Long-term risk of death in patients with infection attended by prehospital emergency services. / Modelo de riesgo de mortalidad a largo plazo en pacientes con infección atendidos por servicios de emergencias prehospitalarios.

OBJECTIVES: To develop and validate a risk model for 1-year mortality based on variables available from early prehospital emergency attendance of patients with infection. MATERIAL AND METHODS: Prospective, observational, noninterventional multicenter study in adults with suspected infection transferred to 4 Spanish hospitals by advanced life-support ambulances from June 1, 2020, through June 30, 2022. We collected demographic, physiological, clinical, and analytical data. Cox regression analysis was used to develop and validate a risk model for 1-year mortality. RESULTS: Four hundred ten patients were enrolled (development cohort, 287; validation cohort, 123). Cumulative mortality was 49% overall. Sepsis (infection plus a Sepsis-related Organ Failure Assessment score of 2 or higher) was diagnosed in 29.2% of survivors vs 56.7% of nonsurvivors. The risk model achieved an area under the receiver operating characteristic curve of 0.89 for 1-year mortality. The following predictors were included in the model: age; institutionalization; age-adjusted Charlson comorbidity index; PaCO2; potassium, lactate, urea nitrogen, and creatinine levels; fraction of inspired oxygen; and diagnosed sepsis. CONCLUSION: The model showed excellent ability to predict 1-year mortality based on epidemiological, analytical, and clinical variables, identifying patients at high risk of death soon after their first contact with the health care system.

OBJETIVO: Diseñar y validar un modelo de riesgo con variables determinadas a nivel prehospitalario para predecir el riesgo de mortalidad a largo plazo (1 año) en pacientes con infección. METODO: Estudio multicéntrico, observacional prospectivo, sin intervención, en pacientes adultos con sospecha infección atendidos por unidades de soporte vital avanzado y trasladados a 4 hospitales españoles entre el 1 de junio de 2020 y el 30 de junio de 2022. Se recogieron variables demográficas, fisiológicas, clínicas y analíticas. Se construyó y validó un modelo de riesgo para la mortalidad a un año usando una regresión de Cox. RESULTADOS: Se incluyeron 410 pacientes, con una tasa de mortalidad acumulada al año del 49%. La tasa de diagnóstico de sepsis (infección e incremento sobre el SOFA basal $ 2 puntos) fue del 29,2% en supervivientes frente a un 56,7% en no supervivientes. El modelo predictivo obtuvo un área bajo la curva de la característica operativa del receptor para la mortalidad a un año fue de 0,89, e incluyó: edad, institucionalización, índice de comorbilidad de Charlson ajustado por edad, presión parcial de dióxido de carbono, potasio, lactato, nitrógeno ureico en sangre, creatinina, saturación en relación con fracción inspirada de oxígeno y diagnóstico de sepsis. CONCLUSIONES: El modelo desarrollado con variables epidemiológicas, analíticas y clínicas mostró una excelente capacidad predictiva, y permitió identificar desde el primer contacto del paciente con el sistema sanitario, a modo de evento centinela, casos de alto riesgo.

Does the priority of ambulance guarantee no delay? a MIPSSTW model of emergency vehicle routing optimization considering complex traffic conditions for highway incidents.

Globally, traffic accidents on the highway network contribute significantly to a high fatality rate, drawing considerable attention from health institutions. The efficiency of transportation plays a vital role in mitigating the severe consequences of these incidents. This study delves into the issues of emergency vehicles experiencing delays despite having priority. Therefore, we construct mixed-integer linear programming with semi-soft time windows (MIPSSTW) model for optimizing emergency vehicle routing in highway incidents. We analyze the time-varying and complex traffic situations and respectively propose corresponding estimation approaches for the travel time of road segments, intersections on the urban road network, and ramp-weave sections on the highway network. Furthermore, we developed a modified cuckoo search(MCS) algorithm to solve this combinatorial problem. Optimization strategies of Lévy flight and dynamic inertial weight strategy are introduced to strengthen the exploration capability and the diversity of solution space of the CS algorithm. Computational experiments based on the Chinese emergency medical system data are designed to validate the efficacy and effectiveness of the MIPSSTW model and MCS algorithm. The results show that our works succeed in searching for high-quality solutions for emergency vehicle routing problems and enhance the efficacy of strategic decision-making processes in the realm of incident management and emergency response systems.

