Patients' pathways to the emergency department: a scoping review.

BACKGROUND: Emergency department (ED) crowding is a common healthcare issue with multiple causes. One important knowledge area is understanding where patients arrived from and what care they received prior to ED admission. This information could be used to inform strategies to provide care for low acuity patients outside of the hospital and reduce unnecessary ED admissions. The aim of this scoping review was to provide a comprehensive overview of global published research examining the acute care trajectory of all ED patients. METHODS: The scoping review was performed according to the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive literature search was performed to identify studies describing where patients arrived from and/or whose pathway of care was before an ED visit. The search was conducted in MEDLINE, Embase, and the Cochrane Library from inception through December 5th, 2022. Two reviewers independently screened the records. RESULTS: Out of the 6,465 records screened, 14 studies from Australia, Canada, Haiti, Norway, Sweden, Switzerland, Belgium, Indonesia, and the UK met the inclusion criteria. Four studies reported on where patients physically arrived from, ten reported how patients were transported, six reported who referred them, and six reported whether medical care or advice was sought prior to visiting an ED. CONCLUSION: This scoping review revealed a lack of studies describing patients' pathways to the ED. However, studies from some countries indicate that a relatively large proportion of patients first seek care or guidance from a primary care physician (PCP) before visiting an ED. However, further research and published data are needed. To improve the situation, we recommend the development and implementation of a template for the uniform reporting of factors outside the ED, including where the patient journey began, which healthcare facilities they visited, who referred them to the ED, and how they arrived.

Mortality rates in Norwegian HEMS-a retrospective analysis from Central Norway.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) provide rapid and specialized care to critically ill or injured patients. Norwegian HEMS in Central Norway serves an important role in pre-hospital emergency medical care. To grade the severity of patients, HEMS uses the National Advisory Committee for Aeronautics' (NACA) severity score. The objective of this study was to describe the short- and long term mortality overall and in each NACA-group for patients transported by HEMS Trondheim using linkage of HEMS and hospital data. METHODS: The study used a retrospective cohort design, aligning with the STROBE recommendations. Patient data from Trondheim HEMS between 01.01.2017 and 31.12.2019 was linked to mortality data from a hospital database and analyzed. Kaplan Meier plots and cumulative mortality rates were calculated for each NACA group at day one, day 30, and one year and three years after the incident. RESULTS: Trondheim HEMS responded to 2224 alarms in the included time period, with 1431 patients meeting inclusion criteria for the study. Overall mortality rates at respective time points were 10.1% at day one, 13.4% at 30 days, 18.5% at one year, and 22.3% at three years. The one-year cumulative mortality rates for each NACA group were as follows: 0% for NACA 1 and 2, 2.9% for NACA 3, 10.1% for NACA 4, 24.7% for NACA 5 and 49.5% for NACA 6. Statistical analysis with a global log-rank test indicated a significant difference in survival outcomes among the groups (p < 2⋅10- 16). CONCLUSION: Among patients transported by Trondheim HEMS, we observed an incremental rise in mortality rates with increasing NACA scores. The study further suggests that a one-year follow-up may be sufficient for future investigations into HEMS outcomes.

Using machine learning to assess the extent of busy ambulances and its impact on ambulance response times: A retrospective observational study.

BACKGROUND: Ambulance response times are considered important. Busy ambulances are common, but little is known about their effect on response times. OBJECTIVE: To assess the extent of busy ambulances in Central Norway and their impact on ambulance response times. DESIGN: This was a retrospective observational study. We used machine learning on data from nearby incidents to assess the probability of up to five different ambulances being candidates to respond to a medical emergency incident. For each incident, the probability of a busy ambulance was estimated by summing the probabilities of candidate ambulances being busy at the time of the incident. The difference in response time that may be attributable to busy ambulances was estimated by comparing groups of nearby incidents with different estimated busy probabilities. SETTING: Medical emergency incidents with ambulance response in Central Norway from 2013 to 2022. MAIN OUTCOME MEASURES: Prevalence of busy ambulances and differences in response times associated with busy ambulances. RESULTS: The estimated probability of busy ambulances for all 216,787 acute incidents with ambulance response was 26.7% (95% confidence interval (CI) 26.6 to 26.9). Comparing nearby incidents, each 10-percentage point increase in the probability of a busy ambulance was associated with a delay of 0.60 minutes (95% CI 0.58 to 0.62). For incidents in rural and urban areas, the probability of a busy ambulance was 21.6% (95% CI 21.5 to 21.8) and 35.0% (95% CI 34.8 to 35.2), respectively. The delay associated with a 10-percentage point increase in busy probability was 0.81 minutes (95% CI 0.78 to 0.84) and 0.30 minutes (95% CI 0.28 to 0.32), respectively. CONCLUSION: Ambulances were often busy, which was associated with delayed ambulance response times. In rural areas, the probability of busy ambulances was lower, although the potentially longer delays when ambulances were busy made these areas more vulnerable.

