ECG signs of acute myocardial ischemia in the prehospital setting of a suspected acute coronary syndrome and its association with outcomes.

AIMS: The aims of this study were (a) to determine the prehospital prevalence of electrocardiographic (ECG) signs of acute myocardial ischemia in patients with suspected acute coronary syndrome and (b) to describe the relationships between the various ECG patterns and the diagnosis of acute myocardial infarction (AMI) and outcomes. METHODS: Prospective cohort study using data from an interventional trial in acute chest pain patients transported by the emergency medical services. These patients were classified into 3 groups: patients with ECG showing signs of acute myocardial ischemia, patients with ECG showing other abnormal changes (bundle-branch block, pacemaker rhythm, Q-wave or T-wave inversion) and patients without significant pathologic findings. All P values are age-adjusted. RESULTS: Among 1546 patients, 312 (20%) had ECG signs of acute myocardial ischemia. Of them, 57% had a final diagnosis of AMI versus 26% of those with other abnormal ECGs and 12% of those with ECG without significant pathologic findings (P<.0001). In all, 53% of all AMI cases involved patients without ECG signs of acute myocardial ischemia. Although ECG signs of acute myocardial ischemia predicted heart failure and ventricular tachyarrhythmias both prior to and after hospital admission, there was no significant difference in 30-day mortality between the 3 patient groups (4.3%, 3.7%, and 1.2%, respectively, P=.11). CONCLUSION: Among patients with a clinical suspicion of AMI in the prehospital setting, the prevalence of ECG signs suggesting AMI was low, as was the ability to identify AMI patients using ECG findings only. We therefore need better instruments in the prehospital triage of patients with acute chest pain.

Being prepared for the unprepared: a phenomenology field study of Swedish prehospital care.

INTRODUCTION: This paper presents a study of prehospital care with particular focus on how ambulance personnel prepare themselves for their everyday assignments. METHODS: The caring science field study took a phenomenological approach, where data were analyzed for meaning. Two specialist ambulance nurses, three registered nurses, and six paramedics participated. RESULTS: The previously known discrepancy between in-hospital care and prehospital care was further interpreted in this study. The pre-information from an emergency medical dispatch (EMD) center provides ambulance personnel with basic expectations as to what they will have to take care of. At the same time that they maintain their certainty and control, our major findings indicate that prehospital care in emergency medical service requires the personnel to be prepared for an open and flexible encounter with the patient; to be prepared for the unprepared, i.e., to be open and to avoid being governed by predetermined statements. DISCUSSION: Our findings suggest that the outcomes of good prehospital care affect patient security. The seemingly time-consuming dialogue with the patient facilitates understanding and decision-making regarding the patient's medical needs, and it is comforting to the patient. The ambulance personnel need to be well prepared for this task and fully understand that the situation might differ considerably from the information provided by the EMD centers. All objective information is of great value in this care context, but ultimately it is the patient who provides reliable information about her/his own situation.

Pre-hospital prediction of death or cardiovascular complications during hospitalisation and death within one year in suspected acute coronary syndrome patients.

OBJECTIVES: To identify pre-hospital predictors of a) death or the development of cardiovascular complications during hospitalisation (primary objective) and b) all-cause death during one year of follow-up (secondary objective), in chest pain patients with suspected acute coronary syndrome (ACS). METHODS: A prospective study that comprised patients in western Sweden, who were transported to hospital by the emergency medical service (EMS) due to chest pain and suspected ACS. Multiple logistic regression was used to identify independent predictors of adverse outcomes. RESULTS: Among all 1600 eligible patients, 21% died or had a cardiovascular complication during hospitalisation and 10% died during one year of follow-up. Nine factors were identified pre-hospitalisation as independent predictors of death or cardiovascular complications during hospitalisation. They were increasing age, a history of congestive heart failure, nausea and/or vomiting, rapid breathing rate, low oxygen saturation, high heart rate, together with ST-segment elevation, ST-segment depression and right bundle branch block on the pre-hospital electrocardiogram (ECG). For the secondary objective of death during one year of follow-up, the following five factors were identified as independent predictors: increasing age, a history of congestive heart failure, dyspnea, low oxygen saturation and left bundle branch block on the pre-hospital ECG. CONCLUSIONS: In the pre-hospital setting of chest pain and suspected ACS, we identified nine predictors of the primary adverse outcome. They were factors representing previous history, symptoms and ECG findings. This information may contribute to the development of a decision support system for the EMS, which then needs to be clinically tested.

Competencies in Swedish emergency departments - The practitioners' and managers' perspective.

