Video laryngoscopy may improve the intubation outcomes in critically ill patients: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: The role of video laryngoscopy in critically ill patients requiring emergency tracheal intubation remains controversial. This systematic review and meta-analysis aimed to evaluate whether video laryngoscopy could improve the clinical outcomes of emergency tracheal intubation. METHODS: We searched the PubMed, Embase, Scopus and Cochrane databases up to 5 September 2024. Randomised controlled trials comparing video laryngoscopy with direct laryngoscopy for emergency tracheal intubation were analysed. The primary outcome was the first-attempt success rate, while secondary outcomes included intubation time, glottic visualisation, in-hospital mortality and complications. RESULTS: Twenty-six studies (6 in prehospital settings and 20 in hospital settings) involving 5952 patients were analysed in this study. Fifteen studies had low risk of bias. Overall, there was no significant difference in first-attempt success rate between two groups (RR 1.05, 95% CI 0.97 to 1.13, p=0.24, I2=89%). However, video laryngoscopy was associated with a higher first-attempt success rate in hospital settings (emergency department: RR 1.13, 95% CI 1.03 to 1.23, p=0.007, I2=85%; intensive care unit: RR 1.16, 95% CI 1.05 to 1.29, p=0.003, I2=68%) and among inexperienced operators (RR 1.15, 95% CI 1.03 to 1.28, p=0.01, I2=72%). Conversely, the first-attempt success rate with video laryngoscopy was lower in prehospital settings (RR 0.75, 95% CI 0.57 to 0.99, p=0.04, I2=95%). There were no differences for other outcomes except for better glottic visualisation (RR 1.11, 95% CI 1.03 to 1.20, p=0.005, I2=91%) and a lower incidence of oesophageal intubation (RR 0.42, 95% CI 0.24 to 0.71, p=0.001, I2=0%) when using video laryngoscopy. CONCLUSIONS: In hospital settings, video laryngoscopy improved first-attempt success rate of emergency intubation, provided superior glottic visualisation and reduced incidence of oesophageal intubation in critically ill patients. Our findings support the routine use of video laryngoscopy in the emergency department and intensive care units. PROSPERO REGISTRATION NUMBER: CRD 42023461887.

Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results.

BACKGROUND: Early assessment of patients with suspected transient ischaemic attack (TIA) is crucial to provision of effective care, including initiation of preventive therapies and identification of stroke mimics. Many patients with TIA present to emergency medical services (EMS) but may not require hospitalisation. Paramedics could identify and refer patients with low-risk TIA, without conveyance to the ED. Safety and effectiveness of this model is unknown. AIM: To assess the feasibility of undertaking a fully powered randomised controlled trial (RCT) to evaluate clinical and cost-effectiveness of paramedic referral of patients who call EMS with low-risk TIA to TIA clinic, avoiding transfer to ED. METHODS: The Transient Ischaemic attack Emergency Referral (TIER) intervention was developed through a survey of UK ambulance services, a scoping review of evidence of prehospital care of TIA and convening a specialist clinical panel to agree its final form. Paramedics in South Wales, UK, were randomly allocated to trial intervention (TIA clinic referral) or control (usual care) arms, with patients' allocation determined by that of attending paramedics.Predetermined progression criteria considered: proportion of patients referred to TIA clinic, data retrieval, patient satisfaction and potential cost-effectiveness. RESULTS: From December 2016 to September 2017, eighty-nine paramedics recruited 53 patients (36 intervention; 17 control); 48 patients (31 intervention; 17 control) consented to follow-up via routine data. Three intervention patients, of seven deemed eligible, were referred to TIA clinic by paramedics. Contraindications recorded for the other intervention arm patients were: Face/Arms/Speech/Time positive (n=13); ABCD2 score >3 (n=5); already anticoagulated (n=2); crescendo TIA (n=1); other (n=8). Routinely collected electronic health records, used to report further healthcare contacts, were obtained for all consenting patients. Patient-reported satisfaction with care was higher in the intervention arm (mean 4.8/5) than the control arm (mean 4.2/5). Health economic analysis suggests an intervention arm quality-adjusted life-year loss of 0.0094 (95% CI -0.0371, 0.0183), p=0.475. CONCLUSION: The TIER feasibility study did not meet its progression criteria, largely due to low patient identification and referral rates. A fully powered RCT in this setting is not recommended. TRIAL REGISTRATION NUMBER: ISRCTN85516498.

