Intensive Ambulance-Delivered Blood-Pressure Reduction in Hyperacute Stroke.

BACKGROUND: Treatment of acute stroke, before a distinction can be made between ischemic and hemorrhagic types, is challenging. Whether very early blood-pressure control in the ambulance improves outcomes among patients with undifferentiated acute stroke is uncertain. METHODS: We randomly assigned patients with suspected acute stroke that caused a motor deficit and with elevated systolic blood pressure (≥150 mm Hg), who were assessed in the ambulance within 2 hours after the onset of symptoms, to receive immediate treatment to lower the systolic blood pressure (target range, 130 to 140 mm Hg) (intervention group) or usual blood-pressure management (usual-care group). The primary efficacy outcome was functional status as assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days after randomization. The primary safety outcome was any serious adverse event. RESULTS: A total of 2404 patients (mean age, 70 years) in China underwent randomization and provided consent for the trial: 1205 in the intervention group and 1199 in the usual-care group. The median time between symptom onset and randomization was 61 minutes (interquartile range, 41 to 93), and the mean blood pressure at randomization was 178/98 mm Hg. Stroke was subsequently confirmed by imaging in 2240 patients, of whom 1041 (46.5%) had a hemorrhagic stroke. At the time of patients' arrival at the hospital, the mean systolic blood pressure in the intervention group was 159 mm Hg, as compared with 170 mm Hg in the usual-care group. Overall, there was no difference in functional outcome between the two groups (common odds ratio, 1.00; 95% confidence interval [CI], 0.87 to 1.15), and the incidence of serious adverse events was similar in the two groups. Prehospital reduction of blood pressure was associated with a decrease in the odds of a poor functional outcome among patients with hemorrhagic stroke (common odds ratio, 0.75; 95% CI, 0.60 to 0.92) but an increase among patients with cerebral ischemia (common odds ratio, 1.30; 95% CI, 1.06 to 1.60). CONCLUSIONS: In this trial, prehospital blood-pressure reduction did not improve functional outcomes in a cohort of patients with undifferentiated acute stroke, of whom 46.5% subsequently received a diagnosis of hemorrhagic stroke. (Funded by the National Health and Medical Research Council of Australia and others; INTERACT4 ClinicalTrials.gov number, NCT03790800; Chinese Trial Registry number, ChiCTR1900020534.).

Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.

BACKGROUND: Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard management by emergency medical services (EMS). Whether and how much MSUs alter outcomes has not been extensively studied. METHODS: In an observational, prospective, multicenter, alternating-week trial, we assessed outcomes from MSU or EMS management within 4.5 hours after onset of acute stroke symptoms. The primary outcome was the score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes according to a patient value system, derived from scores on the modified Rankin scale of 0 to 6, with higher scores indicating more disability). The main analysis involved dichotomized scores on the utility-weighted modified Rankin scale (≥0.91 or <0.91, approximating scores on the modified Rankin scale of ≤1 or >1) at 90 days in patients eligible for t-PA. Analyses were also performed in all enrolled patients. RESULTS: We enrolled 1515 patients, of whom 1047 were eligible to receive t-PA; 617 received care by MSU and 430 by EMS. The median time from onset of stroke to administration of t-PA was 72 minutes in the MSU group and 108 minutes in the EMS group. Of patients eligible for t-PA, 97.1% in the MSU group received t-PA, as compared with 79.5% in the EMS group. The mean score on the utility-weighted modified Rankin scale at 90 days in patients eligible for t-PA was 0.72 in the MSU group and 0.66 in the EMS group (adjusted odds ratio for a score of ≥0.91, 2.43; 95% confidence interval [CI], 1.75 to 3.36; P<0.001). Among the patients eligible for t-PA, 55.0% in the MSU group and 44.4% in the EMS group had a score of 0 or 1 on the modified Rankin scale at 90 days. Among all enrolled patients, the mean score on the utility-weighted modified Rankin scale at discharge was 0.57 in the MSU group and 0.51 in the EMS group (adjusted odds ratio for a score of ≥0.91, 1.82; 95% CI, 1.39 to 2.37; P<0.001). Secondary clinical outcomes generally favored MSUs. Mortality at 90 days was 8.9% in the MSU group and 11.9% in the EMS group. CONCLUSIONS: In patients with acute stroke who were eligible for t-PA, utility-weighted disability outcomes at 90 days were better with MSUs than with EMS. (Funded by the Patient-Centered Outcomes Research Institute; BEST-MSU ClinicalTrials.gov number, NCT02190500.).