Patient experience of non-conveyance in the EMS of Southwest Finland: a descriptive survey study.

BACKGROUND: Emergency Medical Services are dispatched more frequently than before. However, many non-urgent patients do not need ambulance transportation to a healthcare facility after evaluation and treatment on scene. This study explored the experiences of non-conveyed patients. Our research questions were: (1) How have non-conveyed patients experienced the service received from EMS? (2) Does a patient's age, gender, or time of the emergency call impact the patient's experience? METHODS: This descriptive survey study examined non-conveyed Emergency Medical Services patients in the Wellbeing Services County of Southwest Finland. The study period was from March 1, 2023, to March 31, 2023. The study population was 1017. They received a questionnaire that was sent by mail. The questionnaire was formed based on questions previously used in four different questionnaires. We received 247 answers (24.3% response rate). Percentages, medians with interquartile ranges, and non-parametric tests were used in the descriptive analyses. RESULTS: Non-conveyed patients were very satisfied with the paramedics' expertise and behavior, their ability to meet their individual needs, the sense of safety provided by the paramedics, and the instructions given to the patients. Time to receive help (19% rated 3 or less on a scale from 1 to 5), how paramedics introduced themselves (16.5%), and satisfaction with non-conveyance decisions (14.6%) were more frequently rated lower than other areas. Further, pain management stood out in the less favorable evaluations. Still, patients' experiences of the service were positive. The age group, gender, or time of the emergency call were not associated with patient experience. CONCLUSIONS: Patients were very satisfied with the paramedics' interpersonal skills. A more focused approach to pain management and developing EMS to ensure faster patient outreach and clearer explanations of non-conveyance decisions could further enhance the patient experience.

Changes in severity of pediatric suicide attempts before and after coronavirus disease 2019.

BACKGROUND: The recent coronavirus disease 2019 (COVID-19) pandemic and school closures were reported to have negatively impacted the mental health of children and adolescents. This study aimed to examine the change in the number and severity of pediatric suicide attempts before and after the COVID-19 pandemic. METHODS: This study enrolled 54 patients (26 vs. 28 patients before and after the COVID-19 pandemic, respectively) under 19 years of age who were transported to the emergency department as a result of suicide attempts between April 2017 and December 2021. The primary outcome includes the rate of serious suicide attempts (SSAs). RESULTS: The SSA rates were 19% (5/26) and 43% (12/28) before and after the COVID-19 pandemic, respectively (p = 0.62). The average number of transported suicide attempts per month almost doubled (0.72 vs. 1.33, respectively) and suicide attempts as a percentage of all ambulance transportations of individuals under 19 years old increased significantly from 0.95% (26/2729)to 1.98% (28/1414) (p = 0.006). CONCLUSIONS: The COVID-19 pandemic increased the severity of pediatric suicide attempts but not to a statistically significant degree. Social preventive support and early psychological intervention are therefore needed currently and in the future.

Smooth Roads Ahead: Lessons From our Sick Neonate Retrieval Service.

Strategies for free transfer of sick neonates to hospitals are in place, but reports suggest suboptimal status of the same across the country. Over 7 years, our Sick Neonate Retrieval Service (SNRS) transported 165 neonates, of whom 92.1% survived. Safe, stable transportation mandates the presence of a neonatology-trained doctor and nurse in an equipped ambulance.

Telephone triage and dispatch of ambulances to patients with suspected and verified acute stroke - a descriptive study.

