Mortality after paediatric emergency calls for patients with or without pre-existing comorbidity: a nationwide population based cohort study.

BACKGROUND: Life-threatening conditions are infrequent in children. Current literature in paediatric prehospital research is centred around trauma and paediatric out-of-hospital cardiac arrests (POHCA). The aims of this study were to (1) outline the distribution of trauma, POHCA or other medical symptoms among survivors and non-survivors after paediatric emergency calls, and (2) to investigate these clinical presentations' association with mortality in children with and without pre-existing comorbidity, respectively. METHODS: Nationwide population-based cohort study including ground and helicopter emergency medical services in Denmark for six consecutive years (2016-2021). The study included all calls to the emergency number 1-1-2 regarding children ≤ 15 years (N = 121,230). Interhospital transfers were excluded, and 1,143 patients were lost to follow-up. Cox regressions were performed with trauma or medical symptoms as exposure and 7-day mortality as the outcome, stratified by 'Comorbidity', 'Severe chronic comorbidity' and 'None' based on previous healthcare visits. RESULTS: Mortality analysis included 76,956 unique patients (median age 5 (1-12) years). Annual all-cause mortality rate was 7 per 100,000 children ≤ 15 years. For non-survivors without any pre-existing comorbidity (n = 121), reasons for emergency calls were trauma 18.2%, POHCA 46.3% or other medical symptoms 28.9%, whereas the distribution among the 134 non-survivors with any comorbidity was 7.5%, 27.6% and 55.2%, respectively. Compared to trauma patients, age- and sex-adjusted hazard ratio for patients with calls regarding medical symptoms besides POHCA was 0.8 [0.4;1.3] for patients without comorbidity, 1.1 [0.5;2.2] for patients with comorbidity and 6.1 [0.8;44.7] for patients with severe chronic comorbidity. CONCLUSION: In both non-survivors with and without comorbidity, a considerable proportion of emergency calls had been made because of various medical symptoms, not because of trauma or POHCA. This outline of diagnoses and mortality following paediatric emergency calls can be used for directing paediatric in-service training in emergency medical services.

Disparities in prehospital and emergency surgical care among patients with perforated ulcers and a history of mental illness: a nationwide cohort study.

PURPOSE: To compare patients with and without a history of mental illness on process and outcome measures in relation to prehospital and emergency surgical care for patients with perforated ulcer. METHODS: A nationwide registry-based cohort study of patients undergoing emergency surgery for perforated ulcer. We used data from the Danish Prehospital Database 2016-2017 and the Danish Emergency Surgery Registry 2004-2018 combined with data from other Danish databases. Patients were categorized according to severity of mental health history. RESULTS: We identified 4.767 patients undergoing emergency surgery for perforated ulcer. Among patients calling the EMS with no history of mental illness, 51% were identified with abdominal pain when calling the EMS compared to 31% and 25% among patients with a history of moderate and major mental illness, respectively. Median time from hospital arrival to surgery was 6.0 h (IQR: 3.6;10.7). Adjusting for age, sex and comorbidity, patients with a history of major mental illness underwent surgery 46 min (95% CI: 4;88) later compared to patients with no history of mental illness. Median number of days-alive-and-out-of-hospital at 90-day follow-up was 67 days (IQR: 0;83). Adjusting for age, sex and comorbidity, patients with a history of major mental illness had 9 days (95% CI: 4;14) less alive and out-of-hospital at 90-day follow-up. CONCLUSION: One-third of the population had a history of mental illness or vulnerability. Patients with a history of major mental illness were less likely to be identified with abdominal pain if calling the EMS prior to arrival. They had longer delays from hospital arrival to surgery and higher mortality.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients.

BACKGROUND: Mobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability. METHOD: Following a pilot study, we developed a 4-level prehospital mobility score based of the question"How much help did the patient need to be mobilized to the ambulance trolley". Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020-May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics. RESULTS: We included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1). Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86). CONCLUSION: We developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers.

Can acutely ill patients predict their outcomes? A scoping review.

INTRODUCTION: The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care. METHODS: A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome. CONCLUSION: The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care.