Effect of Mobile Stroke Unit Dispatch in all Patients with Acute Stroke or TIA.

OBJECTIVE: To determine the effect of additional mobile stroke unit (MSU) dispatch on functional outcomes among the full spectrum of stroke patients, regardless of subtype or potential contraindications to reperfusion therapies. METHODS: We used data from the nonrandomized Berlin-based B_PROUD study (02/2017 to 05/2019), in which MSUs were dispatched based solely on availability, and the linked B-SPATIAL stroke registry. All patients with final stroke or transient ischemic attack (TIA) diagnoses were eligible. The intervention under study was the additional dispatch of an MSU, an emergency physician-staffed ambulance equipped to provide prehospital imaging and thrombolytic treatment, compared to conventional ambulance alone. The primary outcome was the 3-month modified Rankin Scale (mRS) score, and the co-primary outcome was a 3-tiered disability scale. We identified confounders using directed acyclic graphs and obtained adjusted effect estimates using inverse probability of treatment weighting. RESULTS: MSUs were dispatched to 1,125 patients (mean age: 74 years, 46.5% female), while for 1,141 patients only conventional ambulances were dispatched (75 years, 49.9% female). After confounding adjustment, MSU dispatch was associated with more favorable 3-month mRS scores (common odds ratio [cOR] = 0.82; 95% confidence interval [CI]: 0.71-0.94). No statistically significant association was found with the co-primary outcome (cOR = 0.86; 9% CI: 0.72-1.01) or 7-day mortality (OR = 0.94; 95% CI: 0.59-1.48). INTERPRETATION: When considering the entire population of stroke/TIA patients, MSU dispatch improved 3-month functional outcomes without evidence of compromised safety. Our results are relevant for decision-makers since stroke subtype and treatment eligibility are unknown at time of dispatch. ANN NEUROL 2023;93:50-63.

Exploring the circulating metabolome of sepsis: metabolomic and lipidomic profiles sampled in the ambulance.

BACKGROUND: Sepsis is defined as a dysfunctional host response to infection. The diverse clinical presentations of sepsis pose diagnostic challenges and there is a demand for enhanced diagnostic markers for sepsis as well as an understanding of the underlying pathological mechanisms involved in sepsis. From this perspective, metabolomics has emerged as a potentially valuable tool for aiding in the early identification of sepsis that could highlight key metabolic pathways and underlying pathological mechanisms. OBJECTIVE: The aim of this investigation is to explore the early metabolomic and lipidomic profiles in a prospective cohort where plasma samples (n = 138) were obtained during ambulance transport among patients with infection according to clinical judgement who subsequently developed sepsis, patients who developed non-septic infection, and symptomatic controls without an infection. METHODS: Multiplatform metabolomics and lipidomics were performed using UHPLC-MS/MS and UHPLC-QTOFMS. Uni- and multivariable analysis were used to identify metabolite profiles in sepsis vs symptomatic control and sepsis vs non-septic infection. RESULTS: Univariable analysis disclosed that out of the 457 annotated metabolites measured across three different platforms, 23 polar, 27 semipolar metabolites and 133 molecular lipids exhibited significant differences between patients who developed sepsis and symptomatic controls following correction for multiple testing. Furthermore, 84 metabolites remained significantly different between sepsis and symptomatic controls following adjustment for age, sex, and Charlson comorbidity score. Notably, no significant differences were identified in metabolites levels when comparing patients with sepsis and non-septic infection in univariable and multivariable analyses. CONCLUSION: Overall, we found that the metabolome, including the lipidome, was decreased in patients experiencing infection and sepsis, with no significant differences between the two conditions. This finding indicates that the observed metabolic profiles are shared between both infection and sepsis, rather than being exclusive to sepsis alone.

Ambulance clinician use of capillary blood ketone meters to improve emergency hyperglycaemia care: A stepped-wedged controlled, mixed-methods feasibility study.