Epidemiology and outcomes of out of hospital cardiac arrest in Karachi, Pakistan - A longitudinal study.

Background: Out-of-hospital cardiac arrest (OHCA) is a major cause of morbidity and mortality globally, with survival outcomes remaining poor particularly in many low- and middle-income countries. We aimed to establish a pilot OHCA registry in Karachi, Pakistan to provide insights into OHCA patient demographics, pre-hospital and in-hospital care, and outcomes. Methods: A multicenter longitudinal study was conducted from August 2015-October 2019 across 11 Karachi hospitals, using a standardized Utstein-based survey form. Data was retrospectively obtained from medical records, patients, and next-of-kin interviews at hospitals with accessible medical records, while hospitals without medical records system used on-site data collectors. Demographics, arrest characteristics, prehospital events, and survival outcomes were collected. Survivors underwent follow-up at 1 month, 6 months, 1 year, and 5 years. Results: In total, 1068 OHCA patients were included. Mean age was 55 years, 61.1 % (n = 653) male. Witnessed arrests accounted for 94.9 % of the cases (n = 1013), whereas 89.4 % of the cases (n = 955) were transported via non-EMS. Bystander CPR was performed in 10.3 % (n = 110) cases whereas pre-hospital defibrillation performed in 0.4 % (n = 4). In-hospital defibrillation was performed in 9.9 % (n = 106) cases despite < 5 % shockable rhythms. Overall survival to discharge was 0.75 % (n = 8). Of these 8 patients, 7 patients survived to 1-year and 2 to 5-years. Neurological outcomes correlated with long-term survival. Conclusion: OHCA survival rates are extremely low, necessitating public awareness interventions like CPR training, developing robust pre-hospital systems, and improving in-hospital emergency care through standardized training programs. This pilot registry lays the foundation for implementing interventions to improve survival and emergency medical infrastructure.

Combined effect of intermittent hemostasis and a modified external hemorrhage control device in a lethal swine model.

Background: Non-compressible torso hemorrhage (NCTH) presents the ultimate challenge in pre-hospital care. While external hemorrhage control devices (EHCDs) such as the Abdominal Aortic and Junctional Tourniquet (AAJT) and SAM Junctional Tourniquet (SJT) have been invented, the current design and application strategy requires further improvement. Therefore, researchers devised a novel apparatus named Modified EHCD (M-EHCD) and implemented intermittent hemostasis (IH) as a preventive measure against ischemia-reperfusion injury. The objective of this study was to ascertain the combined effect of M-EHCD and IH on the hemostatic effect of NCTH. Methods: Eighteen swine were randomized to M-EHCD, AAJT or SJT. The NCTH model was established by inducing Class Ⅲ hemorrhagic shock and performing a hemi-transection of common femoral artery (CFA). EHCDs were rapidly fastened since the onset of free bleeding (T0min). The IH strategy was implemented by fully releasing M-EHCD at T40min, T70min and T100min, respectively, whereas AAJT and SJT maintained continuous hemostasis (CH) until T120min. All groups underwent CFA bridging at T110min, and EHCDs were removed at T120min. Reperfusion lasted for 60 min, after which euthanasia was performed. Hemodynamics, intra-vesical pressure (IVP), and blood samples were collected periodically. Histological examinations were also conducted. Results: M-EHCD demonstrated the fastest application time (M-EHCD: 26.38 ± 6.32s vs. SJT: 30.84 ± 5.62s vs. AAJT: 54.28 ± 5.45s, P < 0.001) and reduced free blood loss (M-EHCD: 17.77 ± 9.85g vs. SJT: 51.80 ± 33.70g vs. AAJT: 115.20 ± 61.36g, P = 0.011) compared to SJT and AAJT. M-EHCD exhibited inhibitory effects on heart rate (M-EHCD: 91.83 ± 31.61bpm vs. AAJT: 129.00 ± 32.32bpm vs. SJT: 135.17 ± 21.24bpm, P = 0.041) and shock index. The device's external pressure was lowest in M-EHCD and highest in SJT (P = 0.001). The resultant increase in IVP were still the lowest in M-EHCD (M-EHCD: -0.07 ± 0.45 mmHg vs. AAJT: 27.04 ± 5.03 mmHg vs. SJT: 5.58 ± 2.55 mmHg, P < 0.001). Furthermore, M-EHCD caused the least colonic injury (M-EHCD: 1.17 ± 0.41 vs. AAJT: 2.17 ± 0.41 vs. SJT: 2.17 ± 0.41, P = 0.001). The removal of M-EHCD showed the slightest impact on pH (P < 0.001), while AAJT group was more susceptible to the lethal triad based on the arterial lactate and thrombelastogram results. Conclusions: M-EHCD + IH protected the organs and reduced the risk of the lethal triad by decreasing disruptions to IVP, hemodynamics, acid-base equilibrium and coagulation. M-EHCD + IH was superior to the hemostatic safety and efficacy of AAJT/SJT + CH.