UNLABELLED: The task of emergency departments (EDs) is to provide safe emergency healthcare while adopting a caring, cost-effective approach. Patients attending EDs have different medical and caring needs and it is assumed that practitioners have the requisite competencies to meet those needs. The aim of the present study is to explore what kind of competencies practitioners and managers describe as necessary for the practitioners to perform their everyday work in EDs. METHODS: This study used a qualitative, exploratory design. Interviews were conducted in two EDs. Data were analysed using inductive content analysis. RESULTS: The competence focus in everyday work in EDs is on emergency and life-saving actions. There is a polarisation between medical and caring competencies. There is also tension between professional groups in EDs as well as hierarchical boundaries that influence the ability to develop competencies in everyday work. Medical competencies are valued more and caring competencies are subsequently downgraded. A medical approach to competencies consolidates the view of necessary competencies in everyday work in EDs. CONCLUSIONS: The study shows that the competencies that are valued consolidate the prevailing medical paradigm. There is a traditional, one-sided approach to competencies, a hierarchical distinction between professional groups and unclear occupational functions.

Elderly patients' participation in emergency medical services when offered an alternative care pathway.

As organizational changes in the healthcare system are in progress, to enhance care quality and reduce costs, it is important to investigate how these changes affect elderly patients' experiences and their rights to participate in the choice of healthcare. The aim of this study is to describe elderly patients' lived experience of participating in the choice of healthcare when being offered an alternative care pathway by the emergency medical services, when the individual patient's medical needs made this choice possible. This study was carried out from the perspective of caring science, and a phenomenological approach was applied, where data were analysed for meaning. Data consist of 11 semi-structured interviews with elderly patients who chose a healthcare pathway to a community-based hospital when they were offered an alternative level of healthcare. The findings show that the essence of the phenomenon is described as "There was a ray of hope about a caring encounter and about being treated like a unique human being". Five meaningful constituents emerged in the descriptions: endurable waiting, speedy transference, a concerned encounter, trust in competence, and a choice based on memories of suffering from care. The conclusion is that patient participation in the choice of a healthcare alternative instead of the emergency department is an opportunity of avoiding suffering from care and being objectified.

Anxiolytics in patients suffering a suspected acute coronary syndrome: multi-centre randomised controlled trial in Emergency Medical Service.

BACKGROUND: The prehospital treatment of pain and discomfort among patients who suffer from acute coronary syndrome (ACS) needs a treatment strategy which combines relief of pain with relief of anxiety. AIM: The aim of the present study was to evaluate the impact on pain and anxiety of the combination of an anxiolytic and an analgesic as compared with an analgesic alone in the prehospital setting of suspected ACS. METHODS: A multi-centre randomised controlled trial compared the combination of Midazolam (Mi)+Morphine (Mo) and Mo alone. All measures took part: Prior to randomisation, 15 min thereafter and on admission to a hospital. Inclusion criteria were: 1) pain raising suspicion of ACS and 2) pain score ≥4. PRIMARY ENDPOINT: Pain score after 15 min. RESULTS: In all, 890 patients were randomised to Mi+Mo and 873 to Mo alone. Pain was reduced from a median of 6 to 4 and finally to 3 in both groups. The mean dose of Mo was 5.3 mg in Mi+Mo and 6.0 mg in Mo alone (p<0.0001). Anxiety was reported in 66% in Mi+Mo and in 64% in Mo alone at randomisation (NS); 15 min thereafter in 31% and 39% (p=0.002) and finally in 12% and 26% respectively (p<0.0001). On admission to a hospital nausea or vomiting was reported in 9% in Mi+Mo and in 13% in Mo alone (p=0.003). Drowsiness differed; 15% and 14% were drowsy in Mi+Mo versus 2% and 3% in Mo alone respectively (p<0.001). CONCLUSION: Despite the fact that the combination of anxiolytics and analgesics as compared with analgesics alone reduced anxiety and the requirement of Morphine in the prehospital setting of acute coronary syndrome, this strategy did not reduce patients' estimation of pain (primary endpoint). More effective pain relief among these patients is warranted.

Differentiating frailty in older people using the Swedish ambulance service: a retrospective audit.

The elderly population in Sweden is increasing. This will lead to an increased need for healthcare resources and put extra demands on healthcare professionals. Consequently, ambulance personnel will be faced with the challenge of meeting extra demands from increasing numbers of older people with complex and atypical clinical presentations. Therefore we highlight that great problems exist for ambulance personnel to understand and meet these patients' care needs. Using a caring science approach, we apply the patient's perspective, and the aim of this study is to identify and illuminate the conditions that affect elderly people assessed with the assessment category "general affected health condition". Thus, we have analyzed the characteristics belonging to this specific condition. The method is a retrospective audit, involving a qualitative content analysis of a total of 88 emergency service records. The conclusion is that by using caring science, the concept of frailty which is based on a comprehensive understanding of human life can clarify the state of "general affected health condition", as either illness or ill-health. This offers a new assessment category and outlines care and treatment that strengthen and support the health and wellbeing of the individual elderly person. Furthermore, the concept of frailty ought to be included in "The International Statistical Classification of Diseases and Related Health Problems" (ICD-10).