AIM: To determine whether it was feasible, safe and acceptable for ambulance clinicians to use capillary blood ketone meters for 'high-risk' diabetic ketoacidosis (DKA) recognition and fluid initiation, to inform the need for a full-powered, multi-centre trial. METHODS: Adopting a stepped-wedge controlled design, participants with hyperglycaemia (capillary blood glucose >11.0 mmol/L) or diabetes and unwell were recruited. 'High-risk' DKA intervention participants (capillary blood ketones ≥3.0 mmol/L) received paramedic-led fluid therapy. Participant demographic and clinical data were collated from ambulance and hospital care records. Twenty ambulance and Emergency Department clinicians were interviewed to understand their hyperglycaemia and DKA care experiences. RESULTS: In this study, 388 participants were recruited (Control: n = 203; Intervention: n = 185). Most presented with hyperglycaemia, and incidence of type 1 and type 2 diabetes was 18.5% and 74.3%, respectively. Ketone meter use facilitated 'high-risk' DKA identification (control: 2.5%, n = 5; intervention: 6.5%, n = 12) and was associated with improved hospital pre-alerting. Ambulance clinicians appeared to have a high index of suspicion for hospital-diagnosed DKA participants. One third (33.3%; n = 3) of Control and almost half (45.5%; n = 5) of Intervention DKA participants received pre-hospital fluid therapy. Key interview themes included clinical assessment, ambulance DKA fluid therapy, clinical handovers; decision support tool; hospital DKA management; barriers to hospital DKA care. CONCLUSIONS: Ambulance capillary blood ketone meter use was deemed feasible, safe and acceptable. Opportunities for improved clinical decision making, support and safety-netting, as well as in-hospital DKA care, were recognised. As participant recruitment was below progression threshold, it is recommended that future-related research considers alternative trial designs. CLINICALTRIALS: gov: NCT04940897.

"In the wilderness dealing with difficult situations": Knowledge exchange with care home staff in England on managing seizures and epilepsy - An initial exploration.

PURPOSE: With epilepsy increasingly affecting older adults, seizure-related care needs arise in new settings. Persons in these settings must receive optimal support and challenges identified for remediation. This may entail the epilepsy community researching in unfamiliar environments. One setting is care homes. Seizure-related ambulance incidents in them are common. We conducted the first qualitative study with care home staff to explore their experiences and challenges in managing suspected seizures. METHODS: Three online focus groups were organised for January 2024 to explore ambulance calls, post-incident procedures, and challenges faced by care home staff when managing seizures. Persons were eligible to participate if they worked as a care assistant, nurse or manager in a care home in North-West England. Different recruitment pathways were employed including direct approach, a managers' network, social media and a register of research interested homes. Focus group audio recordings were transcribed and analysed using Hamilton's Rapid Analysis. RESULTS: Recruitment was difficult; 13 care home staff from 12 different homes were ultimately recruited. Despite data saturation not being achieved, insights were gained regarding ambulance call decisions, paperwork navigation, and follow-up care challenges. Patients not having meaningful seizure action plans in place and regulatory restrictions were identified as factors that contributed to potentially avoidable calls for ambulance help being made. CONCLUSION: This study highlights systemic issues in care homes' seizure care, emphasizing the need for further research. The epilepsy community may need to innovate to better research within this increasingly important setting. This study offers insights into the effectiveness of different recruitment strategies.

'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project.

PURPOSE: Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation. METHOD: Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis. RESULTS: Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital. CONCLUSION: Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.

How important are delays in treatment for health outcomes? The case of ambulance response time and cardiovascular events.

The cost effectiveness of medical treatments is not precisely known due to the compounding effect of multiple determining factors. Ambulance response time (RT) to emergency calls is exploited to learn more about the effect of the timing of treatment on health outcomes. This causal relation is identified by exploiting rainfall at the time of the ambulance run as a shock to RT. The analysis focuses on patients who have undergone a cardiac event and shows that a one-minute increase in average RT leads to 105 more deaths each year in one Italian region. Finally, the economic value of the lives that would be saved by reducing RT is quantified to facilitate policymaking.

Long-term effects of a coalmine fire on hospital and ambulance use: An interrupted time series study.