CALL TO ECLS-Acronym for Reporting Patients for Extracorporeal Cardiopulmonary Resuscitation Procedure from Prehospital Setting to Destination Centers.

The acronym CALL TO ECLS has been proposed as a potential tool to support decision-making in critical communication moments when qualifying a patient for the ECPR procedure. The aim of this study is to assess the accuracy of the acronym and validate its content. Validation is crucial to ensure that the acronym is theoretically correct and includes the necessary information that must be conveyed by EMS during the qualification of a patient with out-of-hospital cardiac arrest for ECMO. A survey was conducted using the LimeSurvey platform through the Survey Research System of the Jagiellonian University Medical College over a 6-month period (from December 2022 to May 2023). Usefulness, importance, clarity, and unambiguity were rated on a 4-point Likert scale, from 1 (not useful, not important, unclear, ambiguous) to 4 (useful, important, clear, unambiguous). On the 4-point scale, the Content Validity Index (I-CVI) was calculated as the percentage of subject matter experts who rated the criterion as having a level of importance/clarity/validity/uniqueness of 3 or 4. The Scale-level Content Validity Index (S-CVI) based on the average method was computed as the average of I-CVI scores (S-CVI-AVE) for all considered criteria (protocol). The number of fully completed surveys by experts was 35, and partial completion was obtained in 63 cases. All criteria were deemed significant/useful, with I-CVI coefficients ranging from 0.87 to 0.97. Similarly, the importance of all criteria was confirmed, as all I-CVI coefficients were greater than 0.78 (ranging from 0.83 to 0.97). The average I-CVI score for the ten considered criteria in terms of usefulness/significance and importance exceeded 0.9, indicating high validity of the tool/protocol/acronym. Based on the survey results and analysis of responses provided by experts, a second version was created, incorporating additional explanations. In Criterion 10, an explanation was added-"Signs of life"-during conventional cardiopulmonary resuscitation (ROSC, motor response during CPR). It has been shown that the acronym CALL TO ECLS, according to experts, is accurate and contains the necessary content, and can serve as a system to facilitate communication between the pre-hospital environment and specialized units responsible for qualifying patients for the ECPR.

What influences ambulance clinician decisions to pre-alert emergency departments: a qualitative exploration of pre-alert practice in UK ambulance services and emergency departments.