A classification system for identifying patients dead on ambulance arrival: a prehospital medical record review.

BACKGROUND: Patients dead before arrival of the ambulance or before arrival at hospital may be in- or excluded in mortality analyses, making comparison of mortality difficult. Often only physicians are allowed to declare death, thereby impeding uniform registration of prehospital death. Many studies do not report detailed definitions of prehospital mortality. Our aim was to define criteria to identify and categorize prehospital patients' vital status, and to estimate the proportion of these groups, primarily the proportion of patients dead on ambulance arrival. METHODS: Prehospital medical records review for patients receiving an ambulance in the North Denmark Region from 2019 to 2021 and registered dead on the same or the following day. We defined three vital status categories: (1) Dead on Ambulance Arrival (DOAA), (2) Out-of-Hospital Cardiac Arrest (OHCA) divided into OHCA Basic Life Support (OHCA BLS) and OHCA Advanced treatment, and 3) Alive on Ambulance Arrival. RESULTS: Among 3 174 dead patients, DOAA constituted 28.8%, OHCA BLS 13.4%, OHCA Advanced treatment 31.3%, and Alive on Ambulance Arrival 26.6%. CONCLUSION: We defined exhaustive and mutually exclusive criteria to define vital status, DOAA, OHCA, and Alive on Ambulance Arrival based on prehospital medical records. More than one out of four patients receiving an ambulance and registered dead on the same or the following day were dead already at ambulance arrival. Adding OHCA BLS where resuscitation was terminated without defibrillation or other treatment, increased the proportion of patients dead on ambulance arrival to 42%. We recommend reporting similar categories of vital status to improve valid comparisons of prehospital mortality rates.

Prehospital blood gas analyses in acute patients treated by a ground-based physician-manned emergency unit: a cohort study.

BACKGROUND: The prehospital patients treated by ambulances and mobile emergency care units (MECU) are potentially critically ill or injured. Knowing the risks of serious outcomes in these patients is important for guiding their treatment. Some settings allow for prehospital arterial blood gas analyses. This study aimed to assess the outcomes of prehospital patients in relation to their prehospitally measured lactate, pH, and CO2 levels. The primary outcome was 7-day mortality. METHODS: This register-based cohort study included patients with one or more prehospital blood gas analyses during their prehospital treatment by a physician-manned MECU, from January 2015 to December 2018. The blood samples were analyzed on an ABL90 Flex analyzer. Absolute values with percentages and odds ratios (OR) with 95% confidence intervals (CI) were calculated for the primary and secondary outcomes within prespecified subgroups. RESULTS: The study included 745 patients, with an overall 7-day mortality rate of 20.0%. LACTATE LEVEL: The 7-day mortality rates were 11.5% in patients with normal lactate levels (< 2.0 mmol/L), 14.4% with intermediate lactate levels (2.0-3.9 mmol/L), and 33.0% with high lactate levels (≥ 4.0 mmol/L). This corresponded to an OR of 1.30 (95% CI: 0.75-2.24) in the intermediate lactate group (2.0-3.9 mmol/L) and an OR of 3.77 (95% CI: 2.44-5.85) in the high lactate group (≥ 4.0 mmol/L), compared to the reference group with normal lactate. PH LEVEL: The ORs of 7-day mortality rates were 4.82 (95% CI: 3.00-7.75) in patients with blood pH of < 7.35 and 1.33 (95% CI: 0.65-2.72) in patients with blood pH > 7.45, compared to the reference group with normal pH (7.35-7.45). CO2 LEVEL : The ORs of 7-day mortality rates were 2.54 (95% CI: 1.45-4.46) in patients with blood CO2 of < 4.3 kPa and 2.62 (95% CI: 1.70-4.03) in patients with blood CO2 > 6.0 kPa, compared to the reference group with normal CO2 (4.3-6.0 kPa). CONCLUSIONS: This study found a strong correlation between increasing 7-day mortality rates and high blood lactate levels, low levels of pH, and abnormal CO2 blood levels, in prehospital patients undergoing prehospital blood analysis.