BACKGROUND: In 2014, the Hazelwood coalmine fire in regional Victoria, Australia shrouded nearby communities in smoke for six weeks. Prior investigations identified substantial adverse effects, including increases in the use of health services. In this study, we examined the effects on hospital and ambulance use in the eight years following the fire. METHODS: Using Victorian hospital (Jan 2009-Jun 2022) and ambulance (Jan 2013-Dec 2021) data, we conducted an interrupted time series of changes to the rate of hospital admissions, emergency presentations, and ambulance attendances. A categorical exposure model compared two locations, most-exposed Morwell and less-exposed Latrobe Valley, to the rest of regional Victoria. A continuous exposure model used spatial estimates of fire-related PM2.5. Analyses were stratified by sex, age group (<65/65+ years), and condition (cardiovascular, respiratory, mental health, injury). RESULTS: There were small but significant increases in overall hospital admissions and emergency presentations across all analyses, but little evidence of change in overall ambulance attendances. Effects varied considerably by condition, with the biggest relative increases observed among hospital admissions for mental health conditions and injuries. While cardiovascular-related hospital admissions and emergency presentations increased post-fire, ambulance attendances decreased. CONCLUSIONS: Our findings suggest the Hazelwood coalmine fire likely increased hospital usage. However, it is unclear whether this was due to the direct effects of smoke exposure on health, or the disruptive socioeconomic and behavioural impacts of an environmental disaster that affected how communities engaged with various health services.

Changing the stroke network during pandemic scenarios does not affect the management of patients with a positive Cincinnati prehospital stroke scale.

INTRODUCTION: Time plays a crucial role in the management of stroke, and changing the prehospital emergency network, altering the HUB and spoke relationship in pandemic scenarios, might have an impact on time to fibrinolysis or thrombectomy. The aim of this study was to evaluate the time-dependent stroke emergency network in Lombardy region (Italy) by comparing 2019 with 2020 and early 2021. Three parameters were investigated: (i) time of arrival of the first vehicle at the scene, (ii) overall duration of missions, and (iii) number of patients transported by emergency vehicles. METHODS: Data analysis process conducted using the SAS-AREU portal (SAS Institute, USA). RESULTS: The number of patients with a positive CPSS was similar among the different pandemic waves. Mission duration increased from a mean time (SD) of 52.9 (16.1) min in 2019 to 64.1 (19.7) in 2020 and 55.0 (16.8) in 2021. Time to first vehicle on scene increased to 15.7 (8.4) min in 2020 and 16.0 (7.0) in 2021 compared to 2019, 13.6 (7.2) (P < 0.05). The number of hospital with available stroke units decreased from 46 in 2019 to 10 during the first pandemic wave. CONCLUSIONS: The pandemic forced changes in the clinical mission of many hospitals by reducing the number of stroke units. Despite this, the organization of the emergency system allowed to identify strategic hospitals and thus avoid excessive transport time. The result was an adequate time for fibrinolysis/thrombectomy, in agreement with the guidelines. Coordinated management in emergency situations makes it possible to maintain service quality standards, despite the unfavorable scenario.

Ambulance and helicopter response time. Association with patient outcome and illness severity: Protocol of a systematic literature review and meta-analysis.

BACKGROUND: Response time for emergency medical service units is a key performance indicator. Studies have shown reduced response time association with improved outcome for specific critical conditions. To achieve short response time, emergency vehicles utilize lights and sirens, and crews are allowed to be non-compliant with traffic rules, posing a risk for accident. The purpose of the systematic review and meta-analysis is to provide an overview of the current body of evidence regarding the association, if any, between ambulance and helicopter response time and major complications and mortality in patients conveyed by ambulance and/or helicopter. Our secondary aim will be to enhance knowledge in the field of criteria-based dispatch to provide decision makers with evidence to optimize dispatch of limited resources. RESEARCH QUESTIONS: What is the association between overall emergency medical services unit response time and patient outcomes, major complications, and time-critical conditions? What is the internal and external validity of the included literature? METHODS: We plan the systematic review and meta-analysis to be in accordance with the Cochrane Handbook and Joanna Briggs Institute Manual for Systematic Reviews. The methodology will include formulating the review questions using a Population, Exposure, and Outcome framework. Every study design is eligible, including qualitative, quantitative, and mixed-methods designs. We will include all articles in English, Scandinavian, German, French and Portuguese in this systematic review. RESULTS: We will publish results from the systematic review and meta-analysis in a peer-reviewed journal and we will present the results at scientific conferences and meetings. Results will also be available at www.ahrtemis.dk. CONCLUSION: We will base our conclusions on the findings of the review and meta-analysis.

Challenges Locating the Scene of Emergency: A Qualitative Study of the EMS System in Rwanda.

