COVID-19 pandemic and STEMI: pathway activation and outcomes from the pan-London heart attack group.

OBJECTIVES: To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19. METHODS: We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes RESULTS: There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19. CONCLUSION: These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

Integration of Real-Time Electronic Health Records and Wireless Technology in a Mobile Stroke Unit.

BACKGROUND: UCHealth's Mobile Stroke Unit (MSU) at University of Colorado Hospital is an ambulance equipped with a computed tomography (CT) scanner and tele-stroke capabilities that began clinical operation in Aurora, Colorado January 2016. As one of the first MSU's in the United States, it was necessary to design unique and dynamic information technology infrastructure. This includes high-speed cellular connectivity, Health Insurance Portability and Accountability Act compliance, cloud-based and remote access to electronic medical records (EMR), and reliable and rapid image transfer. Here we describe novel technologies incorporated into the MSU. Technological data-handling aspects of the MSU were reviewed. Functions evaluated include wireless connectivity while in transit, EMR access and manipulation in the field, CT with image transfer from the MSU to the hospital's Picture Archiving Communication System (PACS), and video and audio communication for neurological assessment. METHODS/RESULTS: The MSU wireless system was designed with redundancy to avoid dropped signals during data transfer. Two separate Internet Protocol destinations with split-tunnel architecture are assigned, for videoconferencing and for EMR data transfer. Brain images acquired in the ambulance CT scanner are transferred initially to an onboard laptop, then via Citrix Receiver to the hospital-based PACS server where they can be viewed in PACS or EMR by the stroke neurologist, neuroradiologist, and other providers. PACS and Radiology Information System are 2 of the XenApps utilized by CT technologists on board the MSU. DISCUSSION/CONCLUSIONS: These technologies will serve as a blueprint for development of similar units elsewhere, and as a framework for improvement in this technology.

Nursing students' perceptions of learning nursing skills in the ambulance service.

Several previous studies have explored nursing students' perceptions of clinical learning at hospitals and in other health care facilities, but there are few studies exploring nursing students' perceptions of the clinical learning in the ambulance service. Therefore, the aim of this study was to explore nursing students' perceptions of learning nursing skills in the ambulance service. An inductive qualitative study design with two focus group interviews and content analysis was used. Two themes were identified. The first theme, professional skills, included: Assessment, Prioritizing and initiating care, and Medical treatment and evaluation of interventions. The second theme, a holistic approach to the care included: Cultural, social, and ethical aspects of caring, Decision-making in collaboration with patients, and Care provided in the patients' home. CONCLUSION: The ambulance service provides a learning environment where the students face a multifaceted picture of health and illness. This learning environment helps nursing students to learn independently how to use professional nursing skills and how to care by employing a holistic approach. However, further research is needed to explore if and how this knowledge about nursing and caring in the ambulance service is useful when working as a Registered Nurse in other health care settings.

Development and Pilot Testing of 24/7 In-Ambulance Telemedicine for Acute Stroke: Prehospital Stroke Study at the Universitair Ziekenhuis Brussel-Project.

BACKGROUND: In-ambulance telemedicine is a recently developed and a promising approach to improve emergency care. We implemented the first ever 24/7 in-ambulance telemedicine service for acute stroke. We report on our experiences with the development and pilot testing of the Prehospital Stroke Study at the Universitair Ziekenhuis Brussel (PreSSUB) to facilitate a wider spread of the knowledge regarding this technique. METHODS: Successful execution of the project involved the development and validation of a novel stroke scale, design and creation of specific hardware and software solutions, execution of field tests for mobile internet connectivity, design of new care processes and information flows, recurrent training of all professional caregivers involved in acute stroke management, extensive testing on healthy volunteers, organisation of a 24/7 teleconsultation service by trained stroke experts and 24/7 technical support, and resolution of several legal issues. RESULTS: In all, it took 41 months of research and development to confirm the safety, technical feasibility, reliability, and user acceptance of the PreSSUB approach. Stroke-specific key information can be collected safely and reliably before and during ambulance transportation and can adequately be communicated with the inhospital team awaiting the patient. CONCLUSION: This paper portrays the key steps required and the lessons learned for successful implementation of a 24/7 expert telemedicine service supporting patients with acute stroke during ambulance transportation to the hospital.

Are prehospital treatment or conveyance decisions affected by an ambulance crew's ability to access a patient's health information?

BACKGROUND: A shift from a predominantly emergency service, towards one where a wide range of conditions are managed and treated on scene presents numerous challenges for ambulance services and clinicians. The effective management of a broad range of patients and conditions in the ambulance setting will have an impact on other parts of the health service including emergency departments and primary care. METHODS: A two part online survey was distributed to operational staff working for a regional UK ambulance service. Clinicians were asked to report their experiences of accessing patient information and making decisions about patient management based on four hypothetical patient scenarios. RESULTS: A survey of clinical staff (n = 302) revealed that (i) the vast majority experienced difficulties in accessing patients' health information, (ii) this was particularly true in the out of hours period and (iii) They felt that better access would likely lead to more appropriate selection of care pathways. CONCLUSIONS: Decisions regarding the most appropriate care for patients presenting to the ambulance service are best informed by access to accurate and complete health information and records. An understanding of patients' pre-existing medical conditions, recent treatments and health information is needed for the selection of the most appropriate care; this information is often difficult to obtain in the ambulance service setting.

