Primary care doctors in acute call-outs to severe trauma incidents in Norway - variations by rural-urban settings and time factors.

BACKGROUND: A severely injured patient needs fast transportation to a hospital that can provide definitive care. In Norway, approximately 20% of the population live in rural areas. Primary care doctors (PCDs) play an important role in prehospital trauma care. The aim of this study was to investigate how variations in PCD call-outs to severe trauma incidents in Norway were associated with rural-urban settings and time factors. METHODS: In this study on severe trauma patients admitted to Norwegian hospitals from 2012 to 2018, we linked data from four official Norwegian registries. Through this, we investigated the call-out responses of PCDs to severe trauma incidents. In multivariable log-binomial regression models, we investigated whether factors related to rural-urban settings and time factors were associated with PCD call-outs. RESULTS: There was a significantly higher probability of PCD call-outs to severe trauma incidents in the municipalities in the four most rural centrality categories compared to the most urban category. The largest difference in adjusted relative risk (95% confidence interval (CI)) was 2.08 (1.27-3.41) for centrality category four. PCDs had a significantly higher proportion of call-outs in the Western (RR = 1.46 (1.23-1.73)) and Central Norway (RR = 1.30 (1.08-1.58)) Regional Health Authority areas compared to in the South-Eastern area. We observed a large variation (0.47 to 4.71) in call-out rates to severe trauma incidents per 100,000 inhabitants per year across the 16 Emergency Medical Communication Centre areas in Norway. CONCLUSIONS: Centrality affects the proportion of PCD call-outs to severe trauma incidents, and call-out rates were higher in rural than in urban areas. We found no significant difference in call-out rates according to time factors. Possible consequences of these findings should be further investigated.

Primary care doctors in acute call-outs to severe trauma incidents in Norway - associations with factors related to patients and doctors.

OBJECTIVE: Severe trauma patients need immediate prehospital intervention and transfer to a specialised trauma hospital. In Norway, primary care doctors (PCDs) are an integrated part of the prehospital trauma care. The aim of this study was to investigate the degree to which PCDs were involved in prehospital care of severe trauma patients and how factors related to patients and doctors were associated with call-outs to these incidents. DESIGN: This was a registry-based study in Norway on severe trauma patients with acute hospital admission during the period 2012-2018. SETTING: Data was obtained from three Norwegian official registries. SUBJECTS: By linking the registries, we studied the actions taken by the PCDs, whether they called out to severe trauma incidents. MAIN OUTCOME MEASURES: In multivariable regression models, we investigated whether factors related to the PCDs (age, sex, specialisation in general practice (GP)) and patients (age, sex, duration of hospital stay, type of injury) were associated with call-outs. RESULTS: Out of 4342 severe trauma incidents, PCDs had documented involvement in 1683 (39%) and called out to 644 (15%). Increased proportions of PCD call-outs to severe trauma incidents were significantly associated with lower age of PCD, being a GP specialist, lower patient age, being a male patient, increased length of hospital stay and injuries to the head and the neck. CONCLUSIONS: PCDs called out to a relatively low proportion of severe trauma patients. Several factors related to patients and doctors were associated with call-outs to severe trauma incidents in Norway.

Factors related to doctors and patients affect the Primary Care Doctor's (PCD's) decision to call out to severe trauma incidents.PCDs were involved in 39% out of 4342 severe trauma incidents and called out to 15%.Increased proportion of PCD call-outs to severe trauma incidents was significantly associated with lower age of the PCD and being a GP specialist.Lower patient age, being a male patient, and injury to the head and the neck increased the likelihood of PCD call-outs.

Acute medical missions by helicopter medical service (HEMS) to municipalities with different approach for primary care physicians.