Nurses' and Physicians' Ideas on Initiatives for Effective Use of the Early Warning Score: A Participatory Study.

Ineffective use of the early warning score (EWS) can compromise recognition and response to patients' deteriorating condition. This study explores nurses' and physicians' ideas on initiatives for supporting the effective use of the EWS in a hospital setting. Participatory workshops were conducted, and data were analyzed using content analysis. Ideas generated for integrating new functions into the EWS protocol to facilitate effective use are described. Also recommended was that all users receive training and an update on how to use the EWS score to support acceptance and confidence using the protocol and thereby increase adherence to the EWS. Further research is needed on the efficiency of incorporating nurses' clinical judgment in the EWS protocol within different specialties and the effect on adherence to the tool.

Critically deviating vital signs among patients with non-specific diagnoses-A register-based historic cohort study.

BACKGROUND: One third of ambulance patients receive non-specific diagnoses in hospital. Mortality is 3-4%, however due to the high patient volume this group accounts for 20% of all deaths at day 30. Non-specific diagnoses do not provide much information on causes for death. Vital signs at first contact with ambulance personnel can act as a proxy for the patient's condition. Thus, we aimed to describe the prevalence of abnormal vital signs, as determined by a modified NEWS2, in ambulance patients who received a non-specific hospital diagnosis. Secondly, we examined the association between vital signs, NEWS2 scores, type of non-specific diagnosis, and mortality among these patients. METHODS: Register-based historic cohort study of ambulance patients aged 16+ in the North Denmark Region during 2012-2016, who received a non-specific diagnosis (ICD-10 chapters R or Z) at hospital. We used NEWS2 scores to determine if first vital signs were normal or deviating (including critical). Mortality was estimated with the Kaplan-Meier estimator. Association between vital signs and mortality was evaluated by logistic regression. RESULTS: We included 41,539 patients, 20.9% (N = 8,691) had normal vital signs, 16.3% (N = 6,766) had incomplete vital sign registration, 62.8% (N = 26,082) had deviating vital signs, and of these 6.8% (N = 1,779) were critical. If vital signs were incompletely registered or deviating, mortality was higher compared to normal vital signs. Patients with critical vital signs displayed the highest crude 48-hour and 30-day mortality (7.0% (5.9-8.3) and 13.4% (11.9-15.1)). Adjusting for age, sex, and comorbidity did not change that pattern. Across all vital sign groups, despite severity, the most frequent diagnosis assigned was Z039 observation for suspected disease or condition unspecified. CONCLUSIONS: Most ambulance patients with non-specific diagnoses had normal or non-critical deviating vital signs and low mortality. Around 4% had critical vital signs and high mortality, not explained by age or comorbidity.

Prehospital Early Warning Scores to Predict Mortality in Patients Using Ambulances.

Importance: Early warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services. Objective: To validate EWSs' ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances. Design, Setting, and Participants: This prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023. Main Outcomes and Measures: The primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). Results: There were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores < .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission. Conclusions and Relevance: This study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.

Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study.

BACKGROUND: Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA. METHODS: We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis. RESULTS: All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values. CONCLUSION: This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.

Decision on non-conveyance of patients suspected of COVID-19 in a novel arrangement with assessment visits by paramedics at home.