BACKGROUND: Timely prehospital emergency care significantly improves health outcomes. One substantial challenge delaying prehospital emergency care is in locating the patient requiring emergency services. The goal of this study was to describe challenges emergency medical services (EMS) teams in Rwanda face locating emergencies, and explore potential opportunities for improvement. METHODS: Between August 2021 and April 2022, we conducted 13 in-depth interviews with three stakeholder groups representing the EMS response system in Rwanda: ambulance dispatchers, ambulance field staff, and policymakers. Semi-structured interview guides covered three domains: 1) the process of locating an emergency, including challenges faced; 2) how challenges affect prehospital care; and 3) what opportunities exist for improvement. Interviews lasted approximately 60 min, and were audio recorded and transcribed. Applied thematic analysis was used to identify themes across the three domains. NVivo (version 12) was used to code and organize data. RESULTS: The current process of locating a patient experiencing a medical emergency in Kigali is hampered by a lack of adequate technology, a reliance on local knowledge of both the caller and response team to locate the emergency, and the necessity of multiple calls to share location details between parties (caller, dispatch, ambulance). Three themes emerged related to how challenges affect prehospital care: increased response interval, variability in response interval based on both the caller's and dispatcher's individual knowledge of the area, and inefficient communication between the caller, dispatch, and ambulance. Three themes emerged related to opportunities for processes and tools to improve the location of emergencies: technology to geolocate an emergency accurately and improve the response interval, improvements in communication to allow for real-time information sharing, and better location data from the public. CONCLUSION: This study has identified challenges faced by the EMS system in Rwanda in locating emergencies and identified opportunities for intervention. Timely EMS response is essential for optimal clinical outcomes. As EMS systems develop and expand in low-resource settings, there is an urgent need to implement locally relevant solutions to improve the timely locating of emergencies.

Measuring the Effect of Off-Balancing Vectors on the Delivery of High-Quality CPR during Ambulance Transport: A Proof of Concept Study.

AIM: This study aims to demonstrate the feasibility of quantifying the off-balancing vectors experienced during ambulance transport and comparing them to high-quality cardiopulmonary resuscitation (HQ-CPR) metrics. METHODS: Ten participants completed a total of 20 evolutions of compression-only HQ-CPR in an ambulance driven in a manner that minimized or increased linear and angular off-balancing vectors. Linear and angular velocity, linear and angular acceleration, and linear jerk were recorded. HQ-CPR variables measured were compression fraction and proportion of compressions with depth >5 cm (depth%), rate 100-120 (rate%), full chest recoil (recoil%), and hand position (hand%). A composite score was calculated: [(depth% + rate% + recoil% + hand%)/4) * compression fraction]. Difficulty of HQ-CPR performance was measured with the Borg rating of perceived exertion (RPE) Scale. A series of mixed effects models were fitted regressing each HQ-CPR metric on each off-balancing vector. RESULTS: HQ-CPR data and vector quantity data were successfully recorded in all evolutions. Rate% was negatively associated with increasing linear velocity (slope = -3.82, standard error [SE] 1.12, p = 0.005), linear acceleration (slope = -5.52, SE 1.93, p = 0.013), linear jerk (slope = -17.60, SE 5.78, p = 0.007), angular velocity (slope = -75.74, SE 22.72, p = 0.004), and angular acceleration (slope = -152.53, SE 59.60, p = 0.022). Compression fraction was negatively associated with increasing linear velocity (slope = -1.35, SE 0.37, p = 0.004), linear acceleration (slope = -1.67, SE 0.48, p = 0.003), linear jerk (slope = -4.90, SE 1.86, p = 0.018), angular velocity (slope = -25.66, SE 6.49, p = 0.001), and angular acceleration (slope = -45.35, SE 18.91, p = 0.031). Recoil% was negatively associated with increasing linear velocity (slope = -5.80, SE 2.21, p = 0.023) and angular velocity (slope = -116.96, SE 44.24, p = 0.019)). Composite score was negatively associated with increasing linear velocity (slope = -4.49, SE 1.45, p = 0.009) and angular velocity (slope = -86.13, SE 31.24, p = 0.014) and approached a negative association with increasing magnitudes of linear acceleration (slope -5.54, SE 2.93, p = 0.075), linear jerk (slope = -17.43, SE 8.80, p = 0.064), and angular acceleration (slope = -170.43, SE 80.73, p = 0.051). Borg RPE scale was positively associated with all off-balancing vectors. Depth%, hand%, mean compression depth, and mean compression rate were not correlated with any off-balancing vector. CONCLUSION: Off-balancing vector data can be successfully quantified during ambulance transport and compared with HQ-CPR performance parameters. Increasing off-balancing vectors experienced during ambulance transport are associated with worse HQ-CPR metrics and increased perceived physical exertion. These data may help guide future drive styles, ambulance design, or use of mechanical CPR devices to improve HQ-CPR delivery during selected patient transport scenarios.