BACKGROUND: The prehospital emergency system in Norway involves out-of-hours (OOH) services with on-call physicians. Helicopter emergency medical service (HEMS) are used in cases of severe illness or trauma that require rapid transport and/or an anesthesiologist's services. In recent years, on-call primary care physicians have been less available for call-outs in Norway, and HEMS may be requested for missions that could be adequately handled by on-call physicians. Here, we investigated how different availability of an on-call physician to attend emergency patients at site (call-out) impacted requests and use of HEMS. METHODS: Our analysis included all acute medical missions in an urban and nearby rural OOH district, which had different approach regarding physician call-outs from the OOH service. For this prospective observational study, we used data from both HEMS and the OOH service from November 1st 2017 until November 30th 2018. Standard descriptive statistical analyses were used. RESULTS: The rates of acute medical missions in the urban and rural OOH districts were similar (30 and 29 per 1000 inhabitants per year, respectively). The rate of HEMS requests was significantly higher in the rural OOH district than in the urban district (2.4 vs. 1.7 per 1000 inhabitants per year, respectively). Cardiac arrest and trauma were the major symptom categories in more than one half of the HEMS-attended patients, in both districts. Chest pain was the most frequent reason for an OOH call-out in the rural OOH district (21.1%). An estimated NACA score of 5-7 was found in 47.7% of HEMS patients from the urban district, in 40.0% of HEMS patients from the rural OOH district (p = 0.44), and 12.8% of patients attended by an on-call physician in the rural OOH district (p < 0.001). Advanced interventions were provided by an anesthesiologist to one-third of the patients attended by HEMS, of whom a majority had an NACA score of ≥ 5. CONCLUSIONS: HEMS use did not differ between the two compared areas, but the rate of HEMS requests was significantly higher in the rural OOH district. The threshold for HEMS use seems to be independent of on-call primary care physician involvement.

General practitioners not available - out-of-hospital emergency patients handled by anaesthesiologist in a large Norwegian municipality.

BACKGROUND: Until autumn 2018 the GPs in Bergen Municipality did not attend emergency patients outside the emergency primary care centre. The ambulance staff handled emergencies on their own or were assisted by an anaesthesiologist from the helicopter emergency medical service (HEMS). The aim of this study was to investigate procedures performed by the HEMS anaesthesiologist and to assess the level of skills needed to perform these procedures. METHODS: This study was a retrospective assessment of data from the period 2011 to 2013 on all emergency missions in which patients were dealt with by HEMS, using a rapid-response car in Bergen Municipality. All emergency missions were sorted into three categories: No intervention, Basic or Advanced intervention. This list was made by a research group with anaesthesiologists working for Bergen HEMS and GPs with OOH experience. The list is based on curriculum found in acute medicine courses. RESULTS: HEMS responded to 716 (2.3%) out of a total of 31,696 emergencies in Bergen Municipality during the three years. In more than two-thirds (71%) of these missions, no intervention or only a basic intervention was performed. Most advanced procedures were performed in patients with cardiac arrest. CONCLUSION: By retrospective evaluation of HEMS missions by car in Bergen municipality, we found that nearly one-third of the patients received advanced procedures. Cardiac arrest was the medical condition in which the most advanced procedures were performed. More research is needed to evaluate procedures and the importance of clinical evaluation and physicians' experience in treating these patient groups.KEY POINTSBoth HEMS and on-call GPs are needed in emergency care, and more knowledge will be useful to highlight the level of practical skills needed in these missions.There is a need for better prioritization of when to use HEMS resources and when to use on-call GPs in emergency missions.More than two-thirds of the patients involved in emergency missions received no intervention or just a basic intervention when dealt with by HEMS.This raises the issue of whether an on-call GP could have adequately treated many of the patients in this study in terms of practical skills.

Helicopter emergency medical service (HEMS) activity after increased distance to out-of-hours services: an observational study from Norway.

BACKGROUND: Organizational changes in out-of-hour (OOH) services may have unintended consequences for other prehospital services. Reports indicate an increased use of helicopter emergency medical services (HEMS) after changes in OOH services in Norway due to greater geographical distances for the on-call doctors. We investigated whether HEMS dispatches increased when nine municipalities in Sogn og Fjordane County merged into one large inter-municipal OOH district. METHODS: All primary dispatches of the HEMS in the county between 2004 and 2013 were included. We applied interrupted time series regression to monthly aggregated data to evaluate the impact of the organizational change 1 April 2009. The nine target municipalities were compared to the rest of the municipalities in the county, which served as a control group. A quasipoisson model adjusted for seasonality was found to be most applicable. RESULTS: We included 8,751 dispatches, 5,009 (57.2%) of which were completed with a patient encounter. Overall, we found no alteration in requests for HEMS after 2009 (p = 0.251). Separate analyses of the target municipalities and control group revealed no significant increase after 2009 (p = 0.400 and p = 0.056, respectively). When categorizing the municipalities into urban or rural, we found a general increase in HEMS dispatches for the rural group over the 10-year span (p = 0.045) but no added increase after 2009 (p = 0.502). The urban subgroup showed no change. Distance from the OOH service in regards to travel increased within the nine municipalities after 2009, median [quartiles] (5.0[3.0, 6.2] km vs 26.5[5.0, 62.2] km, p < 0.001). CONCLUSION: After relocating nine local OOH services into one large inter-municipal OOH district, we found no increase in requests for HEMS.