BACKGROUND: During the first weeks of the outbreak of the coronavirus disease 2019 (COVID-19), the North Denmark emergency medical services authorised paramedics to assess patients suspected of COVID-19 at home, and then decide if conveyance to a hospital was required. The aim of this study was to describe the cohort of patients who were assessed at home and their outcomes in terms of subsequent hospital visits and short-term mortality. METHODS: This was a historical cohort study in the North Denmark Region with consecutive inclusion of patients suspected of COVID-19 who were referred to a paramedic's assessment visit by their general practitioner or an out-of-hours general practitioner. The study was conducted from 16 March to 20 May 2020. The outcomes were the proportion of non-conveyed patients who subsequently visited a hospital within 72 hours of the paramedic's assessment visit and mortality at 3, 7 and 30 days. Mortality was estimated using a Poisson regression model with robust variance estimation. RESULTS: During the study period, 587 patients with a median age of 75 (IQR 59-84) years were referred to a paramedic's assessment visit. Three of four patients (76.5%, 95% CI 72.8;79.9) were non-conveyed, and 13.1% (95% CI 10.2;16.6) of the non-conveyed patients were subsequently referred to a hospital within 72 hours of the paramedic's assessment visit. Within 30 days from the paramedic's assessment visit, mortality was 11.1% [95% CI 6.9;17.9] among patients directly conveyed to a hospital and 5.8% [95% CI 4.0;8.5] among non-conveyed patients. Medical record review revealed that deaths in the non-conveyed group had happened among patients with 'do-not-resuscitate' orders, palliative care plans, severe comorbidities, age ≥ 90 years or nursing home residents. CONCLUSIONS: The majority (87%) of the non-conveyed patients did not visit a hospital for the following three days after a paramedic's assessment visit. The study implies that this newly established prehospital arrangement served as a kind of gatekeeper for the region's hospitals in regard to patients suspected of COVID-19. The study also demonstrates that implementation of non-conveyance protocols should be accompanied by careful and regular evaluation to ensure patient safety.

More emergency patients presenting with chest pain.

INTRODUCTION: Throughout recent years the demand for prehospital emergency care has increased significantly. Non-traumatic chest pain is one of the most frequent complaints. Our aim was to investigate the trend in frequency of the most urgent ambulance patients with chest pain, subsequent acute myocardial infarction (AMI) diagnoses, and 48-hour and 30-day mortality of both groups. METHODS: Population-based historic cohort study in the North Denmark Region during 2012-2018 including chest pain patients transported to hospital by highest urgency level ambulance following a 1-1-2 emergency call. Primary diagnoses (ICD-10) were retrieved from the regional Patient Administrative System, and descriptive statistics (distribution, frequency) performed. We evaluated time trends using linear regression, and mortality (48 hours and 30 days) was assessed by the Kaplan Meier estimator. RESULTS: We included 18,971 chest pain patients, 33.9% (n = 6,430) were diagnosed with"Diseases of the circulatory system" followed by the non-specific R- (n = 5,288, 27.8%) and Z-diagnoses (n = 3,634; 19.2%). AMI was diagnosed in 1,967 patients (10.4%), most were non-ST-elevation AMI (39.7%). Frequency of chest pain patients and AMI increased 255 and 22 patients per year respectively, whereas the AMI proportion remained statistically stable, with a tendency towards a decrease in the last years. Mortality at 48 hours and day 30 in chest pain patients was 0.7% (95% CI 0.5% to 0.8%) and 2.4% (95% CI 2.1% to 2.6%). CONCLUSIONS: The frequency of chest pain patients brought to hospital during 2012-2018 increased. One-tenth were diagnosed with AMI, and the proportion of AMI patients was stable. Almost 1 in of 4 high urgency level ambulances was sent to chest pain patients. Only 1 of 10 patients with chest pain had AMI, and overall mortality was low. Thus, monitoring the number of chest pain patients and AMI diagnoses should be considered to evaluate ambulance utilisation and triage.

Prehospital vital sign monitoring in paediatric patients: an interregional study of educational interventions.

BACKGROUND: Prehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives. METHODS: Prospective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region. RESULTS: In North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3-11 months (7.4%), 1-2 years (18.8%), 3-7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3-7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference - 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period. CONCLUSIONS: Mandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases.

Diagnoses and mortality among prehospital emergency patients calling 112 with unclear problems: a population-based cohort study from Denmark.

