Emergency Medical Service Attendances for Adults with Repeat Falls in Western Australia: A State-Wide Retrospective Cohort Study.

OBJECTIVES: The risk of falls increases with age and often requires an emergency medical service (EMS) response. We compared the characteristics of patients attended by EMS in response to repeat falls within 30 days and 12 months of their first EMS-attended fall; and explored the number of days between the index fall and the subsequent fall(s). METHODS: This retrospective cohort study included all adults (> =18 years of age) who experienced their first EMS-attended fall between 1 January 2016 and 31 December 2020, followed up until 31 December 2021. Patients who experienced > =1 subsequent fall, following their first recorded fall, were defined as experiencing repeat falls. Multivariable logistic regression was used to identify the factors associated with repeat falls; and Kaplan-Meier analysis was used to estimate the time (in days) between consecutive EMS-attended falls. RESULTS: A total of 128,588 EMS-attended fall-related incidents occurred involving 77,087 individual patients. Most patients, 54,554 (71%) were attended only once for a fall-related incident (30,280 females; median age 73 years, inter-quartile range (IQR): 55-84). A total of 22,533 (29%) patients experienced repeat EMS-attended falls (13,248 females; median age 83 years, IQR: 74-89, at first call). These 22,533 patients accounted for 58% (74,034 attendances) of all EMS-attendances to fall-related incidents. Time between EMS-attended falls decreased significantly the more falls a patient sustained. Among the 22,533 patients who experienced repeat falls, 13,363 (59%) of repeat falls occurred within 12 months: 3,103 (14%) of patients sustained their second fall within 30 days of their index fall, and 10,260 (46%) between 31 days to 12 months. Patients who were transported to the hospital, via any urgency, at their first EMS-attended fall, had a reduced odds of sustaining a second EMS-attended fall within both 30 days and 31 days to 12 months, compared to non-transported patients. CONCLUSION: Nearly 30% of all patients attended by EMS for a fall, sustained repeat falls, which collectively accounted for nearly 60% of all EMS-attendances to fall-related incidents. Further exploration of the role EMS clinicians play in identifying and referring patients who sustain repeat falls into alternative pathways is needed.

Epidemiology and Severity of Medical Events for Mountain Bikers and Hikers Transported by Ambulance in Western Australia, 2015 to 2020.

INTRODUCTION: Outdoor activities offer physical and mental health benefits. However, incidents can occur requiring ambulance transport to hospital. This study aimed to describe the epidemiology and severity of traumatic and medical incidents for mountain bikers and hikers transported by ambulance within Western Australia. METHODS: This was a retrospective cohort study of ambulance-transported mountain bikers and hikers within Western Australia from 2015 to 2020. Data were extracted from ambulance electronic patient care records. Multivariable analyses were undertaken to identify variables associated with higher patient severity based on the National Early Warning Score 2 (NEWS2). RESULTS: A total of 610 patients required ambulance transport to hospital while mountain biking (n=329; 54%) or hiking (n = 281; 46%). Median age of mountain bikers and hikers was 38 (24-48) y and 49 (32-63) y, respectively. Paramedics reported a fracture in 92 (28%) mountain bikers and 78 (28%) hikers. The predominant injury locations for mountain bikers were upper limbs and for hikers, lower limbs. Cases were trauma related in 92% of mountain bikers and 55% of hikers. A significant association (P<0.001) between the etiology of the ambulance callout and patient severity was found. In trauma etiology cases, the frequency of medium-risk+ NEWS2 severity was 21.4%. In medical cases, the frequency of medium-risk+ severity was 40.8%. CONCLUSION: Both mountain bikers and hikers experienced incidents requiring ambulance transport to hospital. Incidents of a medical etiology had a higher clinical risk, as determined by the NEWS2 scores, regardless of activity being undertaken.

Descriptive Study of Ambulance Attendances for Older Adults with and without Dementia in Western Australia.