OBJECTIVES: In this study we aimed to explore EMCC triage of suspected and confirmed stroke patients to gain more knowledge about the initial phase of the acute stroke response chain. Accurate dispatch at the Emergency Medical Communication Center (EMCC) is crucial for optimal resource utilization in the prehospital service, and early identification of acute stroke is known to improve patient outcome. MATERIALS AND METHODS: We conducted a descriptive retrospective study based on data from the Emergency Department and EMCC records at a comprehensive stroke center in Oslo, Norway, during a six-month period (2019-2020). Patients dispatched with EMCC stroke criteria and/or discharged with a stroke diagnosis were included. We identified EMCC true positive, false positive and false negative stroke patients and estimated EMCC stroke sensitivity and positive predictive value (PPV). Furthermore, we analyzed prehospital time intervals and identified patient destinations to gain knowledge on ambulance services assessments. RESULTS: We included 1298 patients. EMCC stroke sensitivity was 77% (95% CI: 72 - 82%), and PPV was 16% (95% CI: 14 - 18%). EMCC false negative stroke patients experienced an increased median prehospital delay of 11 min (p < 0.001). Upon arrival at the scene, 68% of the EMCC false negative patients were identified as suspected stroke cases by the ambulance services. Similarly, 68% of the false positive stroke patients were either referred to a GP, out-of-hours GP acute clinic, local hospitals or left at the scene by the ambulance services, indicating that no obvious stroke symptoms were identified by ambulance personnel upon arrival at the scene. CONCLUSIONS: This study reveals a high EMCC stroke sensitivity and an extensive number of false positive stroke dispatches. By comparing the assessments made by both the EMCC and the ambulance service, we have identified specific patient groups that should be the focus for future research efforts aimed at improving the sensitivity and specificity of stroke recognition in the EMCC.

A dynamic traffic signal scheduling system based on improved greedy algorithm.

Urbanization has led to accelerated traffic congestion, posing a significant obstacle to urban development. Traditional traffic signal scheduling methods are often inefficient and cumbersome, resulting in unnecessary waiting times for vehicles and pedestrians, exacerbating the traffic situation. To address this issue, this article proposes a dynamic traffic signal scheduling system based on an improved greedy algorithm. Unlike conventional approaches, we introduce a reward function and a cost model to ensure fair scheduling plans. A constraint function is also established, and the traffic signal scheduling is iterated through the feasible matrix using the greedy algorithm to simplify the decision-making process and enhance solution efficiency. Moreover, an emergency module is integrated to prioritize special emergency vehicles, reducing their response time during emergencies. To validate the effectiveness of our dynamic traffic signal scheduling system, we conducted simulation experiments using the Simulation of Urban Mobility (SUMO) traffic simulation suite and the SUMO traffic control interface Traci. The results indicate that our system significantly improves intersection throughput and adapts well to various traffic conditions, effectively resolving urban traffic congestion while ensuring fair scheduling plans.

Vibratory Impact of 3 Different Ambulance Suspension Systems on the Simulated Neonate and Health Care Provider During Normal Driving Conditions.