Caregiver Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs: A Qualitative Study.

OBJECTIVES: Almost half of pediatric EMS calls may be for low-acuity problems. Many EMS agencies have implemented alternative disposition programs for low-acuity patients, including transportation to clinics, substituting taxis for ambulances, and treatment in place without transport to an emergency department. Including children in such programs poses specific challenges, with one concern being potential caregiver opposition. Limited published evidence addresses caregiver perspectives on including children in alternative disposition programs. Our objective was to describe caregiver perspectives of alternative EMS disposition systems for low-acuity pediatric patients. METHODS: We conducted six virtual focus groups (one in Spanish) with caregivers. A PhD-trained facilitator moderated all groups using a semi-structured moderator guide. A hybrid inductive and deductive analytical strategy was used. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 38 participants. Participants had diverse race-ethnicity (39% non-Hispanic white, 29% non-Hispanic Black, and 26% Hispanic) and insurance status (42% Medicaid and 58% private health insurance). There was agreement that caregivers often utilize 9-1-1 for low-acuity complaints. Caregivers were generally supportive of alternative disposition programs, with some important caveats. Potential advantages of alternative dispositions included freeing up resources for more emergent cases, quicker access to care, and more cost-effective and patient-centered care. Caregivers had multiple concerns regarding the effects of alternative disposition programs, including timeliness in receiving care, capabilities of receiving sites (including pediatric expertise), and challenges to care coordination. Additional logistical concerns with alternative disposition programs for children included the safety of taxi services, the loss of parental autonomy, and the potential for inequitable implementation. CONCLUSIONS: Caregivers in our study generally supported alternative EMS dispositions for some children and identified multiple potential benefits of such programs for both children and the health care system. Caregivers were concerned about the safety and logistical details of how such programs would be implemented and wanted to retain final decision-making authority. Caregiver perspectives should be considered when designing and implementing alternative EMS disposition programs for children.

Safe Ground Transport of Pediatric Patients: A Qualitative Assessment of Best Practice Guidelines Implementation.

OBJECTIVE: The National Highway Traffic Safety Administration issued guidelines on the safe transport of pediatric patients to lessen the chance of injury during ambulance transport. However, adherence to these standards have been slow to take hold. The objective of this quality improvement study is to evaluate barriers and facilitators of safe transport at the individual, organizational, and societal levels and identify improvement opportunities in the safe transport of pediatric patients. METHODS: This study was designed using an implementation science framework. Six focus groups were held with EMS clinicians to assess knowledge, behaviors, barriers, and facilitators of safe pediatric transport. Four interviews were conducted with EMS leadership to characterize organizational safe transport practices and policies. Detailed notes were taken during focus groups; interviews were recorded and transcribed. Qualitative data were analyzed using a thematic content analysis approach where team members reviewed transcripts using an established framework and identified major and minor themes related to safe pediatric transport. RESULTS: Three focus groups were conducted in a hospital setting and three were conducted at EMS base stations. Interview participants included two paramedic leaders, an ambulance service chief executive officer, and an ambulance service clinical coordinator. Recurring themes included the belief that children were inherently difficult to transport, the sentiment that training in pediatric transport is lacking, and the acknowledgement that familiarity with pediatric transport guidelines is low. Additionally, a major theme was that situational practicality can take precedence over adherence to best practice recommendations. Participants reported the presence of organizational and external barriers that made it more difficult for EMS personnel to follow safety guidelines. This included equipment unavailability, lack of clear policies, low pediatric patient volume, manufacturer design preferences, and prevailing EMS culture/norms. CONCLUSION: EMS clinicians need hands-on training and knowledge reinforcement in safe pediatric ground ambulance transport. EMS agencies should ensure that their crews have proper equipment, training, and protocols in place. Regulators and manufacturers can be catalysts for the implementation of these recommendations. Substantial change at the individual, organizational, and societal levels are needed to improve the safety of pediatric patients being transported via ground ambulance.