OBJECTIVE: To describe and compare characteristics of ambulance attendances for older adults with and without dementia. METHODS: A retrospective cohort study was conducted using electronic patient care records from the main ambulance service in Western Australia. All attendances for people aged 65 years or older in the years 2019-21 were included. Dementia status was adjudicated from the clinical history and medication lists. Patient and case characteristics of those with and without dementia were compared and stratified by type of residence. RESULTS: There were 277,996 emergency ambulance attendances made by 124,711 older adults, of whom 23.5% had dementia. The mean number of attendances per person was 3.3 in the dementia cohort vs 2.0 in those without dementia. Falls were the leading reason for ambulance attendance. People with dementia were significantly frailer, required longer at-scene intervals, were less likely to be transported as the highest priority, and had lower 30-day survival. CONCLUSIONS: Dementia is common amongst older adults attended by paramedics and is associated with higher ambulance utilization per person. People with dementia attended by paramedics have stronger signals of vulnerability, such as increased frailty. As the number of people living with dementia increases in the future, there are implications for workforce training and service planning. There are opportunities for developing alternatives to emergency department transportation for some people with dementia.

Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial.

OBJECTIVE: To compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress. METHODS: We conducted a parallel group, individual patient, non-blinded randomised controlled trial in Western Australia between March 2016 and December 2018. Eligible patients were aged ≥40 years with acute severe respiratory distress of non-traumatic origin and unresponsive to initial treatments by emergency medical service (EMS) paramedics. Patients were randomised (1:1) to usual care or usual care plus CPAP. The primary outcomes were change in dyspnoea score and change in RR at ED arrival, and hospital length of stay. RESULTS: 708 patients were randomly assigned (opaque sealed envelope) to usual care (n=346) or CPAP (n=362). Compared with usual care, patients randomised to CPAP had a greater reduction in dyspnoea scores (usual care -1.0, IQR -3.0 to 0.0 vs CPAP -3.5, IQR -5.2 to -2.0), median difference -2.0 (95% CI -2.5 to -1.6); and RR (usual care -4.0, IQR -9.0 to 0.0 min-1 vs CPAP -8.0, IQR -14.0 to -4.0 min-1), median difference -4.0 (95% CI -5.0 to -4.0) min-1. There was no difference in hospital length of stay (usual care 4.2, IQR 2.1 to 7.8 days vs CPAP 4.8, IQR 2.5 to 7.9 days) for the n=624 cases admitted to hospital, median difference 0.36 (95% CI -0.17 to 0.90). CONCLUSIONS: The use of prehospital CPAP by EMS paramedics reduced dyspnoea and tachypnoea in patients with acute respiratory distress but did not impact hospital length of stay. TRIAL REGISTRATION NUMBER: ACTRN12615001180505.

A predictive ambulance dispatch algorithm to the scene of a motor vehicle crash: the search for optimal over and under triage rates.

BACKGROUND: Calls for emergency medical assistance at the scene of a motor vehicle crash (MVC) substantially contribute to the demand on ambulance services. Triage by emergency medical dispatch systems is therefore important, to ensure the right care is provided to the right patient, in the right amount of time. A lights and sirens (L&S) response is the highest priority ambulance response, also known as a priority one or hot response. In this context, over triage is defined as dispatching an ambulance with lights and sirens (L&S) to a low acuity MVC and under triage is not dispatching an ambulance with L&S to those who require urgent medical care. We explored the potential for crash characteristics to be used during emergency ambulance calls to identify those MVCs that required a L&S response. METHODS: We conducted a retrospective cohort study using ambulance and police data from 2014 to 2016. The predictor variables were crash characteristics (e.g. road surface), and Medical Priority Dispatch System (MPDS) dispatch codes. The outcome variable was the need for a L&S ambulance response. A Chi-square Automatic Interaction Detector technique was used to develop decision trees, with over/under triage rates determined for each tree. The model with an under/over triage rate closest to that prescribed by the American College of Surgeons Committee on Trauma (ACS COT) will be deemed to be the best model (under triage rate of ≤ 5% and over triage rate of between 25-35%. RESULTS: The decision tree with a 2.7% under triage rate was closest to that specified by the ACS COT, had as predictors-MPDS codes, trapped, vulnerable road user, anyone aged 75 + , day of the week, single versus multiple vehicles, airbag deployment, atmosphere, surface, lighting and accident type. This model had an over triage rate of 84.8%. CONCLUSIONS: We were able to derive a model with a reasonable under triage rate, however this model also had a high over triage rate. Individual EMS may apply the findings here to their own jurisdictions when dispatching to the scene of a MVC.