BACKGROUND: Ambulance clinicians use pre-alerts to inform receiving hospitals of the imminent arrival of a time-critical patient considered to require immediate attention, enabling the receiving emergency department (ED) or other clinical area to prepare. Pre-alerts are key to ensuring immediate access to appropriate care, but unnecessary pre-alerts can divert resources from other patients and fuel 'pre-alert fatigue' among ED staff. This research aims to provide a better understanding of pre-alert decision-making practice. METHODS: Semi-structured interviews were conducted with 34 ambulance clinicians from three ambulance services and 40 ED staff from six receiving EDs. Observation (162 hours) of responses to pre-alerts (n=143, call-to-handover) was also conducted in the six EDs. Interview transcripts and observation notes were imported into NVIVO and analysed using thematic analysis. FINDINGS: Pre-alert decisions involve rapid assessment of clinical risk based on physiological observations, clinical judgement and perceived risk of deterioration, with reference to pre-alert guidance. Clinical experience (pattern recognition and intuition) and confidence helped ambulance clinicians to understand which patients required immediate ED care on arrival or were at highest risk of deterioration. Ambulance clinicians primarily learnt to pre-alert 'on the job' and via informal feedback mechanisms, including the ED response to previous pre-alerts. Availability and access to clinical decision support was variable, and clinicians balanced the use of guidance and protocols with concerns about retention of clinical judgement and autonomy. Differences in pre-alert criteria between ambulance services and EDs created difficulties in deciding whether to pre-alert and was particularly challenging for less experienced clinicians. CONCLUSION: We identified potentially avoidable variation in decision-making, which has implications for patient care and emergency care resources, and can create tension between the services. Consistency in practice may be improved by greater standardisation of guidance and protocols, training and access to performance feedback and cross-service collaboration to minimise potential sources of tension.

Key performance indicators in pre-hospital response to disasters and mass casualty incidents: a scoping review.

PURPOSE: The objective of this study was to offer a comprehensive synthesis of the existing Key performance indicators (KPIs) used in the evaluation of the pre-Hospital response to disasters and mass casualty incidents (MCIs). METHODS: At the end of December 2022 a scoping review has been performed on PubMed, Scopus, Embase, and Medline to identify articles describing the use of KPIs to assess the performance of first responders during the prehospital phase of an MCI (real or simulated). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, fourteen articles were included in the analysis. RESULTS: Eleven articles applied indicators in exercises and/or simulations. Two articles proposed new KPIs, and one used KPIs for developing a model for benchmarking pre-Hospital response. All articles analyzed quantitative indicators of time, whereas two studied indicators of structure, of process, and of outcome as well. CONCLUSION: The findings from this review emphasize the need for employing common terminology and using uniformed data collection tools, if obtaining standardized evaluation method is the goal to be achieved.

Challenges of pre-hospital emergency care at Addis Ababa Fire and Disaster Risk Management Commission, Addis Ababa, Ethiopia: a qualitative study.

BACKGROUND: A challenge to pre-hospital emergency care is any barrier or obstacle that impedes quality pre-hospital care or impacts community pre-hospital utilization. The Addis Ababa Fire and Disaster Risk Management Commission (AAFDRMC) provides pre-hospital emergency services in Addis Ababa, Ethiopia. These services operate under a government-funded organization that delivers free emergency services, including out-of-hospital medical care and transportation to the most appropriate health facility. This study aimed to assess the challenges of pre-hospital emergency care at the Addis Ababa Fire and Disaster Risk Management Commission in Addis Ababa, Ethiopia. METHODS: A qualitative descriptive study was conducted from November 20 to December 4, 2022. Data were collected through in-depth, semi-structured interviews with 21 experienced individuals in the field of pre-hospital emergency care, who were selected using purposeful sampling. A thematic analysis method was used to analyze the data. RESULTS: This study includes twenty-one participants working at the Addis Ababa Fire and Disaster Risk Management Commission. Three major themes emerged. The themes that arose were the participants' perspectives on the challenges of pre-hospital emergency care in Addis Ababa, Ethiopia. CONCLUSION AND RECOMMENDATION: The Fire and Disaster Risk Management Commission faces numerous challenges in providing quality pre-hospital emergency care in Addis Ababa. Respondents stated that infrastructure, communication, and resources were the main causes of pre-hospital emergency care challenges. There has to be more focus on emergency management in light of infrastructure reform, planning, staff training, and education, recruiting additional professional power, improving communication, and making pre-hospital emergency care an independent organization in the city.

Stroke survivor views on ambulance redirection as a strategy to increase access to thrombectomy in England.