OBJECTIVE: Patients and health care providers experience varying degrees of vibration during interfacility ground transport. The impact of vibration on term and preterm neonates may result in physiologic instability and increased risk of intracranial hemorrhage, whereas the impact on health care providers has been shown to include an increase in perceived and physiologic stress levels and may contribute to chronic back and neck pain. This study aimed to evaluate 3 common ambulance suspension systems and the corresponding vibratory impact produced during typical interfacility driving conditions on adult caregiver and neonatal patient mannequins. METHODS: Type 3 ambulances with air, liquid, and traditional suspensions were evaluated using various driving tests to simulate typical road conditions. Vibrations were measured using triaxial accelerometers placed on the chassis, upon the head of a seated caregiver mannequin in the ambulance bench seat, and the head of a neonatal mannequin supine and secured in an isolette. Data analysis included the average vibration frequency, root mean square values, and maximum vibration amplitudes. RESULTS: The results showed that the supine neonatal mannequin experienced the highest vibration frequency and amplitude in the vertical (x) direction, whereas the adult caregiver mannequin experienced higher vibration frequencies in both parallel (y) and lateral (z) directions and the highest vibration amplitude in the y direction. The liquid suspension system consistently demonstrated the lowest vibration levels in all driving conditions and directions, whereas traditional suspension had the highest values. CONCLUSION: This study provides important insights into the vibrations incurred by simulated neonatal patients and health care providers during ambulance transport. The directional vibration frequency and amplitude differ between a neonatal mannequin and an adult mannequin when placed in typical positions with typical restraints during varied ambulance driving conditions. In all directional movements and driving conditions, a liquid suspension system decreases vibration frequency and amplitude more than air or traditional systems. The live patient and caregiver impact of these results should be further investigated.

[(Un)ergonomic working conditions for a paramedic in a medical ambulance]. / (Nie)ergonomiczne warunki pracy ratownika w ambulansie medycznym.

BACKGROUND: The work of a paramedic, is characterised by a high risk of injury. Ergonomic, psychological, and biomechanical factors are considered risk factors in the profession of emergency medical technicians. Ensuring ergonomic working conditions for emergency medical technicians is a priority and requires a thorough assessment both in the design process and during the operation of the ambulance, to provide a diagnosis of the current state and present necessary recommendations for modernization. Identifying stressors will enable the design of an ergonomic interior for the ambulance, ensuring comfort and reliability for members of the emergency medical team, thereby reducing the risk of injuries. MATERIAL AND METHODS: The authors of this article developed a comprehensive methodology for assessing the nuisances occurring during the paramedic's work, which required specialised preliminary research. The research included the measurement and analysis of the paramedic's movement kinematics during typical medical procedures, both at a standstill and while driving the ambulance. For the analysis of motion kinematics, a non-invasive method called myoMotion was employed, and the study was conducted in a Mercedes ambulance. RESULTS: This article contains preliminary results on the evaluation of movement kinematics. These demonstrated the necessity for the paramedic to adopt forced positions when performing medical procedures. The ranges of movement of the individual body parts of the paramedic deviated from accepted norms, resulting in musculoskeletal overload. CONCLUSIONS: The acquired knowledge forms the basis for a detailed analysis of tasks performed within each procedure from the perspective of the spatial structure of the ambulance, the arrangement of equipment and medical supplies, their accessibility during work, and the organization of work within the ambulance. Additional identification of musculoskeletal system stress, its sources, and the formulation of modification recommendations for the ambulance interior will enable ensuring the comfort and reliability of the work for emergency medical teams, thereby reducing the risk of injuries in the workplace. Med Pr Work Health Saf. 2024;75(1):31-44.

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study.

OBJECTIVES: Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021. DESIGN: We conducted a secondary data analysis with a quasi-experimental design. SETTING: We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'. PRIMARY AND SECONDARY OUTCOME MEASURES: We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis. PARTICIPANTS: We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021. RESULTS: 40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001). CONCLUSIONS: A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Association between social support and ambulance use among older people in Japan: an empirical cross-sectional study.

BACKGROUND: Ambulance service demand and utilization are increasing worldwide. To address this issue, the factors that affect ambulance use must be identified. Few studies have examined factors that can intervene and thus reduce the frequency of ambulance use. This study aimed to examine the association between social support and ambulance use among older adults in Japan. We hypothesize that social support is associated with reduced ambulance use. METHODS: This cross-sectional study was conducted as part of the Japan Gerontological Evaluation Study. In December 2019 and January 2020, we collaborated with individuals aged 65 years or above with no long-term care needs. A total of 24,581 participants were included in the analysis. The objective and explanatory variables were ambulance use and social support, respectively. Binomial regression analysis was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Social support was associated with ambulance use. People who had no one to listen to their complaints or worries were significantly more likely to use ambulance services than those who did (OR [95% CI] = 1.26 [1.03-1.53]). People with no one to take care of them when they were ill were also significantly more likely to use ambulance services than those who had someone to provide care (1.15 [1.01-1.31]). Moreover, the results of binomial logistic regression analysis indicated that individuals who called an ambulance but were not hospitalized had significantly lower social support compared to those who did not call an ambulance. CONCLUSIONS: The results suggest that the presence and quality of social support play a significant role in ambulance use among older adults in Japan. Our findings can help policymakers to plan and implement strategies for reducing the burden on emergency medical care.