Motor Vehicle Crash Characteristics That Are Predictive of High Acuity Patients: An Analysis of Linked Ambulance and Crash Data.

BACKGROUND: Motor vehicle crashes (MVCs) comprise a significant component of emergency medical service workload. Due to the potential for life-threatening injuries, ambulances are often dispatched at the highest priority to MVCs. However, previous research has shown that only a small proportion of high-priority ambulance responses to MVCs encounter high acuity patients. Alternative methods for triaging patients over the phone are required to reduce the burden of over-triage. One method is to use information readily available at the scene (e.g. whether a person was a motorcyclist, ejection status or whether an airbag deployed) as potential predictors of high acuity. Methods: A retrospective cohort study was conducted of all MVC patients in Perth attended by St John Western Australia between 2014 and 2016. Ambulance data was linked with Police crash data. The outcome variable of interest was patient acuity, where high acuity was defined as where a patient (1) died on-scene or (2) was transported by ambulance on priority one (lights & sirens) from the scene to hospital. Crash characteristics that are predictive of high acuity patients were identified by estimating crude odds ratios and 95% confidence intervals. Results: Of the 18,917 MVC patients attended by SJ-WA paramedics, 6.4% were classified as high acuity patients. The odds of being a high acuity patient was greater for vulnerable road users (motorcyclists, pedestrians and cyclists) than for motor vehicle occupants (OR 3.19, 95% CI, 2.80-3.64). A 'not ambulant patient' (one identified by paramedics as unable to walk or having an injury incompatible with being able to walk) had 15 times the odds of being high acuity than ambulant patients (OR 15.34, 95% CI, 11.48-20.49). Those who were trapped in a vehicle compared to those not trapped (OR 4.68, 95% CI, 3.95-5.54); and those who were ejected (both partial and full) from the vehicle compared to those not ejected (OR 6.49, 95% CI, 4.62-9.12) had higher odds of being high acuity patients. Discussion: There were two important findings from this study: (1) few MVC patients were deemed to be high acuity; and (2) several crash scene characteristics were strong predictors of high acuity patients.

Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study.

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71-1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03-1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.

Is it Appropriate for Patients to be Discharged at the Scene by Paramedics?

BACKGROUND: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. OBJECTIVE: We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. METHODS: We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. RESULTS: There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4; 95% confidence interval [CI] 3.0-3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3; 95% CI 2.8-3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2; 95% CI 3.4-5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8; 95% CI 0.99-3.2) within 24 hours of discharge compared to those discharged from ED. CONCLUSION: Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.

The impact of new prehospital practitioners on ambulance transportation to the emergency department: a systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis to examine the impact of new prehospital practitioners (NPPs), including emergency care practitioners (EmCPs), paramedic practitioners and extended care paramedics (ECPs), on ambulance transportation to the emergency department (ED). METHODS: We searched MEDLINE, Embase, CINAHL and AUSTHealth databases, and hand searched emergency medicine journals and journal reference lists for relevant papers. To be included, studies were required to target one type of NPP and compare outcomes such as the frequencies of conveyance to the ED, discharge at scene, subsequent ED attendance and/or appropriateness of care between NPPs and conventional ambulance crews. Three investigators independently selected relevant studies. The risk of bias in individual studies was assessed using a validated checklist. We conducted meta-analyses for comparisons which had acceptable heterogeneity (I(2)<75%) and reported pooled estimates of ORs with 95% CIs. RESULTS: 13 studies were identified from 16 584 citation reports. EmCPs were most frequently studied. The majority of studies (77%) did not fully report important potential confounders. NPPs were less likely to convey patients to the ED and more likely to discharge patients at the scene than conventional ambulance crews. Pooled ORs for conveyance to the ED and discharge at the scene by ECPs were 0.09 (95% CI 0.04 to 0.18) and 10.5 (95% CI 5.8 to 19), respectively. The evidence for subsequent ED attendance and appropriateness of care was equivocal. CONCLUSIONS: The NPP schemes reduced transport to the ED; however, the appropriateness of the decision of the NPPs and the safety of patients were not well supported by the reported studies.

