Recommendations for blood sampling in emergency departments from the European Society for Emergency Medicine (EUSEM), European Society for Emergency Nursing (EuSEN), and European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase. Executive summary.

AIM: Blood Sampling Guidelines have been developed to target European emergency medicine-related professionals involved in the blood sampling process (e.g. physicians, nurses, phlebotomists working in the ED), as well as laboratory physicians and other related professionals. The guidelines population focus on adult patients. The development of these blood sampling guidelines for the ED setting is based on the collaboration of three European scientific societies that have a role to play in the preanalytical phase process: EuSEN, EFLM, and EUSEM. The elaboration of the questions was done using the PICO procedure, literature search and appraisal was based on the GRADE methodology. The final recommendations were reviewed by an international multidisciplinary external review group. RESULTS: The document includes the elaborated recommendations for the selected sixteen questions. Three in pre-sampling, eight regarding sampling, three post-sampling, and two focus on quality assurance. In general, the quality of the evidence is very low, and the strength of the recommendation in all the questions has been rated as weak. The working group in four questions elaborate the recommendations, based mainly on group experience, rating as good practice. CONCLUSIONS: The multidisciplinary working group was considered one of the major contributors to this guideline. The lack of quality information highlights the need for research in this area of the patient care process. The peculiarities of the emergency medical areas need specific considerations to minimise the possibility of errors in the preanalytical phase.

Patient-centered outcomes and outcome measurements for people aged 65 years and older-a scoping review.

INTRODUCTION: The aging population is a challenge for the healthcare system that must identify strategies that meet their needs. Practicing patient-centered care has been shown beneficial for this patient-group. The effect of patient-centered care is called patient-centered outcomes and can be appraised using outcomes measurements. OBJECTIVES: The main aim was to review and map existing knowledge related to patient-centered outcomes and patient-centered outcomes measurements for older people, as well as identify key-concepts and knowledge-gaps. The research questions were: How can patient-centered outcomes for older people be measured, and which patient-centered outcomes matters the most for the older people? STUDY DESIGN: Scoping review. METHODS: Search for relevant publications in electronical databases, grey literature databases and websites from year 2000 to 2021. Two reviewers independently screened titles and abstracts, followed by full text review and extraction of data using a data extraction framework. RESULTS: Eighteen studies were included, of which six with involvement of patients and/or experts in the process on determine the outcomes. Outcomes that matter the most to older people was interpreted as: access to- and experience of care, autonomy and control, cognition, daily living, emotional health, falls, general health, medications, overall survival, pain, participation in decision making, physical function, physical health, place of death, social role function, symptom burden, and time spent in hospital. The most frequently mentioned/used outcomes measurements tools were the Adult Social Care Outcomes Toolkit (ASCOT), EQ-5D, Gait Speed, Katz- ADL index, Patient Health Questionnaire (PHQ9), SF/RAND-36 and 4-Item Screening Zarit Burden Interview. CONCLUSIONS: Few studies have investigated the older people's opinion of what matters the most to them, which forms a knowledge-gap in the field. Future research should focus on providing older people a stronger voice in what they think matters the most to them.

A Retrospective Geospatial Simulation Study of Helicopter Emergency Medical Services' Potential Time Benefit Over Ground Ambulance Transport in Northern South Africa.