Introduction: Intravenous thrombolysis and mechanical thrombectomy are effective time-sensitive treatments for selected cases of acute ischaemic stroke. While thrombolysis is widely available, thrombectomy can only be provided at facilities with the necessary equipment and interventionists. Suitable patients admitted to other hospitals require secondary transfer, causing delays to treatment. Pre-hospital ambulance redirection to thrombectomy facilities may improve access but treatment eligibility cannot be confirmed pre-hospital. Some redirected patients would travel further and be displaced without receiving thrombectomy. This study aimed to elicit stroke survivor and carer/relative views about the possible consequences of introducing a conceptual, idealised ambulance redirection pathway. Methods: Focus groups were undertaken using a topic guide describing four hypothetical ambulance redirection scenarios and their possible consequences: earlier treatment with thrombectomy; delayed diagnosis of non-stroke 'mimic' conditions; delayed thrombolysis treatment; and delayed diagnosis of haemorrhagic stroke. Meetings were audio recorded, transcribed verbatim and data analysed thematically using emergent coding. Results: Fifteen stroke survivors and carers/relatives participated in three focus groups. There was wide acceptance of possible low-risk consequences of ambulance redirection, including extended travel time, being further from home and experiencing longer hospital stays. Participants were more uncertain about higher-risk consequences, including delays in diagnosis/treatment for patients unsuitable for thrombectomy, but remained positive about ambulance redirection overall. Participants rationalised acceptance of higher-risk consequences by recognising that redirected patients would still access appropriate treatment, even if delayed. In addition, acceptance of ambulance redirection would be increased if there were robust clinical evidence showing net benefit over secondary transfer pathways. Conclusions: Participant views were generally supportive of ambulance redirection to facilitate access to thrombectomy. Further research is needed to demonstrate overall benefit in an NHS context.

Thermal insulation does not hamper assessment of injuries in trauma CT scans.

PURPOSE: The use of thermal insulations reduces the risk of hypothermia, therefore decreases the risk of death in trauma victims. The aim of the study was to assess whether thermal insulations cause artifacts, which may hinder the diagnosis of injuries, and how the used thermo-systems alter the radiation dose in polytrauma computed tomography. METHODS: Computed tomography scans were made using the road accident victim body wrapped consecutively with 7 different covers. 14 injury areas were listed and evaluated by 22 radiologists. The radiation dose was measured using a dosimeter placed on the victim in the abdominal area. RESULTS: No significant artifacts in any of the tested covers were observed. The presence of few minor artifacts did not hinder the assessment of injuries. Certain materials increased (up to 19,1%) and some decreased (up to -30,3%) the absorbed radiation dose. CONCLUSIONS: Thermal insulation systems tested in this study do not cause significant artifacts hindering assessment of injuries in CT scans. Concern for artifacts and increased radiation dose should not be a reason to remove patients' thermal insulation during performing trauma CT-scanning.

External validation of the preHEART score and comparison with current clinical risk scores for prehospital risk assessment in patients with suspected NSTE-ACS.

BACKGROUND: Emergency Medical Services (EMS) studies have shown that prehospital risk stratification and triage decisions in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) can be improved using clinical risk scores with point-of-care (POC) troponin. In current EMS studies, three different clinical risk scores are used in patients suspected of NSTE-ACS: the prehospital History, ECG, Age, Risk and Troponin (preHEART) score, History, ECG, Age, Risk and Troponin (HEART) score and Troponin-only Manchester Acute Coronary Syndromes (T-MACS). The preHEART score lacks external validation and there exists no prospective comparative analysis of the different risk scores within the prehospital setting. The aim of this analysis is to externally validate the preHEART score and compare the diagnostic performance of the these three clinical risk scores and POC-troponin. METHODS: Prespecified analysis from a prospective, multicentre, cohort study in patients with suspected NSTE-ACS who were transported to an ED between April 2021 and December 2022 in the Netherlands. Risk stratification is performed by EMS personnel using preHEART, HEART, T-MACS and POC-troponin. The primary end point was the hospital diagnosis of NSTE-ACS. The diagnostic performance was expressed as area under the receiver operating characteristic (AUROC), sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV). RESULTS: A total of 823 patients were included for external validation of the preHEART score, final hospital diagnosis of NSTE-ACS was made in 29% (n=235). The preHEART score classified 27% as low risk, with a sensitivity of 92.8% (95% CI 88.7 to 95.7) and NPV of 92.3% (95% CI 88.3 to 95.1). The preHEART classified 9% of the patients as high risk, with a specificity of 98.5% (95% CI 97.1 to 99.3) and PPV of 87.7% (95% CI 78.3 to 93.4). Data for comparing clinical risk scores and POC-troponin were available in 316 patients. No difference was found between the preHEART score and HEART score (AUROC 0.83 (95% CI 0.78 to 0.87) vs AUROC 0.80 (95% CI 0.74 to 0.85), p=0.19), and both were superior compared with T-MACS (AUROC 0.72 (95% CI 0.66 to 0.79), p≤0.001 and p=0.03, respectively) and POC-troponin measurement alone (AUROC 0.71 (95% CI 0.64 to 0.78), p<0.001 and p=0.01, respectively). CONCLUSION: On external validation, the preHEART demonstrates good overall diagnostic performance as a prehospital risk stratification tool. Both the preHEART and HEART scores have better overall diagnostic performance compared with T-MACS and sole POC-troponin measurement. These data support the implementation of clinical risk scores in prehospital clinical pathways. TRIAL REGISTRATION NUMBER: NCT05243485.