"Mind the gap": An exploratory qualitative study of paramedics' experiences attending older adults who fall in Western Australia.

PURPOSE: To explore paramedics' experiences and perspectives about attending and managing older adults who had fallen. PROCEDURES: This qualitative, exploratory study used a purposive sample of paramedics in Western Australia. Participants had at least one year of clinical experience. Semi-structured interviews were undertaken. Data were analysed via an inductive thematic approach. FINDINGS: Fourteen paramedics were interviewed (Median age: 38 years, n = 5 females). The main theme identified that experiences were positive when attending patients with high-acuity medical problems or injuries following falls because binary decision-making (transport vs non-transport) was appropriate. Themes highlighted that decision-making for low-acuity falls attendances was a complex balance between 1) patient context, 2) risk management, 3) paramedic reactions, and 4) the lack of alternate referral pathways available. Experiences could be stressful and frustrating when attending falls call-outs for older adults with no injuries or medical problems. Participants concurred that when transport to hospital was not required there were no available, alternative pathways to refer onwards for appropriate health or social care. CONCLUSION: Attending low-acuity call-outs for falls was often frustrating and required complex decision-making, with gaps in services identified. Further exploration of alternative referral pathways for health care for pre-hospital management of adults who fall is required.

Evidence-based paramedic models of care to reduce unnecessary emergency department attendance--feasibility and safety.

BACKGROUND: As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default 'see and transport to ED' has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either 'see and treat' or 'see and refer' to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance. METHODS/DESIGN: St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. 'Follow-up' will examine these patients using ED data to determine the patient's disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to 'see and treat' or 'see and refer'. The ED disposition (and other clinical outcomes) of these 'ECP protocol identified' patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also 'track' re-presentations to EDs within seven days of the initial presentation. This is a 'virtual experiment' with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding. DISCUSSION: To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.

Latent Dirichlet allocation topic modeling of free-text responses exploring the negative impact of the early COVID-19 pandemic on research in nursing.

AIM: To derive latent topics from free-text responses on the negative impact of the pandemic on research activities and determine similarities and differences in the resulting themes between academic-based and clinical-based researchers. METHODS: We performed a secondary analysis of free-text responses from a cross-sectional online survey conducted by the Japan Academy of Nursing Science of its members in early 2020. The participants were categorized into two groups by workplace (academic-based and clinical-based researchers). Latent Dirichlet allocation (LDA) topic modeling was used to extract latent topics statistically and list important keywords/text associated with the topics. After organizing similar topics by principal component analysis (PCA), we finally derived topic-associated themes by reading the keywords/texts and determining the similarity and differences of the themes between the two groups. RESULTS: A total of 201 respondents (163 academic-based and 38 clinical-based researchers) provided free-text responses. LDA identified eight and three latent topics for the academic-based and clinical-based researchers, respectively. While PCA re-grouped the eight topics derived from the former group into four themes, no merging of the topics from the latter group was performed resulting in three themes. The only theme common to the two groups was "barriers to conducting research," with the remaining themes differing between the groups. CONCLUSIONS: Using LDA topic modeling with PCA, we identified similarities and differences in the themes described in free-text responses about the negative impact of the pandemic between academic-based and clinical-based researchers. Measures to mitigate the negative impact of pandemics on nursing research may need to be tailored separately.

Analgesic agents administered by ambulance personnel to mountain bikers and hikers on trails in Western Australia.