OBJECTIVE: One of the most important benefits of helicopter emergency medical services (HEMS) is a time benefit, either through expedited access to the casualty or a reduction in the transport time to definitive care. However, HEMS utilization does not come without risk to the public and crew or at an insignificant cost. Cost is an essential consideration for health policy decisions, especially in low- to middle-income countries, such as South Africa. The aim of this study was to determine whether there is a time benefit of HEMS dispatch in South Africa compared with simulated driving time. A secondary aim was to determine the distance from the incident site to the hospital at which a time benefit can be guaranteed. METHODS: A retrospective study was undertaken by comparing the prehospital times of patients who underwent HEMS transportation with simulated ground emergency medical services (GEMS) transportation times. Handwritten patient records of actual flights were reviewed and analyzed. The actual flight times recorded were used to calculate the helicopter transport time, activation to scene time, scene time, and scene to hospital time. Times were assigned based on a nonsimultaneous dispatch model, as is used in South Africa. For each helicopter mission, Google Maps (Google Inc, Mountain View, CA) was used to simulate the fastest ground route from the same location of the incident to the same receiving hospital corrected for typical traffic trends. The actual HEMS and simulated GEMS times were compared using the paired t-test. Linear regression analysis was performed to determine a minimum driving distance at which HEMS provides a time benefit. RESULTS: A total of 118 HEMS transports were analyzed, the majority of which were trauma related (n = 115, 97%). HEMS transport resulted in a mean time deficit of -15 minutes (95% confidence interval, -18 to -11; P < .05) compared with simulated GEMS drive times. After regression, HEMS transport provides a time benefit at a driving distance greater than 119 km. CONCLUSION: The current study demonstrated that there was rarely a time benefit for actual primary emergency responses when HEMS was used compared with simulated driving time of GEMS transport. Using a nonsimultaneous dispatch model, a time benefit only occurs when the driving distance from the incident site to the hospital is greater than 119 km. There is an urgent need to critically evaluate HEMS utilization in the South African context.

Pathways to the emergency department - a national, cross-sectional study in Sweden.

BACKGROUND: Swedish Emergency Departments (EDs) see 2.6 million visits annually. Sweden has a strong tradition of health care databases, but information on patients' pathways to the ED is not documented in any registry. The aim of this study was to provide a national overview of pathways, degree of medical acuteness according to triage, chief complaints, and hospital admission rates for adult patients (≥18 years) visiting Swedish EDs during 24 h. METHODS: A national cross-sectional study including all patients at 43 of Sweden's 72 EDs during 24 h on April 25th, 2018. Pathway to the ED, medical acuteness at triage, admission and basic demographics were registered by dedicated assessors present at every ED for the duration of the study. Descriptive data are reported. RESULTS: A total of 3875 adult patients (median age 59; range 18 to 107; 50% men) were included in the study. Complete data for pathway to the ED was reported for 3693 patients (98%). The most common pathway was self-referred walk-in (n = 1310; 34%), followed by ambulance (n = 920; 24%), referral from a general practitioner (n = 497; 1 3%), and telephone referral by the national medical helpline "1177" (n = 409; 10%). In patients 18 to 64 years, self-referred walk-in was most common, whereas transport by ambulance dominated in patients > 64 years. Of the 3365 patients who received a medical acuteness level at triage, 4% were classified as Red (Immediate), 18% as Orange (very urgent), 47% as Yellow (Urgent), 26% as Green (Standard), and 5% as Blue (Non-Urgent). Abdominal or chest pain were the most common chief complaints representing approximately 1/3 of all presentations. Overall, the admission rate was 27%. Arrival by ambulance was associated with the highest rate of admission (53%), whereas walk-in patients and telephone referrals were less often admitted. CONCLUSION: Self-referred walk-in was the overall most common pathway followed by ambulance. Patients arriving by ambulance were often elderly, critically ill and often admitted to in-patient care, whereas arrival by self-referred walk-in was more common in younger patients.

Presentation of the septic patient to the emergency department with respect to age and sex - a retrospective cross-sectional study.