Sleepiness among personnel in the Norwegian Air Ambulance Service.

Purpose To examine the effects of shift work and extended working hours on sleepiness among pilots and Helicopter Emergency Medical Service (HEMS) crew members in the Norwegian Air Ambulance. METHODS: This field study investigated sleepiness during 3 consecutive weeks: the week before work, the work week, and the week after work. The pilots and HEMS crew members (N = 50) kept a wake diary during all 3 weeks and completed reaction time tests during the work week. RESULTS: The overall sleepiness scores were low during all 3 weeks. When comparing the 3 weeks, the lowest sleepiness levels were found for the work week. There was a small difference across work days, in which subjective sleepiness scores were highest the first duty day. No change in the reaction time tests was evident during the work week. The crew members reported being most sleepy at midnight, compared to all the other timepoints over the course of a duty day. Regarding workload and total work time, having larger workload was associated with lower sleepiness scores, while having higher total work time was associated with higher sleepiness score, both compared to the medium category. CONCLUSIONS: The findings indicate that the work schedules and setting for this distinct occupational group do not seem to negatively affect the sleepiness levels.

Loss of life years due to unavailable helicopter emergency medical service: a single base study from a rural area of Norway.

Background: Despite the potential benefits of physician-staffed Helicopter Emergency Medical Service (HEMS), many dispatches to primary HEMS missions in Norway are cancelled before patient encounter. Information is sparse regarding the health consequences when medically indicated HEMS missions are cancelled and the patients are treated by a GP and ambulance staff only. We aimed to estimate the potential loss of life years for patients in these situations. Method: We included all HEMS requests in the period 2010-2013 from Sogn and Fjordane County that were medically indicated but subsequently cancelled. This provided a selection of patients, with the purpose of studying cancellations independently of the patient's medical status A multidisciplinary expert panel retrospectively assessed each patient's potential loss of life years due to the lack of helicopter transport and intervention by a HEMS physician. Results: The study included 184 patients from 176 missions. Because of unavailable HEMS, seven patients (4%) were anticipated to have lost a total of 18 life years. Three patients suffered from myocardial infarction, three from stroke and one from abdominal haemorrhage. The main contribution from HEMS care in these seven cases might have been rapid transport to definitive care. The probability of a patient losing life years when in need of HEMS evacuation was found to be 0.2%. Conclusion: During the four years period seven patients lost 18 life years. Lack of rapid transport seems to be the primary cause of lost life years in this specific geographical area. Key Points Knowledge about to what extent HEMS contributes to an increased survival and a better outcome for patients is limited. Compared to similar studies on life years gained the estimated loss of life years was minor when HEMS evacuation was unavailable in this rural area. The findings indicates that lack of rapid HEMS transport was the primary cause of the estimated loss of life years.

Causes and Management of Sleepiness Among Pilots in a Norwegian and an Austrian Air Ambulance Service-A Comparative Study.

OBJECTIVE: We compared subjectively reported sleepiness and fatigue as well as causes and management strategies for combating sleepiness among pilots working in 2 different helicopter emergency medical services operating with different shift systems. METHODS: Pilots from the Norwegian Air Ambulance (NAA) and Christophorus Flugrettungsverein (CFV) in Austria participated. NAA performs flight missions 24/7, whereas at the time of the study the participating CFV bases did not fly after sunset. The pilots are on duty for 1 week in both services. NAA and CFV used an identical research protocol, including questionnaires about sleep, sleepiness (Epworth Sleepiness Scale and Karolinska Sleepiness Scale), coping strategies, and work-related causes of fatigue. RESULTS: CFV pilots kept busy, whereas NAA pilots slept and did physical exercise as strategies to prevent sleepiness. The majority in both groups used napping and coffee consumption as strategies. CFV pilots reported more frequently than NAA pilots that administrative duties and environmental factors were reasons preventing napping. CONCLUSION: Some differences existed between the 2 pilot groups regarding strategies for managing sleepiness and causes that prevented pilots from napping. Pilots in both groups were healthy, physically active, and had normal Epworth Sleepiness Scale and Karolinska Sleepiness Scale scores.