Performance of 21 Early Warning System scores in predicting in-hospital deterioration among undifferentiated admitted patients managed by ambulance services.

BACKGROUND: The optimal Early Warning System (EWS) scores for identifying patients at risk of clinical deterioration among those transported by ambulance services remain uncertain. This retrospective study compared the performance of 21 EWS scores to predict clinical deterioration using vital signs (VS) measured in the prehospital or emergency department (ED) setting. METHODS: Adult patients transported to a single ED by ambulances and subsequently admitted to the hospital between 1 January 2019 and 18 April 2019 were eligible for inclusion. The primary outcome was 30-day mortality; secondary outcomes included 3-day mortality, admission to intensive care or coronary care units, length of hospital stay and emergency call activations. The discriminative ability of the EWS scores was assessed using the area under the receiver operating characteristic curve (AUROC). Subanalyses compared the performance of EWS scores between surgical and medical patient types. RESULTS: Of 1414 patients, 995 (70.4%) (53.1% male, mean age 68.7±17.5 years) were included. In the ED setting, 30-day mortality was best predicted by VitalPAC EWS (AUROC 0.71, 95% CI (0.65 to 0.77)) and National Early Warning Score (0.709 (0.65 to 0.77)). All EWS scores calculated in the prehospital setting had AUROC <0.70. Rapid Emergency Medicine Score (0.83 (0.73 to 0.92)) and New Zealand EWS (0.88 (0.81 to 0.95)) best predicted 3-day mortality in the prehospital and ED settings, respectively. EWS scores calculated using either prehospital or ED VS were more effective in predicting 3-day mortality in surgical patients, whereas 30-day mortality was best predicted in medical patients. Among the EWS scores that achieved AUROC ≥0.70, no statistically significant differences were detected in their discriminatory abilities to identify patients at risk of clinical deterioration. CONCLUSIONS: EWS scores better predict 3-day as opposed to 30-day mortality and are more accurate when estimated using VS measured in the ED. The discriminatory performance of EWS scores in identifying patients at higher risk of clinical deterioration may vary by patient type.

Outcomes of adult patients discharged at scene by emergency medical services.

BACKGROUND: The outcomes of patients who call an ambulance but are discharged at scene reflect the safety and quality of emergency medical service (EMS) care. While previous studies have examined the outcomes of patients discharged at scene, none have specifically focused on paramedic-initiated discharge. This study aims to describe the outcomes of adult patients discharged at scene by paramedics and identify factors associated with 72-hour outcomes. METHODS: This was a retrospective data linkage study on consecutive adult EMS patients discharged at scene by paramedics in Victoria, Australia, between 1 January 2015 and 30 June 2019. Multivariable logistic regression was used to investigate factors associated with EMS recontact, ED presentation, hospital admission and serious adverse events (death, cardiac arrest, category 1 triage or intensive care unit admission) within 72 hours of the initial emergency call. RESULTS: There were 375 758 cases of adults discharged at scene following EMS attendance, of which 222 571 (59.2%) were paramedic-initiated decisions. Of these, 6.8% recontacted EMS, 5.0% presented to ED, 2.4% were admitted to hospital and 0.3% had a serious adverse event in the following 72 hours. The odds of EMS recontact were increased in cases related to mental health (adjusted OR (AOR) 1.41 (95% CI 1.33 to 1.49)), among low-income government concession holders (AOR 1.61 (95% CI 1.55 to 1.67)) and in areas of low socioeconomic advantage (AOR 1.19 (95% CI 1.13 to 1.25)). The odds of hospital admission were increased in cases related to infection (AOR 3.14 (95% CI 2.80 to 3.52)) and pain (AOR 1.93 (95% CI 1.75 to 2.14)). The strongest driver of serious adverse events was an abnormal vital sign (AOR 4.81 (95% CI 3.87 to 5.98)). CONCLUSION: The occurrence of hospital admission and adverse events is rare in those discharged at scene, suggesting generally safe decision-making. However, increased attention to elderly, multimorbid patients or patients with infection and pain is recommended, as is further research examining the use of tools to aid paramedic recognition of potential for deterioration.

Utilization of emergency medical service and its associated factors among patients visited public hospitals at Hawassa City, Sidama Region, Ethiopia, 2023.

Background: The burden of emergency medical conditions is borne mostly by poorer nations, with a 6 % increase in deaths of adults and children due to emergency conditions between 1990 and 2015. Emergency medical service is crucial to improve outcomes of those injuries and other time-sensitive illnesses. However, access to emergency medical services in Hawassa City is still limited and its' utilization is influenced by different factors. Methods: A facility-based cross-sectional study was conducted among 422 randomly selected clients who visited the emergency service in public hospitals of Hawassa City. A structured interviewer-administered questionnaire adapted by reviewing previous literature was used. The collected data by using the Kobo toolbox was exported into a statical package for social science software for analysis. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used. A binary logistic regression model at a 95 % confidence interval was used to declare an association between dependent and independent variables using the odds ratio. Results: All 422 participants completed the interview with a response rate of 100 %. The mean age of the study participants was 33.73 years with a 14.67 standard deviation. One quarter (24.9 % (95 % CI: 21.1-29.4)) of the study participants have utilized emergency medical services. Urban residence (AOR = 3.48, 95 % CI: 1.69-7.16), ever utilized ambulance service (AOR = 2.37, 95%CI: 1.21-4.67), having Red Cross Association ambulance number (AOR = 2.64, 95%CI: 1.20-5.83) and awareness on presence of free government ambulance (AOR = 3.74, 95%CI: 1.46-9.59) were the predictors of the outcome variable. Conclusion: utilization of emergency medical services in the study area was relatively low when compared with other studies. urban residence, ever utilization of ambulance service, awareness of the presence of free government ambulances, and having a Red Cross Association ambulance number were predictors of utilization of emergency medical service.

"1990 Suwa Seriya" the national pre-hospital care ambulance service of Sri Lanka; a narrative review describing the EMS system with special emphasis on Out of Hospital Cardiac Arrest (OHCA) in Sri Lanka.

Background: Sri Lanka is a leading nation in healthcare provision in the South Asia. Notably, it recorded amongst the lowest maternal and neonatal mortality rates in the region. However a significant deficit in improving all-cause mortality rates was the absence of a cohesive system of pre-hospital care. Method: This narrative review delves into the evolution of Sri Lanka's Emergency Medical Services (EMS) system over the past decade. It examines the historical context, challenges encountered, and the transformative role of the "1990 Suwa Seriya" ambulance service on all causes of morbidity and mortality rates including out-of-hospital cardiac arrest (OHCA). Results: The review elucidates the path from no organised pre-hospital system in 2015 to a comprehensive free to public, pre-hospital care emergency ambulance service that effectively serves 22 million people nationa-wide in 6 short years. Collaborations with emergency medicine, novel approaches to training and credentialing, as well as evolving research initiatives illustrate an approach to be emulated in countries with emerging pre-hospital systems. 1990 Suwa Seriya's response during the COVID-19 pandemic and its implications on public perception are discussed in conjunction with efforts to limit morbidity and mortality from OHCA. Conclusion: In conclusion, the article underscores 1990 Suwa Seriya's dedication to continuous improvement and its potential as a model for bolstering emergency healthcare. By addressing challenges, fostering collaborations, and adapting to crises like the COVID-19 pandemic, 1990 Suwa Seriya exemplifies a pathway towards elevating pre-hospital care standards in lower-middle-income countries (LMICs).

Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study.

BACKGROUND: Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS: Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS: Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS: Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.

Out-of-hospital cardiac arrest in children in Norway: A national cohort study, 2016-2021.

Aim: Children constitute an important and distinct subgroup of out-of-hospital cardiac arrest (OHCA) patients. This population-based cohort study aims to establish current age-specific population incidence, precipitating causes, circumstances, and outcome of paediatric OHCA, to guide a focused approach to prevention and intervention to improve outcomes. Methods: Data from the national Norwegian Cardiac Arrest Registry was extracted for the six-year period 2016-21 for persons aged <18 years. We present descriptive statistics for the population, resuscitation events, presumed causes, treatment, and outcomes, alongside age-specific incidence and total paediatric mortality rates. Results: Three hundred and eight children were included. The incidence of OHCA was 4.6 per 100 000 child-years and markedly higher in children <1 year at 20.9 child-years. Leading causes were choking, cardiac and respiratory disease, and sudden infant death syndrome. Overall, 21% survived to 30 days and 18% to one year. Conclusion: A registry-based approach enabled this study to delineate the characteristics and trajectories of OHCA events in a national cohort of children. Precipitating causes of paediatric OHCA are diverse compared to adults. Infants aged <1 year are at particularly high risk. Mortality is high, albeit lower than for adults in Norway. A rational community approach to prevention and treatment may focus on general infant care, immediate first aid by caretakers, and identification of vulnerable children by primary health providers. Cardiac arrest registries are a key source of knowledge essential for quality improvement and research into cardiac arrest in childhood.

The practice and determinants of ambulance service utilization in pre-hospital settings, Jimma City, Ethiopia.

BACKGROUND: In pre-hospital setting, ambulance provides emergency care and means of transport to arrive at appropriate health centers are as vital as in-hospital care, especially, in developing countries. Accordingly, Ethiopia has made several efforts to improve accessibility of ambulances services in prehospital care system that improves the quality of basic emergency care. Yet, being a recent phenomenon in Ethiopia, empirical studies are inadequate with regard to the practice and determinants of ambulance service utilization in pre-hospital settings. Hence, this study aimed to assess the ambulance service utilization and its determinants among patients admitted to the Emergency Departments (EDs) within the context of pre-hospital care system in public hospitals of Jimma City. METHOD: A cross-sectional study design was used to capture quantitative data in the study area from June to July 2022. A systematic sampling technique was used to select 451 participants. Interviewer-administered questionnaire was used to collect data. Data analysis was done using SPSS version 26.0; descriptive and logistic regressions were done, where statistical significance was determined at p < 0.05. RESULTS: Ambulance service was rendered to bring about 39.5% (of total sample, 451) patients to hospitals. The distribution of service by severity of illnesses was 48.7% among high, and 39.4% among moderately acute cases. The major determinants of ambulance service utilization were: service time (with AOR, 0.35, 95%CI, 0.2-0.6 for those admitted to ED in the morning, and AOR, 2.36, 95%CI, 1.3-4.4 for those at night); referral source (with AOR, 0.2, 95%CI, 0.1-0.4 among the self-referrals); mental status (with AOR, 1.9, 95%CI, 1-3.5 where change in the level of consciousness is observed); first responder (AOR, 6.3 95%CI, 1.5-26 where first responders were the police, and AOR, 3.4, 95%C1, 1.7-6.6 in case of bystanders); distance to hospital (with AOR,0.37, 95%CI, 0.2-0.7 among the patients within ≤15km radius); and prior experience in ambulance use (with AOR, 4.1,95%CI, 2.4-7). CONCLUSION: Although the utilization of ambulance in pre-hospital settings was, generally, good in Jimma City; lower levels of service use among patients in more acute health conditions is problematic. Community-based emergency care should be enhanced to improve the knowledge and use of ambulance services.