Perceptions of professional challenges by emergency medical services providers: a qualitative content analysis study.

INTRODUCTION: Emergency medical services (EMS) providers encounter a variety of challenges due to the unpredictable, uncontrollable, and dynamic conditions in the pre-hospital field. This study explored the perceived professional challenges among EMS providers. MATERIALS AND METHODS: This study was conducted using a qualitative research approach and the method of content analysis. Eighteen EMS providers were purposively selected from EMS stations in Hamadan, Iran. The collected data were then analyzed based on the Granheim and Lundman's method. RESULTS: Based on data analysis, five categories and one theme were identified. The extracted theme was professional challenges. The five categories were as follows: Ineffective policies; multicultural and multidisciplinary factors; ambulance dispatch route problems; legal issues; and abuse against the emergency medical services CONCLUSION: In general, it has been found that EMS providers encounter numerous and complex professional challenges during their work. EMS managers can utilize the findings of the present study to develop strategies for reducing the professional challenges faced by EMS providers. By doing so, they can improve the quality of care in the prehospital field.

The Impact of the COVID-19 Pandemic on Pre-Hospital Emergency Medical Services: The impact of the Covid-19 pandemic on pre-hospital services.

BACKGROUND: The novel coronavirus (COVID-19) disease outbreak started in China and went on to affect the entire world. Healthcare providers were among the communities that faced severe challenges during the pandemic, and this was especially true of Pre-Hospital Emergency Medical Services (PHEMS) providers. OBJECTIVES: This study aims to investigate the effect of the COVID-19 pandemic on service requests submitted to PHEMS providers via calls made to emergency hotlines. METHODS: Data were obtained on calls made to 112 (the emergency hotline) during March - August 2020 (i.e., during the pandemic) and the same period the previous year (i.e., the pre-pandemic period). These 2 data sets were analyzed and compared using the SPSS 26 software package (IBM Corp., Armonk, New York, USA). RESULTS: The results of the analysis indicated that the total number of emergency calls received during the pandemic period (11 745) increased compared to the pre-pandemic period (10 747), whereas there was a decrease in the proportion of trauma-related emergency calls during the pandemic period (5.3%) compared to the pre-pandemic period (6.8%). Furthermore, there was a higher proportion of extended service times among ambulances serving in PHEMS during the pandemic period (ambulance movements longer than 90 seconds: 15.6%) compared to the pre-pandemic period (ambulance movements longer than 90 seconds: 8.6%). Non-emergency ambulance usage rate was 44.90% in the pre-pandemic period and 38.90% in the pandemic period. CONCLUSIONS: As the study's results show that there was an increase in the number of calls to PHEMS during the pandemic period, especially given that a significant portion of these calls consisted of non-emergency calls, it is recommended that measures be taken to reduce the excessive load on PHEMS during a pandemic.

Modelling cost-effectiveness of replacement strategies for ambulance services in the Ministry of Health Malaysia.