BACKGROUND: Patients calling for an emergency ambulance and assessed as presenting with 'unclear problem' account for a considerable part of all emergency calls. Previous studies have demonstrated that these patients are at increased risk for unfavourable outcomes. A deeper insight into the underlying diagnoses and outcomes is essential to improve prehospital treatment. We aimed to investigate which of these diagnoses contributed most to the total burden of diseases in terms of numbers of deaths together with 1- and 30-day mortality. METHODS: A historic regional population-based observational cohort study from the years 2016 to 2018. Diagnoses were classified according to the World Health Organisation ICD-10 System (International Statistical Classification of Diseases and Related Health Problems, 10th edition). The ICD-10 chapters, R ('symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified)' and Z ('factors influencing health status and contact with health services") were combined and designated "non-specific diagnoses". Poisson regression with robust variance estimation was used to estimate proportions of mortality in percentages with 95% confidence intervals, crude and adjusted for age, sex and comorbidities. RESULTS: Diagnoses were widespread among the ICD-10 chapters, and the most were 'non-specific diagnoses' (40.4%), 'circulatory diseases' (9.6%), 'injuries and poisonings' (9.4%) and 'respiratory diseases' (6.9%). The diagnoses contributing most to the total burden of deaths (n = 554) within 30 days were 'circulatory diseases' (n = 148, 26%) followed by 'non-specific diagnoses' (n = 88, 16%) 'respiratory diseases' (n = 85, 15%), 'infections' (n = 54, 10%) and 'digestive disease' (n = 39, 7%). Overall mortality was 2.3% (1-day) and 7.1% (30-days). The risk of mortality was highly associated with age. CONCLUSION: This study found that almost half of the patients brought to the hospital after calling 112 with an 'unclear problem' were discharged with a 'non-specific diagnosis' which might seem trivial but should be explored more as these contributed the second-highest to the total number of deaths after 30 days only exceeded by 'circulatory diseases'.

Increased bystander intervention when volunteer responders attend out-of-hospital cardiac arrest.

Aim: The primary aim was to investigate the association between alarm acceptance compared to no-acceptance by volunteer responders, bystander intervention, and survival in out-of-hospital cardiac arrest. Materials and methods: This retrospective observational study included all suspected out-of-hospital cardiac arrests (OHCAs) with activation of volunteer responders in the Capital Region of Denmark (1 November 2018 to 14 May 2019), the Central Denmark Region (1 November 2018 to 31 December 2020), and the Northern Denmark Region (14 February 2020 to 31 December 2020). All OHCAs unwitnessed by Emergency Medical Services (EMS) were analyzed on the basis on alarm acceptance and arrival before EMS. The primary outcomes were bystander cardio-pulmonary resuscitation (CPR), bystander defibrillation and secondary outcome was 30-day survival. A questionnaire sent to all volunteer responders was used with respect to their arrival status. Results: We identified 1,877 OHCAs with volunteer responder activation eligible for inclusion and 1,725 (91.9%) of these had at least one volunteer responder accepting the alarm (accepted). Of these, 1,355 (79%) reported arrival status whereof 883 (65%) arrived before EMS. When volunteer responders accepted the alarm and arrived before EMS, we found increased proportions and adjusted odds ratio for bystander CPR {94 vs. 83%, 4.31 [95% CI (2.43-7.67)] and bystander defibrillation [13 vs. 9%, 3.16 (1.60-6.25)]} compared to cases where no volunteer responders accepted the alarm. Conclusion: We observed a fourfold increased odds ratio for bystander CPR and a threefold increased odds ratio for bystander defibrillation when volunteer responders accepted the alarm and arrived before EMS.

Prevalence and mortality among patients with COPD hospitalised by ambulance in the 2007-2018 period.

INTRODUCTION: Severe exacerbations in chronic obstructive pulmonary disease (COPD) may require acute medical attention by calling the emergency medical services (EMS) for an ambulance. The 30-day mortality for EMS patients with respiratory diseases appears to have stagnated, which may be due to changes in age, comorbidity or disease severity. We examined trends of occurrence, severity and mortality for EMS patients with COPD. METHODS: A historical population-based cohort study was conducted encompassing patients with COPD who requested an ambulance in the North Denmark Region in the 2007-2018 period. We described acute severity by oxygen saturation and respiratory rate at the arrival of the ambulance along with comorbidity and duration of hospitalisation. RESULTS: A total of 5,969 EMS patients with COPD were identified and the figure nearly doubled from 2007 to 2018. Age and comorbidity were higher in the last part of the period. Furthermore, the initial respiratory rate was higher, oxygen saturation was lower and the duration of hospitalisation was lower in the last part of the period. The 30-day mortality rose from 12.6% to 15.4%, but the odds ratio was not statistically higher and decreased after adjustment. CONCLUSIONS: COPD constituted increasing proportions of those admitted to hospital after calling the EMS. The mortality among EMS patients with COPD may be due to patients being older, having more comorbidities or being more severely acutely ill. The mortality suggests that COPD patients requesting an ambulance should be considered severely ill. FUNDING: none. TRIAL REGISTRATION: not relevant.