A implantação do projeto de atendimento Móvel de Urgência em Salvador/BA: panorama e desafios / Implantation of the Emergency Ambulance Service in Salvador, Bahia: reality and challenges / La implantación del proyecto de Atención de Urgencia Móvil en Salvador/BAHIA: panorama y retos

O estudo objetivou relatar a experiência na implantação e estruturação do projeto do Serviço Móvel de Urgência (SAMU-192), em Salvador, cujas bases legais foram portarias do Ministério da Saúde e a Norma Operacional de Assistência à Saúde 02/2002. O serviço tem como finalidade prestar assistência gratuita ao indivíduo, em um primeiro nível de atenção, com agravos de natureza clínica, cirúrgica, traumática e psiquiátrica que acarretam sofrimento, seqüelas ou morte e ocorrem fora do ambiente hospitalar. O objetivo específico foi garantir o atendimento às situações de urgência e emergência por meio do SAMU-192, regulado, hierarquizado e integrado ao Sistema Único de Saúde, assegurando recursos públicos inclusive integrados à rede complementar de assistência. Despesas para sua instalação foram pactuadas no município e em comissões intergestoras federal e estadual. Os desafios do serviço incluem educação comunitária, capacitação profissional, avaliação de recursos humanos e materiais, na dinâmica e qualidade da atenção.

The goal of this study was to describe the implementation of the emergency ambulance service of Salvador, Bahia (SAMU-192). The Ministry of Health provided the legal basis and regulations for its implementation. The main purpose of this service is the provision of free primary level healthcare to individuals, with clinical, surgical, traumatic and psychiatric aggravations that cause suffering, sequels or death and occur outside the hospital environment. The specific goals of SAMU-192 was to grant free healthcare to urgency and emergency situations, under the hierarchy and regulations of the Single Health System (SUS) of the Brazilian government, assuring that public resources will be available and integrated to the complementary healthcare network. Investments for the installation of the service were agreed on in the city and with federal and state management commissions. To turn SAMU-192 into reality, several challenges need to be accomplished, including community education, professional qualification and evaluation of human and material resources so as to provide basic emergency care with the appropriate quality.

El estudio tuvo por objetivo narrar la experiencia sobre la implantación y estructuración del proyecto de Servicio de Urgencia Móvil (SAMU-192) en Salvador, basado legalmente por decretos del Ministerio de Salud y la Norma Operacional de Asistencia a la Salud 02/2002. La finalidad del servicio es brindar asistencia gratuita fuera del hospital al individuo en un primer nivel de atención, en casos de tipo clínico, quirúrgico, traumático y psiquiátrico que provocan sufrimiento, secuelas o muerte. El objetivo específico fue garantizar la atención en casos de urgencia y emergencia a través del SAMU-192, reglamentado, jerarquizado e integrado al Sistema Único de Salud, asegurando recursos públicos, inclusive integrados a la red complementaria de asistencia. Gastos por instalación fueron establecidos entre la municipalidad y comisiones inter-gestoras federales y estatales. Como retos en la dinámica y calidad de la atención: educación comunitaria, capacitación profesional, evaluación de recursos humanos y materiales.

[Implantation of the emergency ambulance service in Salvador, Bahia: reality and challenges]. / A implantação do projeto de atendimento Móvel de Urgência em Salvador/BA: panorama e desafios.

The goal of this study was to describe the implementation of the emergency ambulance service of Salvador, Bahia (SAMU-192). The Ministry of Health provided the legal basis and regulations for its implementation. The main purpose of this service is the provision of free primary level healthcare to individuals, with clinical, surgical, traumatic and psychiatric aggravations that cause suffering, sequels or death and occur outside the hospital environment. The specific goals of SAMU-192 was to grant free healthcare to urgency and emergency situations, under the hierarchy and regulations of the Single Health System (SUS) of the Brazilian government, assuring that public resources will be available and integrated to the complementary healthcare network. Investments for the installation of the service were agreed on in the city and with federal and state management commissions. To turn SAMU-192 into reality, several challenges need to be accomplished, including community education, professional qualification and evaluation of human and material resources so as to provide basic emergency care with the appropriate quality.

Emerging organizational structures in the ambulance industry in the United States.

This analysis seeks to identify emerging forms of organizations in emergency medical services (EMS) in the United States, to provide examples of them, to relate them to changes in healthcare generally, and to apply a classification scheme. Public policy issues related to these new forms of organizations and lessons from other areas of the healthcare system are identified. Recent changes in the healthcare system in the United States have been marked by modifications in the structure of organizations that provide and pay for health services. New forms of organizations and alliances among existing organizations have emerged in an effort to improve the efficiency of the services provided and to improve organizations' market positions. Reflecting increased competition within EMS and the demands of the changing health-care delivery system, several types of organizations have begun to emerge in EMS that resemble those occurring in health care generally. These include forms of horizontal integration, such as consolidated ambulance services and various models of ambulance service networks; and forms of vertical integration, such as demand management programs and public-private joint ventures. The ultimate end might be complete integration with a carve-out of all non-scheduled care. Although changes in EMS organizations result largely from marketplace decisions by sellers and purchasers, this does not mean that there is no public policy role. While new organizational forms may increase the ambulance industry's efficiency, public policy makers must be concerned about quality and access as well. Some policy responses will promote marketplace changes, others will accept them generally, but will seek to correct problems, and a third group will attempt to restrain the market.

Results of implementation of a contemporary model for ambulance diversions in an integrated healthcare delivery system.

This brief report contains a description of a contemporary, coordinated new system for ambulance diversions, which was implemented in Edmonton area's Capital Health Region in January 1999. The development of this new system was precipitated by the combination of increasing pressures within the acute care system especially being felt within our emergency departments, and mounting evidence that the existing system for ambulance diversions was ineffectual in providing temporary relief of these pressures. The nature of the previous and the new system are compared and contrasted, and data are included to demonstrate that the new system has led to marked reductions in the number of ambulance diversions experienced regionally.