OBJECTIVE: It is challenging to identify sepsis in the emergency department, in part due to the non-specific presentation of septic patients. Current clinical sepsis screening tools rely on vital signs but many patients present with near normal vital signs and are therefore not identified as septic. This suggests that variables, e.g. signs and symptoms, need to be included to improve sepsis detection in the emergency department. Our hypothesis was that the presentation of sepsis differs based age and sex. The potential differences in presentation could be used to apply to future sepsis screening tools. The aim was to analyze the prevalence of keywords reflecting the presentation of septic patients in the emergency department in relation to age and sex. METHOD: Retrospective cross-sectional study. Keywords reflecting sepsis presentation to the emergency department were quantified and compared between age categories and the sex. 479 patients admitted to the emergency department of Södersjukhuset, Stockholm during 2013 and discharged with an ICD-10 code consistent with sepsis were included. We adjusted for multiple comparisons by applying Bonferroni-adjusted significance levels for all comparisons. RESULT: "Pain" and "risk factors for sepsis" were significantly more common among patients younger than 65 years as compared with those 75 years and older: (n = 87/137; 63.5% vs n = 99/240; 41.3%, P-value < 0.000) and (n = 74/137; 54.0% vs 55/240; 22.9%, P-value < 0.000) respectively. "Risk factors for sepsis" was also significantly more common among patients between 65 and 74 years as compared with those 75 years and older: (n = 43/102; 42.2% vs 55/240; 22.9%, P-value < 0.000). "Pain" and "gastrointestinal symptoms" were significantly more common among women as compared with men: (n = 128/224; 57.1% vs n = 102/255; 40.0%, P-value < 0.000) and (n = 82/244; 36.6% vs n = 55/255; 21.6%, P-value < 0.000) respectively. CONCLUSION: The keywords "pain" and "risk factors for sepsis" were more common among younger patients and "pain" and "gastrointestinal symptoms" were more common among women. However, most keywords had a similar prevalence irrespective of age and sex. The results could potentially be used to augment sepsis screening tools or clinical decision tools.

Association between variables measured in the ambulance and in-hospital mortality among adult patients with and without infection: a prospective cohort study.

BACKGROUND: Patients presenting with infection to the ambulance are common, but risk factors for poor outcome are not known. The primary aim of the current study was to study the association between variables measured in the ambulance and mortality among adult patients with and without infection. The secondary aim was to study the association between these variables and mortality in a subgroup of patients who developed sepsis within 36 h. METHODS: Prospective cohort study of 553 ambulance patients with, and 318 patients without infection, performed in Stockholm during 2017-2018. The association between 21 variables (8 keywords related to medical history, 6 vital signs, 4 blood tests, and age, gender, comorbidity) and in-hospital mortality was analysed using logistic regression. RESULTS: Among patients with infection, inability of the patient to answer questions relating to certain symptoms such as pain and gastrointestinal symptoms was significantly associated with mortality in univariable analysis, in addition to oxygen saturation < 94%, heart rate > 110 /min, Glasgow Coma Scale (GCS) < 15, soluble urokinase Plasminogen Activator Receptor (suPAR) 4.0-7.9 ng/mL, suPAR ≥ 8.0 ng/mL and a Charlson comorbidity score ≥ 5. suPAR ≥ 8.0 ng/mL remained significant in multivariable analysis (OR 25.4; 95% CI, 3.2-199.8). Among patients without infection, suPAR ≥ 8.0 ng/mL and a Charlson comorbidity score ≥ 5 were significantly associated with mortality in univariable analysis, while suPAR ≥ 8.0 ng/mL remained significant in multivariable analysis (OR 56.1; 95% CI, 4.5-700.0). Among patients who developed sepsis, inability to answer questions relating to pain remained significant in multivariable analysis (OR 13.2; 95% CI, 2.2-78.9), in addition to suPAR ≥ 8.0 ng/mL (OR 16.1; 95% CI, 2.0-128.6). CONCLUSIONS: suPAR ≥ 8.0 ng/mL was associated with mortality in patients presenting to the ambulance both with and without infection and in those who developed sepsis. Furthermore, the inability of the ambulance patient with an infection to answer questions relating to specific symptoms was associated with a surprisingly high mortality. These results suggest that suPAR and medical history are valuable tools with which to identify patients at risk of poor outcome in the ambulance and could potentially signal the need of enhanced attention. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03249597. Registered 15 August 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03249597 .

Predicting mortality among septic patients presenting to the emergency department-a cross sectional analysis using machine learning.

BACKGROUND: Sepsis is a life-threatening condition, causing almost one fifth of all deaths worldwide. The aim of the current study was to identify variables predictive of 7- and 30-day mortality among variables reflective of the presentation of septic patients arriving to the emergency department (ED) using machine learning. METHODS: Retrospective cross-sectional design, including all patients arriving to the ED at Södersjukhuset in Sweden during 2013 and discharged with an International Classification of Diseases (ICD)-10 code corresponding to sepsis. All predictions were made using a Balanced Random Forest Classifier and 91 variables reflecting ED presentation. An exhaustive search was used to remove unnecessary variables in the final model. A 10-fold cross validation was performed and the accuracy was described using the mean value of the following: AUC, sensitivity, specificity, PPV, NPV, positive LR and negative LR. RESULTS: The study population included 445 septic patients, randomised to a training (n = 356, 80%) and a validation set (n = 89, 20%). The six most important variables for predicting 7-day mortality were: "fever", "abnormal verbal response", "low saturation", "arrival by emergency medical services (EMS)", "abnormal behaviour or level of consciousness" and "chills". The model including these variables had an AUC of 0.83 (95% CI: 0.80-0.86). The final model predicting 30-day mortality used similar six variables, however, including "breathing difficulties" instead of "abnormal behaviour or level of consciousness". This model achieved an AUC = 0.80 (CI 95%, 0.78-0.82). CONCLUSIONS: The results suggest that six specific variables were predictive of 7- and 30-day mortality with good accuracy which suggests that these symptoms, observations and mode of arrival may be important components to include along with vital signs in a future prediction tool of mortality among septic patients presenting to the ED. In addition, the Random Forests appears to be a suitable machine learning method on which to build future studies.

Updated framework on quality and safety in emergency medicine.

OBJECTIVES: Quality and safety of emergency care is critical. Patients rely on emergency medicine (EM) for accessible, timely and high-quality care in addition to providing a 'safety-net' function. Demand is increasing, creating resource challenges in all settings. Where EM is well established, this is recognised through the implementation of quality standards and staff training for patient safety. In settings where EM is developing, immense system and patient pressures exist, thereby necessitating the availability of tiered standards appropriate to the local context. METHODS: The original quality framework arose from expert consensus at the International Federation of Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care (UK, 2011). The IFEM Quality and Safety Special Interest Group members have subsequently refined it to achieve a consensus in 2018. RESULTS: Patients should expect EDs to provide effective acute care. To do this, trained emergency personnel should make patient-centred, timely and expert decisions to provide care, supported by systems, processes, diagnostics, appropriate equipment and facilities. Enablers to high-quality care include appropriate staff, access to care (including financial), coordinated emergency care through the whole patient journey and monitoring of outcomes. Crowding directly impacts on patient quality of care, morbidity and mortality. Quality indicators should be pragmatic, measurable and prioritised as components of an improvement strategy which should be developed, tailored and implemented in each setting. CONCLUSION: EDs globally have a remit to deliver the best care possible. IFEM has defined and updated an international consensus framework for quality and safety.

Helicopter Emergency Medical Services in Trauma Does Not Influence Mortality in South Africa.

OBJECTIVE: Sub-Saharan Africa carries a large trauma burden. Helicopter emergency medical services (HEMS) have been suggested to reduce prehospital time and mortality. It is not clear whether HEMS infers a mortality benefit over ground transport in South Africa. This study aimed to determine whether HEMS improved 30-day mortality over ground emergency medical services (GEMS). METHODS: A retrospective, case-control study was undertaken for major trauma patients transported to a private trauma center in Johannesburg. A 1-year cohort of HEMS patients was extracted and matched to GEMS patients based on mechanism, injury severity or percentage of the total body surface area burned, age, sex, and comorbidities. The odds ratio (OR) for 30-day mortality was calculated to determine the risk of death. RESULTS: A total of 822 cases (HEMS: 272 [33%], GEMS: 550 [67%]) were reviewed. We included 410 patients in the matched cohort with equal distribution between transportation modes. The OR for mortality in the total cohort was 2.69 (95% confidence interval, 1.6-4.6; P = .003) for HEMS patients, whereas in the matched cohort the OR was 1.35 (95% confidence interval, 0.5-3.4; P = .503) for patients transported by HEMS. CONCLUSION: In a matched cohort of major trauma patients, HEMS does not seem to improve mortality over GEMS. These results might reflect the South African HEMS dispatch model.

Forecasting emergency department visits using internet data.

STUDY OBJECTIVE: Using Internet data to forecast emergency department (ED) visits might enable a model that reflects behavioral trends and thereby be a valid tool for health care providers with which to allocate resources and prevent crowding. The aim of this study is to investigate whether Web site visits to a regional medical Web site, the Stockholm Health Care Guide, a proxy for the general public's concern of their health, could be used to predict the ED attendance for the coming day. METHODS: In a retrospective, observational, cross-sectional study, a model for forecasting the daily number of ED visits was derived and validated. The model was derived through regression analysis, using visits to the Stockholm Health Care Guide Web site between 6 pm and midnight and day of the week as independent variables. Web site visits were measured with Google Analytics. The number of visits to the ED within the region was retrieved from the Stockholm County Council administrative database. All types of ED visits (including adult, pediatric, and gynecologic) were included. The period of August 13, 2011, to August 12, 2012, was used as a training set for the model. The hourly variation of visits was analyzed for both Web site and the ED visits to determine the interval of hours to be used for the prediction. The model was validated with mean absolute percentage error for August 13, 2012, to October 31, 2012. RESULTS: The correlation between the number of Web site visits between 6 pm and midnight and ED visits the coming day was significant (r=0.77; P<.001). The best forecasting results for ED visits were achieved for the entire county, with a mean absolute percentage error of 4.8%. The result for the individual hospitals ranged between mean absolute percentage error 5.2% and 13.1%. CONCLUSION: Web site visits may be used in this fashion to predict attendance to the ED. The model works both for the entire region and for individual hospitals. The possibility of using Internet data to predict ED visits is promising.

Non-specific complaints in the ambulance; predisposing structural factors.

BACKGROUND: The pre-hospital assessment non-specific complaint (NSC) often applies to patients whose diagnosis does not match any other specific assessment correlating to particular symptoms or diseases, though some previous studies have found them to be related to serious underlying conditions. The aim was to identify whether the structural factors such as urgency according to the dispatch priority of the Emergency Medical Communication Centre (EMCC) or work load in the Emergency Medical Services (EMS) are predisposing factors for the assessment of NSC instead of a specific assessment. METHODS: All patients with assessed condition NSCs by the EMS to Södersjukhuset during 2011 (n = 493) were compared with gender- and age-matched controls (n = 493), which were randomly drawn from all patients with specific conditions in the EMS, regarding day of week, time of day and priority set by EMCC with chi-squared tests and multivariate logistic regression models. RESULTS: Among patients with NSCs, more were females (58 %) and the median age was 82. Almost all patients were categorized with NSCs during the daytime (8 a.m. to 9 p.m.), i.e. 450 (91 %) as compared to 373 (75 %) of those with specific conditions (p < 0.01). The risk of having an EMS dispatched as low priority by the EMCC was almost doubled among patients with NSCs compared to controls (OR 1.97, 95 % CI 1.38-2.79). CONCLUSIONS: Since patients with NSCs appear most frequently during the hours with most transportations for the EMS, i.e. 10 a.m. to 2 p.m., and the risk of having the assessment NSC was doubled if the EMCC dispatched EMS as low priority, structural factors might be predisposing factors for the assessment.

Non-technical skills needed by medical disaster responders- a scoping review.

BACKGROUND: There is no universal agreement on what competence in disaster medicine is, nor what competences and personal attributes add value for disaster responders. Some studies suggest that disaster responders need not only technical skills but also non-technical skills. Consensus of which non-technical skills are needed and how training for these can be provided is lacking, and little is known about how to apply knowledge of non-technical skills in the recruitment of disaster responders. Therefore, this scoping review aimed to identify the non-technical skills required for the disaster medicine response. METHOD: A scooping review using the Arksey & O´Malley framework was performed. Structured searches in the databases PuBMed, CINAHL Full Plus, Web of Science, PsycInfo and Scopus was conducted. Thereafter, data were structured and analyzed. RESULTS: From an initial search result of 6447 articles, 34 articles were included in the study. These covered both quantitative and qualitative studies and different contexts, including real events and training. The most often studied real event were responses following earthquakes. Four non-technical skills stood out as most frequently mentioned: communication skills; situational awareness; knowledge of human resources and organization and coordination skills; decision-making, critical-thinking and problem-solving skills. The review also showed a significant lack of uniform use of terms like skills or competence in the reviewed articles. CONCLUSION: Non-technical skills are skills that disaster responders need. Which non-technical skills are most needed, how to train and measure non-technical skills, and how to implement non-technical skills in disaster medicine need further studies.

A randomized double-blind trial of intranasal dexmedetomidine versus intranasal esketamine for procedural sedation and analgesia in young children.

BACKGROUND: Procedural sedation and analgesia are commonly used in the Emergency Departments. Despite this common need, there is still a lack of options for adequate and safe analgesia and sedation in children. The objective of this study was to evaluate whether intranasal dexmedetomidine could provide more effective analgesia and sedation during a procedure than intranasal esketamine. METHODS: This was a double-blind equally randomized (1:1) superiority trial of 30 children aged 1-3 years presenting to the Emergency Department with a laceration or a burn and requiring procedural sedation and analgesia. Patients were randomized to receive 2.0 mcg/kg intranasal dexmedetomidine or 1.0 mg/kg intranasal esketamine. The primary outcome measure was highest pain (assessed using Face, Legs, Activity, Cry, Consolability scale (FLACC)) during the procedure. Secondary outcomes were sedation depth, parents' satisfaction, and physician's assessment. Comparisons were done using Mann-Whitney U test (continuous variables) and Fisher's test (categorical variables). RESULTS: Adequate analgesia and sedation were reached in 28/30 patients. The estimated sample size was not reached due to changes in treatment of minor injuries and logistical reasons. The median (IQR) of highest FLACC was 1 (0-3) with intranasal dexmedetomidine and 5 (2-6.75) with intranasal esketamine, (p-value 0.09). 85.7% of the parents with children treated with intranasal dexmedetomidine were "very satisfied" with the procedure and sedation compared to the 46.2% of those with intranasal esketamine, (p-value 0.1). No severe adverse events were reported during this trial. CONCLUSIONS: This study was underpowered and did not show any difference between intranasal dexmedetomidine and intranasal esketamine for procedural sedation and analgesia in young children. However, the results support that intranasal dexmedetomidine could provide effective analgesia and sedation during procedures in young children aged 1-3 years with minor injuries. TRIAL REGISTRATION: Eudra-CT 2017-00057-40, April 20, 2017. https://eudract.ema.europa.eu/.

Hospital disaster preparedness as measured by functional capacity: a comparison between Iran and Sweden.

INTRODUCTION: Hospitals are expected to continue to provide medical care during disasters. However, they often fail to function under these circumstances. Vulnerability to disasters has been shown to be related to the socioeconomic level of a country. This study compares hospital preparedness, as measured by functional capacity, between Iran and Sweden. METHODS: Hospital affiliation and size, and type of hazards, were compared between Iran and Sweden. The functional capacity was evaluated and calculated using the Hospital Safety Index (HSI) from the World Health Organization. The level and value of each element was determined, in consensus, by a group of evaluators. The sum of the elements for each sub-module led to a total sum, in turn, categorizing the functional capacity into one of three categories: A) functional; B) at risk; or C) inadequate. RESULTS: The Swedish hospitals (n = 4) were all level A, while the Iranian hospitals (n = 5) were all categorized as level B, with respect to functional capacity. A lack of contingency plans and the availability of resources were weaknesses of hospital preparedness. There was no association between the level of hospital preparedness and hospital affiliation or size for either country. CONCLUSION: The results suggest that the level of hospital preparedness, as measured by functional capacity, is related to the socioeconomic level of the country. The challenge is therefore to enhance hospital preparedness in countries with a weaker economy, since all hospitals need to be prepared for a disaster. There is also room for improvement in more affluent countries.

Life recovery after disasters: a qualitative study in the Iranian context.

INTRODUCTION: Planned and organized long-term rehabilitation services should be provided to victims of a disaster for social integration, economic self-sufficiency, and psychological health. There are few studies on recovery and rehabilitation issues in disaster situations. This study explores the disaster-related rehabilitation process. METHOD: This study was based on qualitative analysis. Participants included 18 individuals (eight male and ten female) with experience providing or receiving disaster health care or services. Participants were selected using purposeful sampling. Data were collected through in-depth and semi-structured interviews. All interviews were transcribed and content analysis was performed based on qualitative content analysis. RESULTS: The study explored three main concepts of recovery and rehabilitation after a disaster: 1) needs for health recovery; 2) intent to delegate responsibility; and 3) desire for a wide scope of social support. The participants of this study indicated that to provide comprehensive recovery services, important basic needs should be considered, including the need for physical rehabilitation, social rehabilitation, and livelihood health; the need for continuity of mental health care; and the need for family re-unification services. Providing social activation can help reintegrate affected people into the community. CONCLUSION: Effective rehabilitation care for disaster victims requires a clear definition of the rehabilitation process at different levels of the community. Involving a wide set of those most likely to be affected by the process provides a comprehensive, continuous, culturally sensitive, and family-centered plan.

Dynamic ambulance relocation: a scoping review.

OBJECTIVES: Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response times in future medical emergencies. This study aimed to scope the current research on dynamic ambulance relocation. DESIGN: A scoping review was conducted using a structured search in PubMed, Scopus and Web of Science. In total, 21 papers were included. RESULTS: Most papers described research with experimental designs involving the use of mathematical models to calculate the optimal use and temporary relocations of ambulances. The models relied on several variables, including distances, locations of hospitals, demographic-geological data, estimation of new emergencies, emergency medical services (EMSs) working hours and other data. Some studies used historic ambulance dispatching data to develop models. Only one study reported a prospective, real-time evaluation of the models and the development of technical systems. No study reported on either positive or negative patient outcomes or real-life chain effects from the dynamic relocation of ambulances. CONCLUSIONS: Current knowledge on dynamic relocation of ambulances is dominated by mathematical and technical support data that have calculated optimal locations of ambulance services based on response times and not patient outcomes. Conversely, knowledge of how patient outcomes and the working environment are affected by dynamic ambulance dispatching is lacking. This review has highlighted several gaps in the scientific coverage of the topic. The primary concern is the lack of studies reporting on patient outcomes, and the limited knowledge regarding several key factors, including the optimal use of ambulances in rural areas, turnaround times, domino effects and aspects of working environment for EMS personnel. Therefore, addressing these knowledge gaps is important in future studies.

Predicting sepsis using a combination of clinical information and molecular immune markers sampled in the ambulance.

Sepsis is a time dependent condition. Screening tools based on clinical parameters have been shown to increase the identification of sepsis. The aim of current study was to evaluate the additional predictive value of immunological molecular markers to our previously developed prehospital screening tools. This is a prospective cohort study of 551 adult patients with suspected infection in the ambulance setting of Stockholm, Sweden between 2017 and 2018. Initially, 74 molecules and 15 genes related to inflammation were evaluated in a screening cohort of 46 patients with outcome sepsis and 50 patients with outcome infection no sepsis. Next, 12 selected molecules, as potentially synergistic predictors, were evaluated in combination with our previously developed screening tools based on clinical parameters in a prediction cohort (n = 455). Seven different algorithms with nested cross-validation were used in the machine learning of the prediction models. Model performances were compared using posterior distributions of average area under the receiver operating characteristic (ROC) curve (AUC) and difference in AUCs. Model variable importance was assessed by permutation of variable values, scoring loss of classification as metric and with model-specific weights when applicable. When comparing the screening tools with and without added molecular variables, and their interactions, the molecules per se did not increase the predictive values. Prediction models based on the molecular variables alone showed a performance in terms of AUCs between 0.65 and 0.70. Among the molecular variables, IL-1Ra, IL-17A, CCL19, CX3CL1 and TNF were significantly higher in septic patients compared to the infection non-sepsis group. Combing immunological molecular markers with clinical parameters did not increase the predictive values of the screening tools, most likely due to the high multicollinearity of temperature and some of the markers. A group of sepsis patients was consistently miss-classified in our prediction models, due to milder symptoms as well as lower expression levels of the investigated immune mediators. This indicates a need of stratifying septic patients with a priori knowledge of certain clinical and molecular parameters in order to improve prediction for early sepsis diagnosis.Trial registration: NCT03249597. Registered 15 August 2017.

The burden of critical illness among adults in a Swedish region-a population-based point-prevalence study.

BACKGROUND: Patients with critical illness have a high risk of mortality. Key decision-making in the health system affecting the outcomes of critically ill patients requires epidemiological evidence, but the burden of critical illness is largely unknown. This study aimed to estimate the prevalence of critical illness in a Swedish region. Secondary objectives were to estimate the proportion of hospital inpatients who are critically ill and to describe the in-hospital location of critically ill patients. METHODS: A prospective, multi-center, population-based, point-prevalence study on specific days in 2017-2018. All adult (> 18 years) in-patients, regardless of admitting specially, in all acute hospitals in Sörmland, and the patients from Sörmland who had been referred to university hospitals, were included. Patients in the operating theatres, with a psychiatric cause of admission, women in active labor and moribund patients, were excluded. All participants were examined by trained data collectors. Critical illness was defined as "a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and a potential for reversibility". The presence of one or more severely deranged vital signs was used to classify critical illness. The prevalence of critical illness was calculated as the number of critically ill patients divided by the number of adults in the region. RESULTS: A total of 1269 patients were included in the study. Median age was 74 years and 50% of patients were female. Critical illness was present in 133 patients, resulting in an adult population prevalence of critical illness per 100,000 people of 19.4 (95% CI 16.4-23.0). The proportion of patients in hospital who were critically ill was 10.5% (95% CI 8.8-12.3%). Among the critically ill, 125 [95% CI 94.0% (88.4-97.0%)] were cared for in general wards. CONCLUSIONS: The prevalence of critical illness was higher than previous, indirect estimates. One in ten hospitalized patients were critically ill, the large majority of which were cared for in general wards. This suggests a hidden burden of critical illness of potential public health, health system and hospital management significance.

Design of a national patient-centred clinical pathway for sepsis in Sweden.

BACKGROUND: The World Health Organization has adopted a resolution on sepsis and urged member states to develop national processes to improve sepsis care. In Sweden, sepsis was selected as one of the ten first diagnoses to be addressed, when the Swedish government in 2019 allocated funds for patient-centred clinical pathways in healthcare. A national multidisciplinary working group, including a patient representative, was appointed to develop the patient-centred clinical pathway for sepsis. METHODS: The working group mapped challenges and needs surrounding sepsis care and included a survey sent to all emergency departments (ED) in Sweden, and then designed a patient-centred clinical pathway for sepsis. RESULTS: The working group decided to focus on the following four areas: (1) sepsis alert for early detection and management optimisation for the most severely ill sepsis patients in the ED; (2) accurate sepsis diagnosis coding; (3) structured information to patients at discharge after sepsis care and (4) structured telephone follow-up after sepsis care. A health-economic analysis indicated that the implementation of the clinical pathway for sepsis will most likely not drive costs. An important aspect of the clinical pathway is implementing continuous monitoring of performance and process indicators. A national working group is currently building up such a system for monitoring, focusing on extraction of this information from the electronic health records systems. CONCLUSION: A national patient-centred clinical pathway for sepsis has been developed and is currently being implemented in Swedish healthcare. We believe that the clinical pathway and the accompanying monitoring will provide a more efficient and equal sepsis care and improved possibilities to monitor and further develop sepsis care in Sweden.