How Patients Who Are Transported by Ambulance Experience Dyspnea and the Use of a Dyspnea Scale: A Qualitative Study.

Approximately 7% of all dispatched ambulances in Denmark are for patients for whom breathing difficulties are the main cause for using ambulance services. Objective measurements are routinely carried out in the ambulances, but little is known of the patients' subjective experience of dyspnea. The purpose of this study was to investigate how patients with acute dyspnea, transported to hospital by ambulance, experience their situation, along with their experience of the use of a dyspnea scale. The study was carried out in the North Denmark Region. Transcribed patient interviews and field notes were analyzed and interpreted with inspiration from Paul Ricoeur. For interviews, we included 12 patients with dyspnea who were transported to the hospital by ambulance: six women and six men all aged 60 years or above. Observations were made over six ambulance transports related to dyspnea. Three themes emerged: "anxiety", "reassurance in the ambulance" and "acceptance of the dyspnea measurements in the ambulance". Several patients expressed anxiety due to their dyspnea, which was substantiated by observations in the ambulance. The patients expressed different perspectives on what improved the situation (treatment, reassurance by ambulance professionals). The patients and the ambulance personnel were, in general, in favor of the dyspnea scale.

Prehospital Release of Patients After Treatment in an Anesthesiologist-Staffed Mobile Emergency Care Unit.

Importance: Prehospital treatment and release of patients may reduce unnecessary transports to the hospital and may improve patient satisfaction. However, the safety of patients should be paramount. Objective: To determine the extent of unplanned emergency department (ED) contacts, short-term mortality, and diagnostic patterns in patients treated and released by a prehospital anesthesiologist supervising a mobile emergency care unit (MECU). Design, Setting, and Participants: This retrospective cohort study used a manual review of prehospital and in-hospital medical records to investigate all living patients who were treated and released by an MECU in Odense, Denmark, between January 1, 2011, and December 31, 2020. Patients were followed up for 30 days after initial contact with the prehospital service. Main Outcomes and Measures: Primary outcome measures included unplanned contacts with the emergency department less than 48 hours after prehospital treatment and prehospital assigned diagnosis. Secondary outcomes consisted of mortality at 48 hours and 7 and 30 days. Results: A total of 3141 patients were identified; 384 were excluded and 2757 were included in the analysis. The median patient age was 40 (IQR, 14-66) years; 1296 (47.0%) were female and 1461 (53.0%) were male. Two hundred thirty-nine patients (8.7% [95% CI, 7.6%-9.8%]) had unplanned contact with the ED within 48 hours; this rate was doubled for patients with respiratory diseases (37 of 248 [14.9% (95% CI, 10.7%-20.0%)]). Fifty-nine of 60 patients who died within 48 hours of release had terminal illness. Excluding these patients, the mortality rates were 0.04% at 48 hours, 0.8% at 7 days, and 2.4% at 30 days. Two thousand sixty-one patients (74.8%) had primarily nondefinitive observational diagnoses. Conclusions and Relevance: The findings of this cohort study suggest that prehospital treatment and subsequent release at the scene is safe. One patient in 12 attended the ED within the ensuing 48 hours. However, for patients with respiratory diseases, this rate was doubled. Hospital admission could be avoided for some patients in the end stage of a terminal illness.

Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review.

AIM: This systematic review explored how non-medical factors influence the prehospital resuscitation providers' decisions whether or not to resuscitate adult patients with cardiac arrest. METHODS: We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings. RESULTS: We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient's characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers' characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers' had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests. CONCLUSIONS: Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest.