Alfentanil for Pain Relief in a Swedish Emergency Medical Service - An Eleven-Year Follow-up on Safety and Effect.

OBJECTIVES: Pain is a common symptom in prehospital emergency care and pain treatment in this context can be challenging. While previous research has assessed the use of morphine and other synthetic opioids for pain management in this setting, the evaluation of alfentanil is limited. The objective of this study was to evaluate the safety and effect of intravenous alfentanil when administered by ambulance nurses in prehospital emergency care. METHODS: This retrospective observational study consecutively included patients suffering from pain, treated with alfentanil in a Swedish EMS service from September 2011 to 31 September 2022. Data regarding occurrence of adverse events (AE), serious adverse events (SAE) - were used for safety evaluation and pain scores with a visual analogue scale (VAS) before and after treatment were used for evaluation of pain treatment. These data were extracted from the electronic patients' medical records database for analysis. Univariate logistic regression analysis was used to identify significant predictors of AE following injection of alfentanil by nurses in prehospital emergency care. RESULTS: During the evaluation period 17,796 patients received pain relief with alfentanil. Adverse events affected 2.5% of the patients, while serious adverse events were identified in 25 cases (0.01%). Out of the 5970 patients with a complete VAS score for pain, the median VAS score was 8 (IQR 3) before treatment and 4 (IQR 3) after treatment. The mean reduction in pain measured by VAS was -4.1 ± 2.6 from the time before, to the evaluation after alfentanil administration. The administration frequency increased during the first year up to a steady level during the later part of the evaluation period. CONCLUSIONS: This study proposes that alfentanil represents a safe and efficacious alternative for addressing urgent pain relief within the prehospital emergency context. Alfentanil demonstrates efficacy in alleviating pain across various conditions, with a relatively low risk of adverse events or serious adverse events when administered cautiously.

Epidemiology of patients assessed for trauma by Swedish ambulance services: a retrospective registry study.

BACKGROUND: There is a lack of knowledge regarding the epidemiology of severe trauma assessed by Swedish emergency medical services (EMS). AIM: To investigate the prevalence of trauma in Sweden assessed by EMS from a national perspective and describe patient demography, aetiology, trauma type, prehospital triage and clinical outcomes. METHODS: Data from two national quality registries, the Swedish Ambulance Registry and the Swedish Trauma Registry (SweTrau) were collected from January 1 to December 31, 2019. Inclusion criteria were an Emergency Symptoms and Signs code equivalent to trauma in the Swedish Ambulance Registry and criteria fulfilled for SweTrau inclusion. Exclusion criteria were patients < 18 years old, those not transported to a hospital and those without a personal identification number. RESULTS: In total, 53,120 patients with trauma were included (14% of primary EMS missions involving a personal identification number). Of those, 2,278 (4.3%) patients (median age: 45 years; 32% women) were reported in SweTrau to have severe or potentially severe trauma (penetrating: 7%, blunt: 93%). In terms of including all causes of trauma, the code for 'trauma alert activation' was most frequent (55%). The most frequent injury mechanism was an injury caused by a car (34%). Most (89%) cases were assigned Priority 1 (life-threatening condition) at the dispatch centre. 62% were regarded as potentially life threatening upon EMS arrival, whereas 29% were assessed as non-life-threatening. Overall, 25% of the patients had new injury severity scores > 15. 12% required invasive treatment, 11% were discharged with severe disability and the 30-day mortality rate was 3.6%. CONCLUSION: In this cross-sectional study, 14% of the primary EMS missions for one year were caused by trauma. However, only a small proportion of these cases are severe injuries, and the risk of severe disabilities and death appears to be limited. The most frequent aetiology of a severe trauma is injury caused by a car, and most severe traumas are blunt. Severe traumas are given the highest priority at the dispatch centre in the vast majority of cases, but nearly one-third of these cases are considered a low priority by the EMS nurse. The latter leaves room for improvement.

Prehospital recognition of stroke is associated with a lower risk of death.

OBJECTIVE: Among patients assessed by the emergency medical service (EMS) and hospitalized with a final diagnosis of stroke, to describe delays, patient characteristics, actions taken and outcome in relation to the early recognition of stroke by the EMS clinician. METHODS: Patients admitted to any of six stroke units in Region Västra Götaland, Sweden, with a final diagnosis of stroke from 1 January 2013 to 31 December 2015 were included. Data on follow-up were retrieved from the Swedish Stroke Register. RESULTS: In all, 5467 patients were included. Stroke was recognized by the EMS clinician in 4396 cases (80.4%). The mean difference in the time from dialling 112 until arrival at the stroke unit was 556 min shorter when stroke was recognized, while the mean difference in the time from dialling 112 until a preliminary report from a computed tomography (CT) scan was 219 min shorter as compared with the patients in whom stroke was not recognized. After adjustment for age, sex, neurological deficits and coma, a lack of suspicion of stroke on EMS arrival was associated with an increased risk of death during three months of follow-up (odds ratio 1.66; 95% confidence interval 1.19-2.32; p = .003). CONCLUSION: Among patients with a stroke, more than 80% were recognized by the EMS clinician. Early recognition of stroke was associated with a markedly shorter time until arrival at the stroke unit and until the preliminary report of a CT scan. A lack of early stroke recognition was associated with an increased risk of death.

Suboptimal prehospital decision- making for referral to alternative levels of care - frequency, measurement, acceptance rate and room for improvement.

BACKGROUND: The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from "time-sensitive conditions" delaying diagnosis and treatment. Thus, four questions arise: 1) How often are time-sensitive cases referred to primary care or self-care advice? 2) How can we measure and define the level of inappropriate clinical decision-making? 3) What is acceptable? 4) How to increase patient safety? MAIN TEXT: To what extent time-sensitive cases are non-conveyed varies. About 5-25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1-3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%. The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome. In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories. There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another. CONCLUSION: A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.

Prehospital lactate levels in blood as a seizure biomarker: A multi-center observational study.

OBJECTIVE: The objective of this study was to assess the value of prehospital measurement of lactate level in blood for diagnosis of seizures in cases of transient loss of consciousness. METHODS: Between March 2018 and September 2019, prehospital lactate was measured with a point-of-care device by the emergency medical services in an area serving a population of 900 000. A total of 383 cases of transient loss of consciousness were identified and categorized as tonic-clonic seizure (TCS), other seizure, syncope, or other cause, according to the final diagnosis in the electronic medical records system. Receiver operating characteristic curve analyses were used to identify the optimal lactate cut-off. RESULTS: A total of 383 cases were included (135 TCS, 42 other seizure, 163 syncope, and 43 other causes). The median lactate level in TCS was 7.0 mmol/L, compared to a median of 2.0 mmol/L in all other cases (P < .001). The area under the curve (AUC) of TCS vs nonepileptic causes was 0.87 (95% confidence interval [CI] 0.83-0.91). The optimal cut-off (Youden index, 67.8%) was 4.75 mmol/L, with 79% sensitivity (95% CI 71-85) and 89% specificity (95% CI 85-93) for TCS. SIGNIFICANCE: Prehospital lactate can be a valuable tool for identifying seizures in transient loss of consciousness. For acceptable specificity, a higher cut-off than that previously demonstrated for hospital-based measurements must be used when values obtained close to the time of the event are interpreted.

Difficulties in the prehospital assessment of patients with TIA/stroke.

BACKGROUND: In patients with TIA/stroke, early assessment is critical. AIM: To describe patients who were not directly transported to hospital by ambulance after prehospital assessment. METHODS: Patients hospitalized with TIA/stroke in Gothenburg, Data were obtained from the EMS and hospital case record system. RESULTS: There were 7,812 patients with TIA/stroke, of which 4,853 (62%) were candidates for EMS transport. Among them, 176 (3.6%) were not directly transported to hospital by ambulance. In 45% of them, delay from symptom onset to calling for EMS was ≤24 hours. On EMS arrival, common symptom was dizziness (28%), followed by weakness in arm or leg (21%), loss of sensibility (13%), speech disturbances (7%), and facial numbness (4%). The modified National Institute of Health Stroke Score (mNIHSS) was 0 in 80% and >1 in two per cent. The NIHSS at the emergency department was 1-4 in 39% and 5-15 in six per cent. The EMS clinician made the decision not to transport the patient to hospital by the EMS in 84%, the dispatcher in 12% and the patient or relatives in four per cent. Patients were involved in the decision in 51%. Final diagnosis was stroke in 74% and the proportion who were independent in normal daily activities at hospital discharge decreased by 15% compared with before event. CONCLUSION: About 3%-4% of patients with TIA/stroke were not directly transported to hospital by EMS after prehospital assessment. The most common symptom was dizziness. Decision-support tools for EMS to identify time-sensitive conditions are required.

Limited need for hospital resources among patients brought to hospital by the emergency medical services.

BACKGROUND: In Sweden, the majority of patients who are transported to hospital by the emergency medical services (EMS) are relatively old and the majority suffer from comorbidity. About half these patients are admitted to a hospital ward and will stay in hospital. However, the other half will only make a visit to the emergency department (ED). The burden on the ED is extensive and many elderly patients have to stay for many hours in the ED. AIM: To describe the patients who are brought to hospital by the EMS, with particular emphasis on those that were discharged from the ED, and to assess the proportion of these patients who did not require hospital resources, which could mean that they were candidates for primary care (PC). METHODS: An observational analysis of a cohort of patients who were transported to hospital by the EMS in 2016 in the Municipality of Gothenburg. RESULTS: In all, 5,326 patients were transported to hospital by the EMS of which 52% were discharged directly from the ED. These patients included 37% assessed as not requiring hospital resources. The three most common causes of contact with the EMS in this subset were abdominal pain (15%), back pain (8%) and non-specified disease (7%). Of these patients, 77% had contact with a physician in the ED, whereas 6% had contact with a nurse and 17% left the ED without any contact. Twenty-six per cent were given advice on follow-up in PC. CONCLUSIONS: Among patients who were brought to hospital by the EMS, more than half were discharged directly from the ED. Among these patients, 37% were assessed as not requiring hospital resources. These patients comprised 15% of the overall study cohort and may be candidates for primary care.

Patient characteristics, triage utilisation, level of care, and outcomes in an unselected adult patient population seen by the emergency medical services: a prospective observational study.

BACKGROUND: Crowding in the emergency department (ED) is a safety concern, and pathways to bypass the ED have been introduced to reduce the time to definitive care. Conversely, a number of low-acuity patients in the ED could be assessed by the emergency medical services (EMS) as requiring a lower level of care. The limited access to primary care in Sweden leaves the EMS nurse to either assess the patient as requiring the ED or to stay at the scene. This study aimed to assess patient characteristics and evaluate the initial assessment by and utilisation of the ambulance triage system and the appropriateness of non-transport decisions. METHODS: A prospective observational study including 6712 patients aged ≥16 years was conducted. The patient records with 72 h of follow-up for non-transported patients were reviewed. Outcomes of death, time-critical conditions, complications within 48 h and final hospital assessment were evaluated. The Mann-Whitney U test, Fisher's exact test, and Spearman's rank correlation were used for statistical analysis. RESULTS: The median patient age was 66 years, and the most common medical history was a circulatory diagnosis. Males received a higher priority from dispatchers and were more frequently assessed at the scene as requiring hospital care. A total of 1312 patients (19.7%) were non-transported; a history of psychiatric disorders or no medical history was more commonly noted among these patients. Twelve (0.9%) of the 1312 patients not transported were later admitted with time-critical conditions. Full triage was applied in 77.4% of the cases, and older patients were triaged at the scene as an 'unspecific condition' more frequently than younger patients. Overall, the 30-day mortality was 4.1% (n = 274). CONCLUSIONS: Age, sex, medical history, and presentation all appear to influence the initial assessment. A number of patients transported to ED could be managed at a lower level of care. A small proportion of the non-transported patients were later diagnosed with a time-critical condition, warranting improved assessment tools at the scene and education of the personnel focusing on the elderly population. These results may be useful in addressing resource allocation issues aiming at increasing patient safety.

Characteristics and outcomes of patients with dyspnoea as the main symptom, assessed by prehospital emergency nurses- a retrospective observational study.

BACKGROUND: Dyspnoea (breathing difficulty) is among the most commonly cited reasons for contacting emergency medical services (EMSs). Dyspnoea is caused by several serious underlying medical conditions and, based on patients individual needs and complex illnesses or injuries, ambulance staff are independently responsible for advanced care provision. Few large-scale prehospital studies have reviewed patients with dyspnoea. This study aimed to describe the characteristics and final outcomes of patients whose main symptom was classified as dyspnoea by the prehospital emergency nurse (PEN). METHODS: This retrospective observational study included patients aged > 16 years whose main symptom was dyspnoea. All the enrolled patients were assessed in the south-western part of Sweden by PENs during January and December, 2017. Of 7260 assignments (9% of all primary missions), 6354 fulfilled the inclusion criteria. Analysis was performed using descriptive statistics, and the tests used were odds ratios and Kaplan-Meier analysis. RESULTS: The patients mean age was 73 years, and approximately 56% were women. More than 400 different final diagnostic codes (International Statistical Classification of Diseases and Related Health Problems [ICD]-10th edition) were observed, and 11% of the ICD-10 codes denoted time-critical conditions. The three most commonly observed aetiologies were chronic obstructive pulmonary disease (20.4%), pulmonary infection (17.1%), and heart failure (15%). The comorbidity values were high, with 84.4% having previously experienced dyspnoea. The overall 30-day mortality was 11.1%. More than half called EMSs more than 50 h after symptom onset. CONCLUSIONS: Among patients assessed by PENs due to dyspnoea as the main symptom there were more than 400 different final diagnoses, of which 11% were regarded as time-critical. These patients had a severe comorbidity and 11% died within the first 30 days.

Pre-hospital predictors of an adverse outcome among patients with dyspnoea as the main symptom assessed by pre-hospital emergency nurses - a retrospective observational study.

BACKGROUND: Dyspnoea is one of the most common reasons for patients contacting emergency medical services (EMS). Pre-hospital Emergency Nurses (PENs) are independently responsible for advanced care and to meet these patients individual needs. Patients with dyspnoea constitute a complex group, with multiple different final diagnoses and with a high risk of death. This study aimed to describe on-scene factors associated with an increased risk of a time-sensitive final diagnosis and the risk of death. METHODS: A retrospective observational study including patients aged ≥16 years, presenting mainly with dyspnoea was conducted. Patients were identified thorough an EMS database, and were assessed by PENs in the south-western part of Sweden during January to December 2017. Of 7260 missions (9% of all primary missions), 6354 were included. Among those, 4587 patients were randomly selected in conjunction with adjusting for unique patients with single occasions. Data were manually collected through both EMS- and hospital records and final diagnoses were determined through the final diagnoses verified in hospital records. Analysis was performed using multiple logistic regression and multiple imputations. RESULTS: Among all unique patients with dyspnoea as the main symptom, 13% had a time-sensitive final diagnosis. The three most frequent final time-sensitive diagnoses were cardiac diseases (4.1% of all diagnoses), infectious/inflammatory diseases (2.6%), and vascular diseases (2.4%). A history of hypertension, renal disease, symptoms of pain, abnormal respiratory rate, impaired consciousness, a pathologic ECG and a short delay until call for EMS were associated with an increased risk of a time-sensitive final diagnosis. Among patients with time-sensitive diagnoses, approximately 27% died within 30 days. Increasing age, a history of renal disease, cancer, low systolic blood pressures, impaired consciousness and abnormal body temperature were associated with an increased risk of death. CONCLUSIONS: Among patients with dyspnoea as the main symptom, age, previous medical history, deviating vital signs, ECG pattern, symptoms of pain, and a short delay until call for EMS are important factors to consider in the prehospital assessment of the combined risk of either having a time-sensitive diagnosis or death.

High-resolution mapping of epilepsy prevalence, ambulance use, and socioeconomic deprivation in an urban area of Sweden.

OBJECTIVE: Geographic differences in epilepsy prevalence between areas of different socioeconomic standing have been demonstrated in the United Kingdom, but knowledge from other health care systems is scarce. Our objective was to compare epilepsy prevalence and emergency medical service (EMS) assignments for seizures in areas of different socioeconomic standings in the urban area of Gothenburg. METHODS: Register-based study in Gothenburg (population 690 000), the second largest city in Sweden. Epilepsy cases were identified in the comprehensive national patient register in 2014-2015. EMS assignments were identified in the EMS dispatch system in 2013-2018. Socioeconomic variables were mean income and proportion of welfare recipients. RESULTS: Significant correlations were seen between epilepsy prevalence and the proportion of welfare recipients (r = .49, P = .0014) and annual income per capita (r = -.42, P = .0071). There were 7907 assignments for seizures during the study years. GPS-based analysis showed that most assignments occurred in the city center. In addition, several high-density areas correlated with areas with a high proportion of inhabitants receiving welfare. Correlation analysis showed significant associations between the number of EMS assignments per capita and the proportion of welfare recipients (r = .31, P < .0001) and income (r = -.19, P < .0001). When comparing representative areas, a greater proportion of assignments was given the highest priority in high status areas compared to low status areas, both by the dispatch center and EMS clinicians on scene. SIGNIFICANCE: Our findings that epilepsy prevalence and seizure frequency differ with socioeconomic status on a microgeographic level considerably strengthen the generalizability of previous observations across different health care systems. Differences in priority may reflect health utilization behavior or access to neurologic care.

The performance of the EMS triage (RETTS-p) and the agreement between the field assessment and final hospital diagnosis: a prospective observational study among children < 16 years.

BACKGROUND: The rapid triage and treatment system for paediatrics (RETTS-p) has been used by the emergency medical services (EMS) in the west of Sweden since 2014. The performance of the RETTS-p in the pre-hospital setting and the agreement between the EMS nurse's field assessment and the hospital diagnosis is unknown. The aim of this study was to evaluate the performance of the RETTS-p in the EMS and the agreement between the EMS field assessment and the hospital diagnosis. METHODS: A prospective observational study was conducted among 454 patients < 16 years of age who were assessed and transported to the PED. Two instruments were used for comparison: 1) Classification of an emergent patient according to predefined criteria as compared to the RETTS-p and 2) Agreement between the EMS nurse's field assessment and the hospital diagnosis. RESULTS: Among all children, 11% were identified as having vital signs associated with an increased risk of death and 7% were diagnosed in hospital with a potentially life-threatening condition. Of the children triaged with RETTS-p (85.9%), 149 of 390 children (38.2%) were triaged to RETTS-p red or orange (life-threatening, potentially life-threatening), of which 40 (26.8%) children were classified as emergent. The hospitalised children were triaged with the highest frequency to level yellow (can wait; 41.5%). In children with RETTS-p red or orange, the sensitivity for a defined emergent patient was 66.7%, with a corresponding specificity of 67.0%. The EMS field assessment was in agreement with the final hospital diagnosis in 80% of the cases. CONCLUSIONS: The RETTS-p sensitivity in this study is considered moderate. Two thirds of the children triaged to life threatening or potentially life threatening were later identified as non-emergent. Of those, one in six was discharged from the PED without any intervention. Further, one third of the children were under triaged, the majority were found in the yellow triage level (can wait). The highest proportion of hospitalised patients was found in the yellow triage level. Our result is in agreement with previous studies using other triage instruments. A computerised decision support system might help the EMS triage to increase sensitivity and specificity.

Adverse events in prehospital emergency care: a trigger tool study.

BACKGROUND: Prehospital emergency care has developed rapidly during the past decades. The care is given in a complex context which makes prehospital care a potential high-risk activity when it comes to patient safety. Patient safety in the prehospital setting has been only sparsely investigated. The aims of the present study were 1) To investigate the incidence of adverse events (AEs) in prehospital care and 2) To investigate the factors contributing to AEs in prehospital care. METHODS: We used a retrospective study design where 30 randomly selected prehospital medical records were screened for AEs each month in three prehospital organizations in Sweden during a period of one year. A total of 1080 prehospital medical records were included. The record review was based on the use of 11 screening criteria. RESULTS: The reviewers identified 46 AEs in 46 of 1080 (4.3%) prehospital medical records. Of the 46 AEs, 43 were classified as potential for harm (AE1) (4.0, 95% CI = 2.9-5.4) and three as harm identified (AE2) (0.3, 95% CI = 0.1-0.9). However, among patients with a life-threatening condition (priority 1), the risk of AE was higher (16.5%). The most common factors contributing to AEs were deviations from standard of care and missing, incomplete, or unclear documentation. The most common cause of AEs was the result of action(s) or inaction(s) by the emergency medical service (EMS) crew. CONCLUSIONS: There were 4.3 AEs per 100 ambulance missions in Swedish prehospital care. The majority of AEs originated from deviations from standard of care and incomplete documentation. There was an increase in the risk of AE among patients who the EMS team assessed as having a life-threatening condition. Most AEs were possible to avoid.

Pediatric trauma patients in Swedish ambulance services -a retrospective observational study of assessments, interventions, and clinical outcomes.

BACKGROUND: Pediatric trauma patients constitute a significant portion of the trauma population treated by Swedish Emergency Medical Services (EMS), and trauma remains a notable cause of death among Swedish children. Previous research has identified potential challenges in prehospital assessments and interventions for pediatric patients. In Sweden, there is limited information available regarding pediatric trauma patients in the EMS. The aim of this study was to investigate the prevalence of pediatric trauma patients within the Swedish EMS and describe the prehospital assessments, interventions, and clinical outcomes. METHODS: This retrospective observational study was conducted in a region of Southwestern Sweden. A random sample from ambulance and hospital records from the year 2019 was selected. Inclusion criteria were children aged 0-16 years who were involved in trauma and assessed by EMS clinicians. RESULTS: A total of 440 children were included in the study, representing 8.4% of the overall trauma cases. The median age was 9 years (IQR 3-12), and 60.5% were male. The leading causes of injury were low (34.8%) and high energy falls (21%), followed by traffic accidents. The children were assessed as severely injured in 4.5% of cases. A quarter of the children remained at the scene after assessment. Complete vital signs were assessed in 29.3% of children, and 81.8% of children were assessed according to the ABCDE structure. The most common intervention performed by prehospital professionals was the administration of medication. The mortality rate was 0.2%. CONCLUSIONS: Pediatric trauma cases accounted for 8.4% of the overall trauma population with a variations in injury mechanisms and types. Vital sign assessments were incomplete for a significant proportion of children. The adherence to the ABCDE structure, however, was higher. The children remained at the scene after assessment requires further investigation for patient safety.

Development of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care.

BACKGROUND: Emergency Medical Services (EMS) are a unique setting because care for the chief complaint is given across all ages in a complex and high-risk environment that may pose a threat to patient safety. Traditionally, a reporting system is commonly used to raise awareness of adverse events (AEs); however, it could fail to detect an AE. Several methods are needed to evaluate patient safety in EMS. In this light, this study was conducted to (1) develop a national ambulance trigger tool (ATT) with a guide containing descriptions of triggers, examples of use, and categorization of near misses (NMs), no harm incidents (NHIs), and harmful incidents (HIs) and (2) use the ATT on randomly selected ambulance records. METHODS: The ambulance trigger tool was developed in a stepwise manner through (1) a literature review; (2) three sessions of structured group discussions with an expert panel having knowledge of emergency medical service, patient safety, and development of trigger tools; (3) a retrospective record review of 900 randomly selected journals with three review teams from different geographical locations; and (4) inter-rater reliability testing between reviewers. RESULTS: From the literature review, 34 triggers were derived. After removing clinically irrelevant ones and combining others through three sessions of structured discussions, 19 remained. The most common triggers identified in the 900 randomly selected records were deviation from treatment guidelines (30.4%), the patient is non conveyed after EMS assessment (20.8%), and incomplete documentation (14.4%). The positive triggers were categorized as a near miss (40.9%), no harm (3.7%), and harmful incident (0.2%). Inter-rater reliability testing showed good agreement in both sessions. CONCLUSION: This study shows that a trigger tool together with a retrospective record review can be used as a method to measure the frequency of harmful incidents, no harm incidents, and near misses in the EMS, thus complementing the traditional reporting system to realize increased patient safety.

Characteristics of a trauma population in an ambulance organisation in Sweden: results from an observational study.

BACKGROUND: Globally, injuries are a major health problem, and in Sweden, injuries are the second most common reason for ambulance dispatch. However, there is a knowledge gap regarding the epidemiology of injuries requiring assessment by emergency medical services (EMS) in Sweden. The aim of the present study was to describe the prehospital population with injuries that have been assessed and treated by EMS. METHODS: A randomly selected retrospective sample was collected from 1 January through 31 December 2019 in a region in southwestern Sweden. Data were collected from ambulance and hospital medical records. RESULTS: Among 153,724 primary assignments, 26,697 (17.4%) were caused by injuries. The study cohort consisted of 5,235 patients, of whom 50.5% were men, and the median age was 63 years. The most common cause of injury was low-energy fall (51.4%), and this was the cause in 77.8% of those aged > 63 years and in 26.7% of those aged ≤ 63 years. The injury mechanism was a motor vehicle in 8.0%, a motorcycle in 2.1% and a bicycle in 4.0%. The most common trauma location was the residential area (55.5% overall; 77.9% in the elderly and 34.0% in the younger group). In the prehospital setting, the most frequent clinical sign was a wound (33.2%), a closed fracture were seen in 18.9% and an open fracture in 1.0%. Pain was reported in 74.9% and 42.9% reported severe pain. Medication was given to 42.4% of patients before arrival in the hospital. The most frequent triage colour according to the RETTS was orange (46.7%), whereas only 4.4% were triaged red. Among all patients, 83.6% were transported to the hospital, and 27.8% received fracture treatment after hospital admission. The overall 30-day mortality rate was 3.4%. CONCLUSION: Among EMS assignments in southwestern Sweden, 17% were caused by injury equally distributed between women and men. More than half of these cases were caused by low-energy falls, and the most common trauma location was a residential area. The majority of the victims had pain upon arrival of the EMS, and a large proportion appeared to have severe pain.

Prediction of the Risk of Sepsis by Using Analysis of Plasma Glucose and Serum Lactate in Ambulance Services: A Prospective Study.

INTRODUCTION: The early recognition of patients with sepsis is difficult and the initial assessment outside of hospitals is challenging for ambulance clinicians (ACs). Indicators that ACs can use to recognize sepsis early are beneficial for patient outcomes. Research suggests that elevated point-of-care (POC) plasma glucose and serum lactate levels may help to predict sepsis in the ambulance service (AS) setting. STUDY OBJECTIVE: The aim of this study was to test the hypothesis that the elevation of POC plasma glucose and serum lactate levels may help to predict Sepsis-3 in the AS. METHODS: A prospective observational study was performed in the AS setting of Gothenburg in Sweden from the beginning of March 2018 through the end of September 2019. The criteria for sampling POC plasma glucose and serum lactate levels in the AS setting were high or intermediate risk according to the Rapid Emergency Triage and Treatment System (RETTS), as red, orange, yellow, and green if the respiratory rate was >22 breaths/minutes. Sepsis-3 were identified retrospectively. A primary and secondary analyses were carried out. The primary analysis included patients cared for in the AS and emergency department (ED) and were hospitalized. In the secondary analysis, patients who were only cared for in the AS and ED without being hospitalized were also included. To evaluate the predictive ability of these biomarkers, the area under the curve (AUC), sensitivity, specificity, and predictive values were used. RESULTS: A total of 1,057 patients were included in the primary analysis and 1,841 patients were included in the secondary analysis. In total, 253 patients met the Sepsis-3 criteria (in both analyses). The AUC for POC plasma glucose and serum lactate levels showed low accuracy in predicting Sepsis-3 in both the primary and secondary analyses. Among all hospitalized patients, regardless of Sepsis-3, more than two-thirds had elevated plasma glucose and nearly one-half had elevated serum lactate when measured in the AS. CONCLUSIONS: As individual biomarkers, an elevated POC plasma glucose and serum lactate were not associated with an increased likelihood of Sepsis-3 when measured in the AS in this study. However, the high rate of elevation of these biomarkers before arrival in hospital highlights that their role in clinical decision making at this early stage needs further evaluation, including other endpoints than Sepsis-3.