Transfusion practice in Central Norway - a regional cohort study in patients suffering from major haemorrhage.

BACKGROUND: In patients with major hemorrhage, balanced transfusions and limited crystalloid use is recommended in both civilian and military guidelines. This transfusion strategy is often applied in the non-trauma patient despite lack of supporting data. The aim of this study was to describe the current transfusion practice in patients with major hemorrhage of both traumatic and non-traumatic etiology in Central Norway, and discuss if transfusions are in accordance with appropriate massive transfusion protocols. METHODS: In this retrospective observational cohort study, data from four hospitals in Central Norway was collected from 01.01.2017 to 31.12.2018. All adults (≥18 years) receiving massive transfusion (MT) and alive on admission were included. MT was defined as transfusion of ≥10 units of packed red blood cells (PRBC) within 24 hours, or ≥ 5 units of PRBC during the first 3 hours after admission to hospital. Clinical data was collected from the hospital blood bank registry (ProSang) and electronic patient charts (CareSuite PICIS). Patients undergoing cardiothoracic surgery or extracorporeal membrane oxygenation treatment were excluded. RESULTS: A total of 174 patients were included in the study, of which 85.1% were non-trauma patients. Seventy-six per cent of all patients received plasma:PRBC in a ratio ≥ 1:2 (high ratio) and 59.2% of patients received platelets:PRBC in a ratio ≥ 1:2 (high ratio). 32.2% received a plasma:PRBC-ratio ≥ 1:1, and 23.6% platelet:PRBC-ratio ≥ 1:1. Median fluid infusion of crystalloids in all patients was 5750 mL. Thirty-seven per cent of all patients received tranexamic acid, 53.4% received calcium and fibrinogen concentrate was administered in 9.2%. CONCLUSIONS: Most patients had a non-traumatic etiology. The majority was transfused with high ratios of plasma:PRBC and platelet:PRBC, but not in accordance with the aim of the local protocol (1:1:1). Crystalloids were administered liberally for both trauma and non-trauma patients. There was a lower use of hemostatic adjuvants than recommended in the local transfusion protocol. Awareness to local protocol should be increased.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjunct treatment in life threatening postpartum hemorrhage: Fourteen years' experience from a single Norwegian center.

INTRODUCTION: Postpartum hemorrhage (PPH) remains a global health problem. The introduction of resuscitative endovascular balloon occlusion of the aorta (REBOA) in 2008 sought to enhance the management of hemorrhagic shock during PPH. In this study, we present a single Norwegian center's experience with REBOA as a supportive treatment in combating life threatening PPH. MATERIAL AND METHODS: This is a historical cohort study from St Olav's University Hospital, with data from period 2008-2021. It includes all patients who underwent REBOA as an adjunct treatment due to life threatening PPH, analyzing the outcomes and trends over a 14-year period. RESULTS: A total of 37 patients received REBOA as an adjunct treatment. All procedures were technically successful, achieving hemodynamic stability with an immediate average increase in systolic blood pressure of 36 ± 22 mmHg upon initial balloon inflation. Additionally, a downward trend was noted in the frequency of hysterectomies and the volume of blood transfusions required over time. No thromboembolic complications were observed. CONCLUSIONS: Our 14 years of experience at St Olav's Hospital suggests that REBOA serves as a safe and effective adjunct interventional technique for managing life-threatening PPH. Furthermore, the findings indicate that incorporating a multidisciplinary approach to enable rapid aortic occlusion can potentially reduce the necessity for blood transfusions and hysterectomies.

Excellent agreement of Norwegian trauma registry data compared to corresponding data in electronic patient records.