Self reported involvement in emergency medicine among GPs in Norway.

OBJECTIVE: To examine general practitioners' (GPs') perception of their role in emergency medicine and participation in emergency services including ambulance call outs, and the characteristics of the GPs and casualty clinics associated with the GPs' involvement in emergency medicine. DESIGN: Cross-sectional online survey. SETTING: General practice. SUBJECTS: General practitioners in Norway (n = 1002). MAIN OUTCOME MEASURES: Proportion of GPs perceiving that they have a large role in emergency medicine, regularly being on call, and the proportion of ambulance callouts with GP participation. RESULTS: Forty six percent of the GPs indicated that they play a large role in emergency medicine, 63 percent of the GPs were regularly on call, and 28 percent responded that they usually took part in ambulance call outs. Multivariable logistic regression analyses indicated that these outcomes were strongly associated with participation in multidisciplinary training. Furthermore, the main outcomes were associated with traits commonly seen at smaller casualty clinics such as those with an absence of nursing personnel and extra physicians, and based on the distance to the hospital. CONCLUSION: Our findings suggest that GPs play an important role in emergency medicine. Multidisciplinary team training may be important for their continued involvement in prehospital emergencies. Key Points  Health authorities and other stakeholders have raised concerns about general practitioner's (GPs) participation in emergency medicine, but few have studied opinions and perceptions among the GPs themselves. • Norwegian GPs report playing a large role in emergency medicine, regularly being on call, and taking part in selected ambulance call outs. • A higher proportion of GPs who took part in team training perceived themselves as playing a large role in emergency medicine, regularly being on call, and taking part in ambulance call outs. • These outcomes were also associated with attributes commonly seen at smaller casualty clinics.

Treatment, transport, and primary care involvement when helicopter emergency medical services are inaccessible: a retrospective study.

OBJECTIVE: To examine handling of cancelled helicopter emergency medical services (HEMS) missions with a persisting medical indication. DESIGN: Retrospective observational study. SETTING AND SUBJECTS: Cancelled HEMS missions with persisting medical indication within Sogn og Fjordane county in Norway during the period of 2010-2013. Both primary and secondary missions were included. MAIN OUTCOME MEASURES: Primary care involvement, treatment and cooperation within the prehospital system. RESULTS: Our analysis included 172 missions with 180 patients. Two-thirds of the patients (118/180) were from primary missions. In 95% (112/118) of primary missions, GPs were alerted, and they examined 62% (70/112) of these patients. Among the patients examined by a GP, 30% (21/70) were accompanied by a GP during transport to hospital. GP involvement did not differ according to time of day (p = 0.601), diagnostic group (p = 0.309), or patient's age (p = 0.409). In 41% of primary missions, the patients received no treatment or oxygen only during transport. Among the secondary missions, 10% (6/62) of patients were intubated or received non-invasive ventilation and were accompanied by a physician or nurse anaesthetist during transport. CONCLUSIONS: Ambulance workers and GPs have an important role when HEMS is unavailable. Our findings indicated good collaboration among the prehospital personnel. Many of the patients were provided minimal or no treatment, and treatment did not differ according to GP involvement. Key Points Knowledge about handling and involvement of prehospital services in cancelled helicopter emergency medical services (HEMS) missions are scarce. Ambulance workers and general practitioners have an important role when HEMS is unavailable Minimal or no treatment was given to a large amount of the patients, regardless of which health personnel who encountered the patient.

Exploring optimal air ambulance base locations in Norway using advanced mathematical modelling.