Objective: To describe the types of analgesic medications administered to patients who were attended by ambulance on recreational trails while mountain biking or hiking and report on the reduction in pain by these agents. Methods: This is a retrospective cohort study of patients attended by ambulance (2015-2021) after mountain biking or hiking, on Western Australia (WA) trails. All data were extracted from electronic patient care records created by ambulance personnel who attended the patient. We compared patient and case characteristics between mountain bikers and hikers and the reduction in pain scores achieved by different analgesics. Results: A total of 717 patients were included. Paramedics reported traumatic aetiology for mountain bikers in 92 % of cases and hikers in 58 % of cases. A pain score out of 10 was recorded for 538 (75 %) patients. The median (inter-quartile range) initial pain score was 6 (2-8) and the median final pain score was 3 (1-5). Around 48 % of these 538 patients reported ≥25 % reduction in their pain score. A reduction of ≥25 % in their pain score was greatest in those patients who received intravenous fentanyl (81 %), followed by patients administered multiple analgesics (72 %) and methoxyflurane only (52 %). Even 37 % of 134 patients who received no analgesia still reported ≥25 % reduction in their pain score by hospital arrival. Conclusion: Trauma was the most common reason mountain bikers and hikers on trails called an ambulance and a large proportion of these patients were in pain on ambulance arrival. Further work assessing the effectiveness of safe, non-opioid analgesics, additional to methoxyflurane, is needed to ensure non-registered practitioners such as first aid providers and event medical teams can offer suitable safe analgesics to these patients. Additionally, among patients given no pharmacological analgesic agent, almost half still achieved a >25 % reduction in their pain scores which reiterates the importance of non-pharmacological pain reduction strategies.

Types and anatomical locations of injuries among mountain bikers and hikers: A systematic review.

BACKGROUND: Mountain biking and hiking continue to grow in popularity. With new participants to these sports, it is likely the number of injuries will increase. To assist medical personnel in the management of these patients we attempted to quantify the types and locations of injuries sustained by mountain bikers and hikers. Objective The objective of this systematic review is to identify the type and anatomical location of injuries for both mountain bikers and hikers. METHODS: A systematic search was undertaken using CINAHL, Cochrane, ProQuest, PubMed and Scopus databases. Reviewers assessed the eligibility of articles by a title/abstract review and final full-text review. Studies were included if the types of injuries were reported by medical personnel and contained anatomical locations. Studies were excluded if it did not take place on a trail or if the injuries were self-reported. Risk of bias was assessed utilising the Joanna Briggs Institute (JBI) checklists for study quality. No meta-analysis or comparison between mountain bikers and hikers was possible due to the high heterogeneity of the definition of injury. RESULTS: A total of 24 studies met the inclusion criteria, 17 covering mountain biking and 7 hiking. This represented 220,935 injured mountain bikers and 17,757 injured hikers. The most common type of injuries sustained by mountain bikers included contusions, abrasions and minor lacerations, which made up between 45-74% of reported injuries in studies on competitive racing and 8-67% in non-competitive studies. Fractures represented between 1.5-43% of all reported injuries. The most injured region was the upper limbs reported in 10 of 17 studies. For hikers the most common injuries included blisters and ankle sprains with blisters representing 8-33% of all reported injuries. The most common body location to be injured by hikers was a lower limb in all 7 studies. CONCLUSIONS: This is the first systematic review to report on the injury epidemiology of the two most common trail users; mountain bikers and hikers. For participants in both activities the majority of injuries were of minor severity. Despite this, the high proportions of upper limb fractures in mountain bikers and ankle sprains in hikers cannot be ignored. TRIAL REGISTRATION: Registration: This systematic review was prospectively registered with the University of York PROSPERO database on the 12/4/2021 (CRD42021229623) https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021229623.

The prehospital management of ambulance-attended adults who fell: A scoping review.

BACKGROUND: The ageing population is requiring more ambulance attendances for falls. This scoping review aimed to map and synthesise the evidence for the prehospital management of Emergency Medical Services (EMS) attended adult patients who fall. METHODS: The Joanna Briggs Institute methods for scoping reviews were used. Six databases were searched (Medline, Scopus, CINAHL, Cochrane, EMBASE, ProQuest), 1st August 2021. Included sources reported: ambulance attended (context), adults who fell (population), injuries, interventions or disposition data (concept). Data were narratively synthesised. RESULTS: One-hundred and fifteen research sources met the inclusion criteria. Detailed information describing prehospital delivered EMS interventions, transport decisions and alternative care pathways was limited. Overall, adults< 65 years were less likely than older adults to be attended repeatedly and/or not transported. Being male, falling from height and sustaining severe injuries were associated with transport to major trauma centres. Older females, falling from standing/low height with minor injuries were less likely to be transported to major trauma centres. CONCLUSION: The relationship between patient characteristics, falls and resulting injuries were well described in the literature. Other evidence about EMS management in prehospital settings was limited. Further research regarding prehospital interventions, transport decisions and alternative care pathways in the prehospital setting is recommended.