BACKGROUND: The Norwegian Trauma Registry (NTR) is designed to monitor and improve the quality and outcome of trauma care delivered by Norwegian trauma hospitals. Patient care is evaluated through specific quality indicators, which are constructed of variables reported to the registry by certified registrars. Having high-quality data recorded in the registry is essential for the validity, trust and use of data. This study aims to perform a data quality check of a subset of core data elements in the registry by assessing agreement between data in the NTR and corresponding data in electronic patient records (EPRs). METHODS: We validated 49 of the 118 variables registered in the NTR by comparing those with the corresponding ones in electronic patient records for 180 patients with a trauma diagnosis admitted in 2019 at eight public hospitals. Agreement was quantified by calculating observed agreement, Cohen's Kappa and Gwet's first agreement coefficient (AC1) with 95% confidence intervals (CIs) for 27 nominal variables, quadratic weighted Cohen's Kappa and Gwet's second agreement coefficient (AC2) for five ordinal variables. For nine continuous, one date and seven time variables, we calculated intraclass correlation coefficient (ICC). RESULTS: Almost perfect agreement (AC1 /AC2/ ICC > 0.80) was observed for all examined variables. Nominal and ordinal variables showed Gwet's agreement coefficients ranging from 0.85 (95% CI: 0.79-0.91) to 1.00 (95% CI: 1.00-1.00). For continuous and time variables there were detected high values of intraclass correlation coefficients (ICC) between 0.88 (95% CI: 0.83-0.91) and 1.00 (CI 95%: 1.00-1.00). While missing values in both the NTR and EPRs were in general negligeable, we found a substantial amount of missing registrations for a continuous "Base excess" in the NTR. For some of the time variables missing values both in the NTR and EPRs were high. CONCLUSION: All tested variables in the Norwegian Trauma Registry displayed excellent agreement with the corresponding variables in electronic patient records. Variables in the registry that showed missing data need further examination.

Utopia for Norwegian helicopter emergency medical services: Estimating the number of bases needed to radically bring down response times, and lives needed to be saved for cost effectiveness.

OBJECTIVES: Helicopter Emergency Medical Services (HEMS) throughout Europe are generally on scene within 10-15 minutes. In Norway, however, with its 13 HEMS bases, only 75% of the population can currently be reached within half an hour. We estimate the number of HEMS bases needed to reach the full Norwegian population within 10-15 minutes, and discuss implications regarding cost effectiveness. METHODS: Using geographic location and population characteristics from Norway's 428 municipalities as input to the Maximal Covering Location Problem-a mathematical location optimization model-we estimate the number of HEMS bases required along with accompanying personnel and healthcare costs. We estimate the minimum number of lives that would have to be saved to achieve a net social benefit of zero. RESULTS: To reach 99% or 100% of the Norwegian population by HEMS within 15 minutes 78 or 104 bases are needed, respectively. The incremental need for personnel going from 20 to 15 minutes for 99/100% of the population is 602/728, with an accompanying incremental cost of 228/276 million EURO per year. A yearly total of 280/339 additional lives would have to be saved to obtain a net social benefit of zero. Then, the HEMS-system as a whole would be cost effective although the least efficient bases still would not be. CONCLUSIONS: Reducing Norwegian HEMS response times to 10-15 minutes requires a drastic increase in the number of HEMS bases needed. Choice of ethical philosophy (utilitarianism or egalitarianism) determines when the expansion might be considered cost effective.

Community paramedicine: cost-benefit analysis and safety evaluation in paramedical emergency services in rural areas - a scoping review.

OBJECTIVE: To examine the current knowledge and possibly identify gaps in the knowledge base for cost-benefit analysis and safety concerning community paramedicine in rural areas. DESIGN: Scoping review. DATA SOURCES: MEDLINE via PubMed, CINAHL, Cochrane and Embase up to December 2020. STUDY SELECTION: All English studies involving community paramedicine in rural areas, which include cost-benefit analysis or safety evaluation. DATA EXTRACTION: This scoping review follows the methodology developed by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We systematically searched for all types of studies in the databases and the reference lists of key studies to identify studies for inclusion. The selection process was in two steps. First, two reviewers independently screened 2309 identified articles for title and abstracts and second performed a full-text review of 24 eligible studies for inclusion. RESULTS: Three articles met the inclusion criteria concerning cost-benefit analysis, two from Canada and one from USA. No articles met the inclusion criteria for safety evaluation. CONCLUSION: There are knowledge gaps concerning safety evaluation of community paramedicine in rural areas. Three articles were included in this scoping review concerning cost-benefit analysis, two of them showing positive cost-effectiveness with community paramedicine in rural areas.

Injuries after violence and accidents - the forgotten pandemic? / Skader etter vold og ulykker ­ den glemte pandemi?

All information on injuries should be collected in a national injury registry devised for research. This will pave the way for a new strategy for injury prevention.

Posttraumatic Stress Responses and Psychological Well-being in Norwegian Medical Helicopter Personnel.