BACKGROUND: Emergency Medical Service (EMS) is a very crucial aspect of the healthcare system in providing urgent management and transportation of patients during emergencies. The sustainability of the services is however greatly impacted by the quality and age of ambulances. While this has led to numerous replacement policy recommendations, the implementations are often limited due to a lack of evidence and financial constraints. This study thus aims to develop a cost-effectiveness model and testing the model by evaluating the cost-effectiveness of 10-year and 15-year compulsory ambulance replacement strategies in public healthcare for the Malaysian Ministry of Health (MOH). METHODS: A Markov model was developed to estimate the cost and outcomes ambulance replacement strategies over a period of 20 years. The model was tested using two alternative strategies of 10-year and 15-year. Model inputs were derived from published literature and local study. Model development and economic analysis were accomplished using Microsoft Excel 2016. The outcomes generated were costs per year, the number of missed trips and the number of lives saved, in addition to the Incremental Cost-Effectiveness Ratio (ICER). One-Way Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were conducted to identify the key drivers and to assess the robustness of the model. RESULTS: Findings showed that the most expensive strategy, which is the implementation of 10 years replacement strategy was more cost-effective than 15 years ambulance replacement strategy, with an ICER of MYR 11,276.61 per life saved. While an additional MYR 13.0 million would be incurred by switching from a 15- to 10-year replacement strategy, this would result in 1,157 deaths averted or additional live saved per year. Sensitivity analysis showed that the utilization of ambulances and the mortality rate of cases unattended by ambulances were the key drivers for the cost-effectiveness of the replacement strategies. CONCLUSIONS: The cost-effectiveness model developed suggests that an ambulance replacement strategy of every 10 years should be considered by the MOH in planning sustainable EMS. While this model may have its own limitation and may require some modifications to suit the local context, it can be used as a guide for future economic evaluations of ambulance replacement strategies and further exploration of alternative solutions.

The effect of power stretchers on occupational injury rates in an urban emergency medical services system.

BACKGROUND: To examine occupational injury rates in a dual-response emergency medical services (EMS) system before and after implementation of a power-lift stretcher system. METHODS: The seasonally-adjusted occupational injury rate was estimated relative to medical call volume (per 1000 calls) and workers (per 100 FTEs) from 2009 to 2019, and stratified by severity (lost-time, healthcare only), role (EMS, FIRE) and type (patient-handling). Power-lift stretchers were adopted between 2013 and 2015. Preinjury versus postinjury rates were compared using binomial tests. Interrupted time series (ITS) analysis was used to estimate the trend and change in injuries related to patient-handling, with occupational illnesses serving as control. RESULTS: Binomial tests revealed varied results, with reductions in the injury rate per 1000 calls (-14.0%) and increases in the rate per 100 FTEs (+14.1%); rates also differed by EMS role and injury severity. ITS analysis demonstrated substantial reductions in patient-handling injuries following implementation of power-lift stretchers, both in the injury rate per 1000 calls (-50.4%) and per 100 FTEs (-46.6%), specifically among individuals deployed on the ambulance. Injury rates were slightly elevated during the winter months (+0.8 per 100 FTEs) and lower during spring (-0.5 per 100 FTEs). CONCLUSIONS: These results support the implementation of power-lift stretchers for injury prevention in EMS systems and demonstrate advantages of ITS analysis when data span long preintervention and postintervention periods.

Site of Ambulance Origination and Billing for Out-of-Network Services.