Use of ketamine wafer for pain management by volunteer emergency medical technicians in rural Western Australia.

OBJECTIVE: To describe the use of sublingual ketamine wafers administered by volunteer emergency medical technicians (EMTs) for pain management to patients in rural Western Australia (WA). METHODS: This retrospective cohort study included patients older than 12 years who were attended by volunteer EMTs in Esperance, Lancelin and Kalbarri, WA and received analgesic medications from 2018 to 2021. Patients who received ketamine wafers with/without other analgesics were compared to (i) patients who received only oral paracetamol and (ii) patients who received inhalational methoxyflurane without ketamine wafers with/without paracetamol. RESULTS: The present study included 826 patients, among whom 149 patients received ketamine wafer with/without other analgesics, 82 paracetamol only and 595 methoxyflurane with/without paracetamol. Patients who received ketamine wafers were younger (median age 49 years vs 54 years for the paracetamol group vs 58 years for the methoxyflurane group), required a longer median transport interval (56 min vs 20 min vs 8 min), trauma-related (73% vs 35% vs 54%), and presented higher median initial pain score (9 vs 3 vs 8 out of 10) than those who received paracetamol and those who received methoxyflurane, respectively. Eight in the ketamine wafers group (5.4%) had a record of nausea/vomiting after the administration of ketamine wafers. CONCLUSIONS: Sublingual ketamine wafer was administered by volunteer EMTs without any evidence of major adverse events in rural WA and deemed useful as an additional pain management option when long transport to hospital was needed. No other symptoms that may be associated with the use of ketamine were recorded.

Epidemiology of ambulance-attended adults who fell in Western Australia 2015 - 2021: An increasing incidence in an ageing population.

BACKGROUND: Emergency Medical Services (EMS) are attending an increasing number of adults who fall. This study aimed to describe the incidence, patient characteristics, treatments and disposition of ambulance attended patients who fell in Western Australia (WA). METHODS: An ordinal logistic regression (using STATA) was conducted in this retrospective cohort study, analysing predictors of lower compared to higher transport urgency levels. Participants were adults ( ≥ 18 years) who fell and required ambulance attendance in WA between 1st January 2015 - 31st December 2021. RESULTS: A total of 188,720 patients (female = 107,811, 57 %) were attended by ambulances after falls, (median age = 80 years [IQR 67-87]). The age-standardized incidence rate of ambulance attended falls increased from 115 cases/100,000 person-years to 161 cases/100,000 person-years between 2015 and 2021. A total of 89,140 (47 %) patients had an injury recorded by paramedics, most often lacerations or suspected fractures. The electronic patient care record showed, 50,044 (26.5 %) patients received medication and 30,954 (16.4 %) patients received other intervention, e.g., ECG. A total of 148,050 (78 %) patients were transported to hospital with the following urgency levels: 2,371 (2 %) via urgency one; 27,882 (19 %) via urgency two, 93,447 (63 %) via urgency three and 22,584 (15 %) via urgency four and five ( < 1 % unknown urgency). Positive predictors of lower level transport urgency to hospital included being female and older than 65 years of age. CONCLUSION: Older, female patients had higher odds of being transported via a lower urgency, with 50 % of this cohort transported via urgency three. While 19 % of patients were attended via a Priority one, only 1 % were transported to hospital via urgency one. The incidence rate of falls requiring ambulance attendance has increased over time, increasing the demand placed on EMS annually.

Propensity-matched comparisons of factors negatively affecting research activities during the COVID-19 pandemic between nursing researchers working in academic and clinical settings in Japan.