[Documentation of prehospital emergency care]. / Över 100 doktorsavhandlingar inom den prehospitala akutsjukvården i Sverige.

The scientific documentation of prehospital emergency care in Sweden is slowly expanding. The first thesis on the value of a mobile coronary care unit was defended in 1982. Since then, at least 106 theses have been defended at 15 educational institutes in Sweden. The theses can be divided into nine different themes, of which acute disease and prognostic factors (n = 30) is the most common, followed in order of frequency by caring, assessment and decision (n = 18), patient and next of kin perspective (n = 14), trauma (n = 1 1), competence, learning, and education (n = 10), care needs, cooperation, and prioritization (n = 10), disaster (n = 7), workers' health and environment (n = 3), and ethics and values (n = 3). The University of Gothenburg had the highest number of theses defended (n = 28), followed by the Karolinska Institute (n = 24) and the University of Umeå (n = 10). The theses were written by 64 nurses, 36 physicians, two public health specialists, one physiotherapist, one priest, one social worker, and one statistician.

The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards.

BACKGROUND: Mass casualty incidents (MCI) pose significant challenges to existing resources, entailing multiagency collaboration. Triage is a critical component in the management of MCIs, but the lack of a universally accepted triage system can hinder collaboration and lead to preventable loss of life. This multinational study uses validated patient cards (cases) based on real MCIs to evaluate the feasibility and effectiveness of a novel Translational Triage Tool (TTT) in primary triage assessment of mass casualty victims. METHODS: Using established triage systems versus TTT, 163 participants (1575 times) triaged five patient cases. The outcomes were statistically compared. RESULTS: TTT demonstrated similar sensitivity to the Sieve primary triage method and higher sensitivity than the START primary triage system. However, the TTT algorithm had a lower specificity compared to Sieve and higher over-triage rates. Nevertheless, the TTT algorithm demonstrated several advantages due to its straightforward design, such as rapid assessment, without the need for additional instrumental interventions, enabling the engagement of non-medical personnel. CONCLUSIONS: The TTT algorithm is a promising and feasible primary triage tool for MCIs. The high number of over-triages potentially impacts resource allocation, but the absence of under-triages eliminates preventable deaths and enables the use of other personal resources. Further research involving larger participant samples, time efficiency assessments, and real-world scenarios is needed to fully assess the TTT algorithm's practicality and effectiveness in diverse multiagency and multinational contexts.

Induction of IgM, IgA and IgE antibodies in colorectal cancer patients vaccinated with a recombinant CEA protein.

PURPOSE: Previous clinical studies have indicated that natural IgM antibodies have the ability to induce apoptosis of tumor cells but IgE and IgA may also mediate tumor cell killing (in addition to IgG). The aim of the study was to analyse induction of IgM, IgA and IgE antibodies in patients vaccinated with the tumor associated antigen CEA. METHODS: Twenty-four resected CRC patients without macroscopic disease were immunized seven times with CEA ± GM-CSF. Four different dose schedules were used over a 12-month period. IgM, IgA and IgE antibody responses against recombinant CEA were determined by ELISA. Patients were monitored immunologically for 36 months and clinically for 147 months. RESULTS: GM-CSF significantly augmented the anti-CEA response for all three antibody classes. Low dose of CEA tended to induce a higher IgM, IgA or IgE anti-CEA antibody response than higher. Anti-CEA IgA antibodies could lyse CEA positive tumor cells in antibody dependent cellular cytotoxicity (ADCC) as well as in complement dependent cytotoxicity (CDC). A significant correlation between survival and high IgA anti-CEA titers was noted (p = 0.02) irrespective of GM-CSF treatment. CONCLUSIONS: The observation that IgA anti-CEA antibodies were cytotoxic and associated with improved survival might indicate that also these antibodies may exert a clinical anti-tumor effect.