BACKGROUND: Helicopter emergency medical services are an important part of many healthcare systems. Norway has a nationwide physician staffed air ambulance service with 12 bases servicing a country with large geographical variations in population density. The aim of the study was to estimate optimal air ambulance base locations. METHODS: We used high resolution population data for Norway from 2015, dividing Norway into >300 000 1 km×1 km cells. Inhabited cells had a median (5-95 percentile) of 13 (1-391) inhabitants. Optimal helicopter base locations were estimated using the maximal covering location problem facility location optimisation model, exploring the number of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, both in green field scenarios and conditioning on the current base structure. We reanalysed on municipality level data to explore the potential information loss using coarser population data. RESULTS: For a 45 min threshold, 90% of the population could be covered using four bases, and 100% using nine bases. Given the existing bases, the calculations imply the need for two more bases to achieve full coverage. Decreasing the threshold to 30 min approximately doubles the number of bases needed. Results using municipality level data were remarkably similar to those using fine grid information. CONCLUSIONS: The whole population could be reached in 45 min or less using nine optimally placed bases. The current base structure could be improved by moving or adding one or two select bases. Municipality level data appears sufficient for proper analysis.

Potential cardiac arrest - an observational study of pre-hospital medical response.

OBJECTIVES: A previous study showed that Norwegian GPs on call attended around 40% of out-of-hospital medical emergencies. We wanted to investigate the alarms of prehospital medical resources and the doctors' responses in situations of potential cardiac arrests. DESIGN AND SETTING: A three-month prospective data collection was undertaken from three emergency medical communication centres, covering a population of 816,000 residents. From all emergency medical events, a sub-group of patients who received resuscitation, or who were later pronounced dead at site, was selected for further analysis. RESULTS: 5,105 medical emergencies involving 5,180 patients were included, of which 193 met the inclusion criteria. The GP on call was alarmed in 59 %, and an anaesthesiologist in 43 % of the cases. When alarmed, a GP attended in 84 % and an anaesthesiologist in 87 % of the cases. Among the patients who died, the GP on call was alarmed most frequently. CONCLUSION: Events involving patients in need of resuscitation are rare, but medical response in the form of the attendance of prehospital personnel is significant. Norwegian GPs have a higher call-out rate for patients in severe situations where resuscitation was an option of treatment, compared with other "red-response" situations. Key points This study investigates alarms of and call-outs among GPs and anaesthesiologists on call, in the most acute clinical situations: Medical emergencies involving patients in need of resuscitation were rare. The health care contribution by pre-hospital personnel being called out was significant. Compared with other acute situations, the GP had a higher attendance rate to patients in life-threatening situations.

Dispatch guideline adherence and response interval-a study of emergency medical calls in Norway.

BACKGROUND: The Emergency Medical Communication Centre (EMCC) operators in Norway report using the Norwegian Index for Medical Emergency Assistance (Index), a criteria-based dispatch guideline, in about 75 % of medical emergency calls. The main purpose of a dispatch guideline is to assist the operator in securing a correct response as quickly as possible. The effect of using the guideline on EMCC response interval is as yet unknown. We wanted to ascertain an objective measure of guideline adherence, and explore a possible effect on emergency medical dispatch (EMD) response interval. METHODS: Observational cross-sectional study based on digital telephone recordings and EMCC records; 299 random calls ending in acute and urgent responses from seven strategically selected EMCCs were included. Ability to confirm location and patient consciousness within an acceptable time interval and structural use of criteria cards were indicators used to create an overall guideline adherence variable. We then explored the relationship between different levels of guideline adherence and EMD response interval. RESULTS: The overall guideline adherence was 80 %. Location and patient consciousness were confirmed within 1 min in 83 % of the calls. The criteria cards were used systematically as intended in 64 % of the cases. Total median response interval was 2:28, with 2:01 for acute calls and 4:10 for urgent calls (p < 0.0005). Lower guideline adherence was associated with higher EMD response interval (p < 0.0005). CONCLUSION: The measured guideline adherence was higher than previously reported by the operators themselves. Patient consciousness was rapidly confirmed in the majority of cases. Failure to use Index criteria as intended result in delayed ambulance dispatch and a potential risk of undertriage.

Helicopter emergency medical services response times in norway: do they matter?

OBJECTIVE: The main objective of the Norwegian air ambulance service is to provide advanced emergency medicine to critically ill or severely injured patients. The government has defined a time frame of 45 minutes as the goal within which 90% of the population should be reached. The aims of this study were to document accurate flying times for rotor wing units to the scene and to determine the rates of acute primary missions in Norway. METHODS: We analyzed operational data from every acute primary mission from all air ambulance bases in Norway in 2011, focusing on the flying time taken to reach scene, the municipality requesting the flight, and the severity score data. RESULTS: A total of 5,805 acute primary missions were completed in Norway in 2011. The median flying time was 19 minutes (25%-75% percentiles: 13-28). The mean mission rate for the 17 bases was 7.5 (95% confidence interval, 7.4-7.8 per 10,000 inhabitants). The overall mean (standard deviation) National Committee on Aeronautics score for all missions was 4.07 (1.30). CONCLUSION: The government's expectation of serving the entire population via HEMS within 45 minutes appears to be achieved on a national level. However, vast differences remain in the flying times and rates between bases.

