcomes associated with them necessitates further investigation to enable policymakers to make guided decisions in improving the management of acute ischaemic strokes. Hence, our study aimed to identify interventions done and their impact on thrombolysis rate and onset-to-door (OTD) time. Methods: We searched PubMed, Embase, CINAHL and RCN to identify studies published between 1 January 2010 and 30 June 2020. The primary outcome of this study is investigating the impact of interventions done on paramedics services on the rTPA administration rate and OTD timing. Other outcomes include improvement in door-to-needle (DTN), door-to-imaging (DTI) and onset- to-needle (OTN) time. Random effect models were used to analyse the effects of the interventions carried out. Results: We gathered 621 papers, of which 11 met the eligibility criteria. The interventions carried out were bypass (n=3), education (n=2), pre-notification (n=4) and telemedicine (n=2). Based on the random effect model, rTPA administration was significantly higher in the intervention arm of ischemic stroke patients (n=7) with an OR of 1.45 (95%CI, 1.01-2.06). The trend was significantly higher with bypass intervention (OR 2.23 95%CI, 1.55-3.2), while the result with pre-notification (OR 0.53 95%CI, 0.09-2.95) and education (OR 1.51 95%CI, 0.87-2.60) were not significant. Conclusions: Paramedic interventions appear to have considerable effectiveness in improving the rates of rTPA, especially when the interventions used bypass mechanisms. This study provides detailed information on the net and quantitative benefits of the interventions and suggests the use of such interventions to reduce the pre-hospital delay of stroke patients and improve the rates of intravenous thrombolysis.

The construction industry accounts for 13% of the global Gross Domestic Product (GDP). The industry is directly impacting the economy, society and the environment. Also, the industry generates 38% of total global energy and process-related CO2, 25-50% global consumption of various types of materials including timber and stones, as well as 50% of landfill wastes. However, the industry has prolonged problems of low productivity, low digitalisation and low innovation adoption. These problems cause severe damage to the environment and global resources. One reason for the problems is the fragmentation of the supply chain in the architecture, engineering and construction sector. Also, the industry suffers from deficiencies in the ability to develop and use digital tools in design, construction, operation and post-operation processes. Extensive digital transformation and industrialisation to different extents are urgently needed to boost productivity, digitalisation and innovation adoption, so as to foster sustainable development in the sector. To address the industry's problems and enable sustainable adoption of emerging technologies and innovations in the sector, firstly, the motivations of this thesis include the need for digital transformation and industrialised construction with integrated digital systems and automated workflow. Secondly, there is a need to bring digital fabrication, which is one aspect of digital transformation and industrialised construction in the current practice, from its nascent stage to large-scale adoption, so as to fully unfold its potential. Thirdly, the sector requires a systematic rethinking of the design for digital fabrication adoption in practice. The adoption entails early involvement of information, stakeholders and their knowledge of the downstream construction process during the upstream design process. This requires a combined value chain between design and construction. Hence, new strategies to enable and manage digital fabrication in the early design process are needed. Fourthly, more research and development on integrated and innovative management for designing for digital fabrication is required to enable digital transformation for sustainable development. The sector requires a more comprehensive understanding of how stakeholders can foster digital transformation in order to enable sustainable development in the economy, society and environment under the people, process and technology framework. Thereby, this thesis develops the concept of Design for Digital Fabrication (DfDFAB) under the people, process and technology framework, as well as the three pillars of sustainability - economy, society and environment. DfDFAB refers to a novel design management approach used to achieve the successful adoption of digital fabrication in practice. The concept possesses an integrated value chain during design development. Also, DfDFAB can be further expressed in the broader context of industrialised construction, which comprises digitalisation, integration and sustainability through systemic innovations. In this dissertation, DfDFAB is developed from three perspectives. Firstly, digital fabrication adoption is a complex type of innovation or change. Digital fabrication is beyond the fabrication process but a complex system that involves interrelated people, processes and technologies. Secondly, digital fabrication adoption in design requires integration in management - process integration, information integration and organisation integration. Thirdly, designing for digital fabrication requires novel governance that includes project delivery models and contract design to incorporate liabilities during digital design and digital fabrication processes. To the author's knowledge, there is very little research that explores these three perspectives in the fields of construction management and automation. This could hinder the adoption of emerging technologies and innovations in the sector. This dissertation presents a research framework with four objectives. Firstly, this thesis identifies enablers and their relational ontology networks to investigate the complex system of digital fabrication adoption in design. Secondly, digital systems integration is explored to investigate the industry needs and perceived benefits of using digital systems for adoption, as well as the potential strategies derived from the correlations of the needs. Thirdly, this thesis studies project integration, which comprises process integration, information integration and organisational integration through process mapping. This reveals the inter-relationship between state-of-the-art Building Information Modelling (BIM), early contractor involvement and digital fabrication in the design process, as well as the design practices for designing for digital fabrication. Fourthly, the liability factors and the corresponding contract design to manage digital design and digital fabrication are studied. The research includes also the contractual provisions in existing commonly used project delivery models in current practice. The four objectives in this thesis lead to the impacts of people, technology, process and governance respectively. Furthermore, this dissertation presents the reflections on sustainability through the study of designing for digital transformation to foster sustainable development and achieve the 17 sustainable development goals. This thesis identifies 27 digital transformation practices and validates them with examples from case studies of the construction industry in Japan. This thesis contributes to the body of knowledge in the fields of construction management and automation by the identification of complex networks in designing for digital fabrication, the development of potential strategies to address the industry needs for digital systems integration for digital fabrication adoption in design, the examination of the causes and effects of project integration and design practices to manage design for digital fabrication, as well as the development of the conceptual framework for contracts and contractual provisions to manage digital design and digital fabrication in construction projects. In addition, this thesis contributes to practice to different extents such as elaborating on takeaways that can assist designers and design managers to adopt and manage DFAB in design in projects in current practice. The contributions can provide immediate benefits to the industry because this thesis consists of industry-oriented research, where data were collected from the current practice. In this dissertation, the future research outlook that includes digitalisation of complex networks in DfDFAB, integrated project delivery models to industrialise digital fabrication in projects, as well as sustainable development and the triple bottom line in the next-generation Industry 4.0, are discussed., ISBN:978-3-907363-06-5