Ambulance Traffic Crashes in Japan: Characteristics of Casualties and Efforts to Improve Ambulance Safety.

BACKGROUND: An ambulance traffic crash not only leads to injuries among emergency medical service (EMS) professionals but also injures patients or their companions during transportation. We aimed to describe the incidence of ambulance crashes, seating location, seatbelt use for casualties (ie, both fatal and nonfatal injuries), ambulance safety efforts, and to identify factors affecting the number of ambulance crashes in Japan. METHODS: We conducted a nationwide survey of all fire departments in Japan. The survey queried each fire department about the number of ambulance crashes between January 1, 2017, and December 31, 2019, the number of casualties, their locations, and seatbelt usage. Additionally, the survey collected information on fire department characteristics, including the number of ambulance dispatches, and their safety efforts including emergency vehicle operation training and seatbelt policies. We used regression methods including a zero-inflated negative binomial model to identify factors associated with the number of crashes. RESULTS: Among the 726 fire departments in Japan, 553 (76.2%) responded to the survey, reporting a total of 11,901,210 ambulance dispatches with 1,659 ambulance crashes (13.9 for every 100,000 ambulance dispatches) that resulted in a total of 130 casualties during the 3-year study period (1.1 in every 100,000 dispatches). Among the rear cabin occupants, seatbelt use was limited for both EMS professionals (n = 3/29, 10.3%) and patients/companions (n = 3/26, 11.5%). Only 46.7% of the fire departments had an internal policy regarding seatbelt use. About three-fourths of fire departments (76.3%) conducted emergency vehicle operation training internally. The output of the regression model revealed that fire departments that conduct internal emergency vehicle operation training had fewer ambulance crashes compared to those that do not (odds of being an excessive zero -2.20, 95% CI: -3.6 to -0.8). CONCLUSION: Two-thirds of fire departments experienced at least one crash during the study period. The majority of rear cabin occupants who were injured in ambulance crashes were not wearing a seatbelt. Although efforts to ascertain seatbelt compliance were limited, Japanese fire departments have attempted a variety of methods to reduce ambulance crashes including internal emergency vehicle operation training, which was associated with fewer ambulance crashes.

Crystalloid Fluid Management of Non-Traumatic Hypotension by New South Wales Ambulance.

INTRODUCTION: Shock is circulatory insufficiency, inadequate oxygen delivery, and cellular hypoxia. Intravenous fluids are essential for shock management. Despite treatment, patients can face persistent shock with ongoing hypotension, contributing to higher mortality. This analysis aims to quantify hypotensive non-traumatic cases in an Australian ambulance service, determine persistent hypotension prevalence, and assess paramedic-administered intravascular fluids' impact on blood pressure changes. METHODS: This study is a retrospective analysis of prehospital fluid resuscitation by New South Wales Ambulance paramedics during 2022. Hypotension is defined as a systolic blood pressure of ≤ 90 mmHg, and persistent hypotension is a systolic blood pressure consistently below 90 mmHg across all observations, with a final blood pressure below 90 mmHg. This study aimed to determine the volume of fluid resuscitation at which a plateau in population-level systolic blood pressure response is observed, by calculating the derivative of the fitted logistic regression model. Moreover, this analysis identified the relative contribution of factors influencing the probability of an attempt at intravenous or intraosseous access using machine learning. RESULTS: Among 796,865 attendances, 23,049 (2.9%) involved non-traumatic patients with hypotension. In total 7,388 (32.1%) of the hypotensive cases resulted in persistent hypotension, of which 3,235 (43.8%) received Hartmann's solution and 1,745 (53.9%) received at least 500 ml of fluids but still had hypotension. The model showed that systolic blood pressure tends to stop increasing after 500-600 milliliters of fluid are given. This suggests that, on average, giving more fluid than this may not raise blood pressure further in a prehospital setting, though individual patient needs can differ. The top four factors from the machine learning shows that as initial respiratory rate goes up, the probability of intravascular access rises. Transport times less than 20 min are associated with a smaller chance of access and younger patients are less likely to receive an attempt. Finally, extremes of systolic blood pressure are more likely to receive access attempts. CONCLUSION: This study found that three percent of non-traumatic attendances have at least one episode of hypotension, and that more than half of these have persistent hypotension. Only 44% of persistently hypotensive received fluids, and half of persistently hypotensive patients stayed hypotensive despite a reasonable volume of prehospital crystalloids.

Identifying high cholesterol in the ambulance setting: a mixed-methods cohort study to tackle health inequality.

BACKGROUND: Individuals with low socio-economic status (SES) have disproportionate rates of cardio- vascular disease (CVD) but poorer engagement with preventative health. This study aimed to compare characteristics of individuals with and without hyperlipidaemia and describe their health behaviours. METHODS: A mixed-methods study between January and December 2022. Patients aged ≥40 years using the ambulance service with blood pressure of ≥140/90 had their total cholesterol measured using a point of care device. Data including blood pressure, smoking status, National Early Warning Score 2 and clinical frailty scale (CFS) were analysed. RESULTS: Of 203 patients (59% female, mean age 65.7 years), 115 (56.7%) had total cholesterol ≥5.1 mmol/L. Thirty patients (14.8%) sought treatment and received either statins (n = 9; 4.4%), dietary modification (n = 7; 3.4%) or no further intervention (n = 14; 6.9%), whilst 85 patients (41.9%) took no further action. Lower CFS (OR 0.53 [0.31-0.93]) and higher total cholesterol (OR 2.07 [1.03-2.76]) predicted seeking further management. SES was not associated with hyperlipidaemia or likelihood of seeking further management, rather this was dictated by competing co-morbidity, poor health literacy and digital divide. CONCLUSIONS: Undiagnosed hyperlipidaemia exists in patients using the ambulance service, irrespective of SES. Individual and healthcare system factors prevent engagement in cholesterol lowering behaviours.

The policy case for designating EMS teams for vulnerable patient populations: Evidence from an intervention in Boston.

This study documents more than five years of analysis that drove the policy case, deployment, and retrospective evaluation for an innovative service model that enables Boston Emergency Medical Services (EMS) to respond quickly and effectively to investigation incidents in an area of heavy need in Boston. These investigation incidents are typically calls for service from passers-by or other third-party callers requesting that Boston EMS check in on individuals, often those who may appear to have an altered mental status or to be unhoused. First, this study reports the pre-intervention analytics in 2017 that built the policy case for service segmentation, a new Community Assistance Team designated "Squad 80" that primarily responds to investigation incidents in one broad area of the city with high rates of substance abuse and homelessness, helping patients who often refuse ambulance transport connect to social services. Second, this study reports a post-intervention, observational evaluation of its operational advantages and trade-offs. We observe that incidents involving the Community Assistance Team have significantly shorter response times and result in fewer transports to emergency departments than investigation incidents not involving the unit, leading to fewer ambulance unit-hours utilized across the system. This study documents the descriptive analytics that built the successful policy case for a substantive change in the healthcare-delivery supply chain in Boston and how this change offers operational advantages. It is written to be an accessible guide to the analysts and policy makers considering emergency services segmentation, an important frontier in equitable public-service delivery.

'If It Was Easy Somebody Would Have Fixed It': An Exploration of Loneliness and Social Isolation Amongst People Who Frequently Call Ambulance Services.

INTRODUCTION: The aim of the study was to explore social isolation and loneliness in those who frequently contacted the ambulance service, what factors contributed to this and how unmet needs could be addressed. METHODS: Semi-structured interviews with staff from the ambulance service and service users who were identified as frequently contacting the ambulance service. Service users also completed the UCLA loneliness scale and personal community maps. Data were analysed thematically before triangulation with the UCLA loneliness scale and personal community maps. RESULTS: The final analysis was drawn from 15 staff and seven service user participants. The relationship between social isolation and loneliness and contacting the ambulance service was a contributing, but not the driving, factor in contacting the ambulance service. For service users, we identified three key themes: (1) impact on activities of daily living and loneliness and/or isolation as a result of a health condition; (2) accessing appropriate health and social care services to meet needs; (3) the link between social isolation and/or loneliness and contact with the ambulance service. The analysis of staff data also highlighted three key themes: (1) social isolation and/or loneliness in their role; (2) access to other appropriate health and social care services; (3) the impact of austerity and Covid-19 on social isolation and/or loneliness. CONCLUSIONS: Our research emphasises the complex nature of social isolation and loneliness, including the cyclic nature of poor health and social isolation and loneliness, and how this contributes to contact with the ambulance service. PATIENT OR PUBLIC CONTRIBUTION: The advisory group for the study was supported by a public and patient representative who contributed to the design of the study documentation, data analysis and authorship.