Out-of-hours doctors' decisions on call-outs in emergency situations.

BACKGROUND: Several earlier studies have shown that doctors in local out-of-hours emergency primary health care participate in call-outs to varying degrees. It is the out-of-hours doctor who decides whether to respond with a call-out. We wished to study the assessments that form the basis of this decision. MATERIAL AND METHOD: We interviewed the out-of-hours doctors in the county of Hordaland who had been alerted about an emergency incident on the health radio network during an evening or night shift, apart from at weekends. The interview period lasted from July to October 2012 and was linked directly to specific alarm calls. RESULTS: There were 252 relevant incidents, 72 of which were investigated. A total of 47 of the 95 doctors contacted were interviewed (49%). The doctor responded with a call-out in 65 % of the incidents. Normally it was the content of the message about the patient's medical condition that was critical for the doctor's decision to respond with a call-out, while it was most often practical aspects that meant that she/he did not respond in this way. When the doctor responded with a call-out, and later assessed the call-out as necessary, the patient's need for medical expertise was the most important reason given. INTERPRETATION: In the incidents studied, the decision on whether or not to respond with a call-out was based on a balanced consideration of the patient's needs and what was practically possible for the doctor. The out-of-hours doctors experienced a need for medical expertise in many emergency medical situations.

Chest pain out-of-hours - an interview study of primary care physicians' diagnostic approach, tolerance of risk and attitudes to hospital admission.

BACKGROUND: Acute chest pain constitutes a considerable diagnostic challenge outside hospitals. This will often lead to uncertainty in choosing the right management, and the physicians' approach may be influenced by their knowledge of diagnostic measures and their tolerance of risk. The aim of this study was to investigate primary care physicians' diagnostic approach, tolerance of risk and attitudes to hospital admission in patients with acute chest pain out-of-hours in Norwegian primary care. METHODS: Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with "chest pain" were analysed. Tolerance of risk was measured by the Pearson Risk Scale and the Tolerance of Risk Scale, the latter developed for this study. RESULTS: "Patient history and symptoms" was considered the most important, and "negative ECG" and "effect of sublingual nitroglycerine" the least important aspects in the diagnostic approach. There were no significant differences in length of experience or gender when testing "risk avoiders" against the rest. Almost all physicians felt that their risk assessment out-of-hours was reasonably good, and felt reasonably safe, but only 50% agreed with the statement "I don't worry about my decisions after I've made them". Concerning chest pain patients only, 51% of the physicians were worried about complaints being made about them, 75% agreed that admitting someone to hospital put patients in danger of being "over-tested", and 51% were more likely to admit the patient if the patient herself wanted to be admitted. CONCLUSIONS: Physicians working out-of-hours showed considerable differences in their diagnostic approach, and not all physicians diagnose patients with chest pain according to current guidelines and evidence. Continuous medical education must focus on the diagnostic approach in patients with chest pain in primary care and empowerment of physicians through training and emphasis on risk assessment and "tolerance of risk".

Management of chest pain: a prospective study from Norwegian out-of-hours primary care.

BACKGROUND: Chest pain is a common diagnostic challenge in primary care and diagnostic measures are often aimed at confirming or ruling out acute ischaemic heart disease. The aim of this study was to investigate management of patients with chest pain out-of-hours, including the use of ECG and laboratory tests, assessment of severity of illness, and the physicians' decisions on treatment and admittance to hospital. METHODS: Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with "chest pain" were analysed. RESULTS: A total of 832 patients with chest pain were registered. The first 100 patients (corresponding doctor-patient pairs) were included in the study according to the predefined inclusion criteria. Median age of included patients was 46 years, men constituted 58%. An ECG was taken in 92 of the patients. Of the 24 patients categorised to acute level of response, 15 had a NACA-score indicating a potentially or definitely life-threatening medical situation. 50 of the patients were admitted to a hospital for further management, of which 43 were thought to have ischaemic heart disease. Musculoskeletal pain was the second most common cause of pain (n = 22). Otherwise the patients were thought to have a variety of conditions, most of them managed at a primary care level. CONCLUSIONS: Patients with chest pain presenting at out-of-hours services in Norway are investigated for acute heart disease, but less than half are admitted to hospital for probable acute coronary syndrome, and only a minority is given emergency treatment for acute coronary syndrome. A wide variety of other diagnoses are suggested by the doctors for patients presenting with chest pain. Deciding the appropriate level of response for such patients is a difficult task, and both over- and under-triage probably occur in out-of-hours primary care.