AIM: To determine the factors associated with reduced research activities during the COVID-19 pandemic in 2020 by comparing nursing researchers working in academic and clinical settings. METHODS: This was a secondary analysis of data collected by the Japan Academy of Nursing Sciences, which conducted a cross-sectional online survey when the pandemic began. We included respondents who worked in either academic or clinical settings and responded that the pandemic negatively affected their research activities. First, we computed a propensity score (PS) using a logistic regression model. Then we performed a one-to-one ratio matching between the groups based on the PS to control imbalances between the groups. We identified the factors negatively affecting research activities and who to consult about research concerns by comparing the groups using Chi-square or Fisher's exact tests. RESULTS: There were 1,532 participants, with a response rate of 16.1%. After PS matching, 214 participants (107 for each group) were included. We identified three significant factors associated with reduced research activities: (i) time required for learning new information and communication technology (ICT) skills; (ii) time required for supporting colleagues with ICT issues; and (iii) time required for preparing and evaluating teaching materials. Approximately 20% of our participants in both settings had nobody to consult regarding research concerns. CONCLUSION: We found that the time spent on ICT-related issues negatively affected the research activities of nursing researchers when the pandemic began in Japan. In such an emergency, nursing researchers needed an opportunity to share their difficulties as a part of a support service.

Machine learning and natural language processing to identify falls in electronic patient care records from ambulance attendances.

We derived machine learning models utilizing features generated by natural language processing (NLP) of free-text data from an ambulance services provider to identify fall cases. The data comprised samples of electronic patient care records care records (ePCRs) from St John Western Australia (WA), the sole ambulance services provider in most of WA. We manually labeled fall cases by reviewing the free-text summary. The models used features including case characteristics (e.g., age) and text frequency-inverse document frequency (tf-idf) of each word of the free-text generated by NLP. Support vector machine (SVM) and random forest were used as classifiers. We compared the performance of the models against the manual identification of falls by recall, precision, and F-measure. A total of 9,447 cases (1%) were randomly sampled, of which 1,648 (17%) were labeled as fall. The best model was an SVM model using case characteristics and tf-idf's of the first 100 words of free-text, with recall of 0.84, precision of 0.86, and F-measure of 0.85. This performance was better than an SVM model with only case characteristics. Machine-learning models incorporated with features generated by NLP improved the performance of classifying fall cases compared with models without such features. Scope remains for further improvement.

Ambulance dispatch prioritisation for traffic crashes using machine learning: A natural language approach.

INTRODUCTION: Demand for emergency ambulances is increasing, therefore it is important that ambulance dispatch is prioritised appropriately. This means accurately identifying which incidents require a lights and sirens (L&S) response and those that do not. For traffic crashes, it can be difficult to identify the needs of patients based on bystander reports during the emergency phone call; as traffic crashes are complex events, often with multiple patients at the same crash with varying medical needs. This study aims to determine how well the text sent to paramedics en-route to the traffic crash scene by the emergency medical dispatcher (EMD), in combination with dispatch codes, can predict the need for a L&S ambulance response to traffic crashes. METHODS: A retrospective cohort study was conducted using data from 2014 to 2016 traffic crashes attended by emergency ambulances in Perth, Western Australia. Machine learning algorithms were used to predict the need for a L&S response or not. The features were the Medical Priority Dispatch System (MPDS) determinant codes and EMD text. EMD text was converted for computation using natural language processing (Bag of Words approach). Machine learning algorithms were used to predict the need for a L&S response, defined as where one or more patients (a) died before hospital admission, (b) received L&S transport to hospital, or (c) had one or more high-acuity indicators (based on an a priori list of medications, interventions or observations. RESULTS: There were 11,971 traffic crashes attended by ambulances during the study period, of which 22.3 % were retrospectively determined to have required a L&S response. The model with the highest accuracy was using an Ensemble machine learning algorithm with a score of 0.980 (95 % CI 0.976-0.984). This model predicted the need for an L&S response using both MPDS determinant codes and EMD text. DISCUSSION: We found that a combination of EMD text and MPDS determinate codes can predict which traffic crashes do and do not require a lights and sirens ambulance response to the scene with a high degree of accuracy. Emergency medical services could deploy machine learning algorithms to improve the accuracy of dispatch to traffic crashes, which has the potential to result in improved system efficiency.