Importance: The No Surprises Act implemented in 2022 aims to protect patients from surprise out-of-network (OON) bills, but it does not include ground ambulance services. Understanding ground ambulance OON and balance billing patterns from previous years could guide legislation aimed to protect patients following ground ambulance use. Objective: To characterize OON billing from ground ambulance services by evaluating whether OON billing risk differs by the site of ambulance origination (home, hospital, nonhospital medical facility, or scene of incident). Design, Setting, and Participants: Cross-sectional study of the Merative MarketScan dataset between January 1, 2015, and December 31, 2020, using claims-based data from employer-based private health insurance plans in the US. Participants included patients who utilized ground ambulances during the study period. Data were analyzed from June to December 2023. Exposure: Medical encounter requiring ground ambulance transportation. Main Outcomes and Measures: Ground ambulance OON billing prevalence was calcuated. Linear probability models adjusted for state-level mixed effects were fit to evaluate OON billing probability across ambulance origins. Secondary outcomes included the allowed payment, patient cost-sharing amounts, and potential balance bills for OON ambulances. Results: Among 2 031 937 ground ambulance services (1 375 977 unique patients) meeting the inclusion and exclusion criteria, 1 072 791 (52.8%) rides transported men, and the mean (SD) patient age was 41 (18) years. Of all services, 1 113 676 (54.8%) were billed OON. OON billing probabilities for ambulances originating from home or scene were higher by 12.0 percentage points (PP) (95% CI, 11.8-12.2 PP; P < .001 for home; 95% CI, 11.7-12.2 PP; P < .001 for scene) vs those originating from hospitals. Mean (SD) total financial burden, including cost-sharing and potential balance bills per ambulance service, was $434.70 ($415.99) per service billed OON vs $132.21 ($244.92) per service billed in-network. Conclusions and Relevance: In this cross-sectional study of over 2 million ground ambulance services, ambulances originating from home, the scene of an incident, and nonhospital medical facilities were more likely to result in OON bills. Legislation is needed to protect patients from surprise billing following use of ground ambulances, more than half of which resulted in OON billing. Future legislation should at minimum offer protections for these subsets of patients often calling for an ambulance in urgent or emergent situations.

The non-conveyance of trauma patients in Swedish emergency medical services: a retrospective observational study of the trauma population not transported to an emergency department.

INTRODUCTION: Due to a systemic modification in Swedish emergency medical services (EMS) staffing in recent years, the nature of the Swedish EMS has changed. Transport to an emergency department (ED) is no longer the only option. Referrals and non-conveyance form a growing part of EMS assignments. Trauma is one of the most common causes of death and accounts for 17% of Swedish EMS assignments. The aim of this study was to describe the characteristics and clinical outcomes of non-conveyed trauma patients who were assessed, treated and triaged by the EMS to gain a better understanding of, and to optimise, transport and treatment decisions. METHODS: The study had a descriptive, retrospective and epidemiologic design and was conducted by reviewing EMS and hospital records for 837 non-conveyed trauma patients in the southwest of Sweden in 2019. RESULTS: Three in four non-conveyed trauma patients did not seek further medical care within 72 h following EMS assessment. The patients who were admitted to hospital later were often older, had suffered a fall and had a medical history. Half of all the incidents occurred in a domestic environment, and head trauma was the major complaint. Less than 1% of the studied patients died. CONCLUSION: Most of the non-conveyed trauma patients did not seek further medical care after being discharged at the scene. Falling was the most common trauma event, and for the older population, this meant a higher risk of hospital admission. The reasons for falls should therefore be investigated thoroughly prior to non-conveyance decisions. Future studies should focus on the reasons for non-conveyance and measure the morbidity and invalidity outcomes rather than mortality.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients.

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.

Toward an application of automatic evaluation system for central facial palsy using two simple evaluation indices in emergency medicine.

A stroke is a medical emergency and thus requires immediate treatment. Paramedics should accurately assess suspected stroke patients and promptly transport them to a hospital with stroke care facilities; however, current assessment procedures rely on subjective visual assessment. We aim to develop an automatic evaluation system for central facial palsy (CFP) that uses RGB cameras installed in an ambulance. This paper presents two evaluation indices, namely the symmetry of mouth movement and the difference in mouth shape, respectively, extracted from video frames. These evaluation indices allow us to quantitatively evaluate the degree of facial palsy. A classification model based on these indices can discriminate patients with CFP. The results of experiments using our dataset show that the values of the two evaluation indices are significantly different between healthy subjects and CFP patients. Furthermore, our classification model achieved an area under the curve of 0.847. This study demonstrates that the proposed automatic evaluation system has great potential for quantitatively assessing CFP patients based on two evaluation indices.