Factors affecting communication during telephone triage in medical call centres: a mixed methods systematic review.

BACKGROUND: Telephone triage is used to optimise patient flow in emergency primary healthcare. Poor communication can lead to misunderstandings and compromise patient safety. To improve quality, a comprehensive understanding of factors affecting communication in medical call centres in primary care is needed. The aim of this review was to identify such factors and to describe how they affect communication during telephone triage. METHOD: A mixed-method systematic review was performed. In April 2021 and June 2023, MEDLINE, Embase, CINAHL, and Web of Science were searched for original studies describing communication during telephone triage in primary care medical call centres handling all types of medical problems from an unselected population. All studies were screened by two authors, blinded to each other's decisions. Disagreements were resolved by a third author. A framework was created by the thematic synthesis of the qualitative data and later used to synthesise the quantitative data. By using convergent integrated synthesis, the qualitative and quantitative findings were integrated. The Mixed Methods Appraisal Tool was used to assess methodological limitations. RESULTS: Out of 5087 studies identified in the search, 62 studies were included, comprising 40 qualitative, 16 quantitative and six mixed-method studies. Thirteen factors were identified and organised into four main themes: organisational factors, factors related to the operator, factors related to the caller and factors in the interaction. Organisational factors included availability, working conditions and decision support systems. Factors related to the operator were knowledge and experience, personal qualities and communication strategies. Factors related to the caller were individual differences and the presented medical problem. Factors in the interaction were faceless communication, connection between operator and caller, third-person caller and communication barriers. The factors seem interrelated, with organisational factors affecting all parts of the conversation, and the operator's communication in particular. CONCLUSION: Many factors affect the structure, content, and flow of the conversation. The operators influence the communication directly but rely on the organisation to create a working environment that facilitates good communication. The results are mainly supported by qualitative studies and further studies are needed to explore and substantiate the relevance and effect of individual factors. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022298022.

The MeSH heading "Call Center" is due for an update: why we recommend the more precise heading "Emergency Medical Communication Center".

Call centers can be found in various industries. However as a Medical Subject Heading (MeSH) the term "Call centers" does not reflect the critical purpose of handling emergency calls. We recommend "emergency medical communication center(s)", as this provides clarity and precision regarding the primary function and purpose of the center.

Sleep and Sleepiness Measured by Diaries and Actigraphy among Norwegian and Austrian Helicopter Emergency Medical Service (HEMS) Pilots.

The study examined sleep and sleepiness among shift working Helicopter Emergency Medical Service pilots from Norway (Norwegian Air Ambulance; NAA) and Austria (Christophorus Flugrettungverein; CFV). Both pilot groups (N = 47) worked seven consecutive 24 h shifts. Sleep was assessed by diaries and actigraphy while sleepiness was assessed by the Karolinska Sleepiness Scale, all administered throughout the workweek. The results indicated that all pilots had later bedtime (p < 0.05) and wake-up time (p < 0.01) as they approached the workweek end, but no change during the workweek was evident regarding wake after sleep onset, time in bed, total sleep time, or sleep efficiency. The NAA pilots had later bedtime (p < 0.001) and wake-up time (p < 0.001), spent more time awake after sleep onset (p < 0.001), more time in bed (p < 0.001), slept longer (p < 0.01), and had lower sleep efficiency (p < 0.001) compared with the CFV pilots. The sleepiness levels of all pilots were slightly elevated on the first workday but lower on the following workdays (day 2p < 0.001, day 3p < 0.05). For both pilot groups, no major change in sleep or sleepiness parameters throughout the workweek was detected. The NAA pilots reported somewhat more disturbed sleep but obtained more sleep compared with the CFV pilots.