OBJECTIVE: Emergency medical personnel are exposed to multiple stressors, including those of psychological etiologies. The aim of this study was to report the prevalence of anxiety, depression, and posttraumatic stress symptoms in Norwegian medical helicopter personnel and to determine to what degree they report personal growth or deprecation due to exposure to work-related events. METHODS: This was a web-based, cross-sectional survey performed among rescue paramedics and physicians staffing helicopter emergency medical services and search and rescue helicopters between May 5, 2021, and July 5, 2021. Questions included demographic data, the traumatic events exposure index, the Generalized Anxiety Disorder 7 scale, the Patient Health Questionnaire 9 (Depression), the posttraumatic change scale, and the posttraumatic symptom scale. RESULTS: Of the 245 eligible participants, 10 declined to take part and 74 failed to answer, producing a response rate of 66% (72 rescue paramedics and 89 physicians). Of the study population, 3.9 % reported manifest posttraumatic stress disorder symptoms, and 1.9% described moderate to severe depression and anxiety. The majority (76%) described posttraumatic emotional growth because of their work experience. CONCLUSION: Despite exposure to several traumatic stressors, participants reported a lower prevalence of posttraumatic stress symptoms, depression, and anxiety compared with a Norwegian adult population.

A cross-sectional study of mental health-, posttraumatic stress symptoms and post exposure changes in Norwegian ambulance personnel.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been shown to be elevated among first responders (Emergency Medical Services, fire service, police force) compared to the general population. Examining the prevalence of mental health issues in a work force with an elevated occupational risk is fundamental towards ensuring their wellbeing and implementing safeguard measures. The goal of this study is therefore to report the prevalence of depression, anxiety, posttraumatic development, and PTSD in Norwegian ambulance personnel. METHODS: This study is a cross-sectional, anonymous, web-based survey (Questback®), performed among operative personnel employed in the Emergency Medical Services in the Regional Health Trust of Central Norway between 18. February and 9. April 2021. The study was sent to 1052 eligible participants. Questions reported demographic data, a traumatic events exposure index, Patient Health Questionnaire-9 (Depression), Generalized Anxiety Disorder-7 scale, Posttraumatic symptom scale (PTSD) and Posttraumatic change scale. RESULTS: The response rate in this study was 45.5% (n = 479/1052). The mean age of respondents was 37.1 years (std. 11.1) and 52.8% (n = 253) were male. Of the respondents, 80.6% (n = 386) were married or had a partner, and 91.6% (n = 439) reported having access to a peer support programme, with 34.9% (n = 167) reporting that they had utilized peer support. In this study, 5% (n = 24) showed a prevalence of manifest posttraumatic stress disorder symptoms, while 8.6% (n = 41) reported moderate to severe depression and 2.9% (n = 14) presented moderate to severe symptoms of general anxiety. Of the respondents, 77.2% (n = 370) reported personal growth because of their work experiences. CONCLUSIONS: This study indicates that Norwegian ambulance personnel report a prevalence of posttraumatic stress symptoms and depression, which is slightly higher for men, and lower for the female proportion in this study, when compared to an adult Norwegian population. The vast majority of respondents reported personal growth because of their work experience, and both the degree of peer support and having a partner seem to influence levels of posttraumatic stress and -development.

A prospective observational study comparing two supraglottic airway devices in out-of-hospital cardiac arrest.

BACKGROUND: Airway management in patients with out of hospital cardiac arrest (OHCA) is important and several methods are used. The establishment of a supraglottic airway device (SAD) is a common technique used during OHCA. Two types of SAD are routinely used in Norway; the Kings LTS-D™ and the I-gel®. The aim of this study was to compare the clinical performance of these two devices in terms of difficulty, number of attempts before successful insertion and overall success rate of insertion. METHODS: All adult patients with OHCA, in whom ambulance personnel used a SAD over a one-year period in the ambulance services of Central Norway, were included. After the event, a questionnaire was completed and the personnel responsible for the airway management were interviewed. Primary outcomes were number of attempts until successful insertion, by either same or different ambulance personnel, and the difficulty of insertion graded by easy, medium or hard. Secondary outcomes were reported complications with inserting the SAD's. RESULTS: Two hundred and fifty patients were included, of whom 191 received I-gel and 59 received LTS-D. Overall success rate was significantly higher in I-gel (86%) compared to LTS-D (75%, p = 0.043). The rates of successful placements were higher when using I-gel compared to LTS-D, and there was a significant increased risk that the insertion of the LTS-D was unsuccessful compared to the I-gel (risk ratio 1.8, p = 0.04). I-gel was assessed to be easy to insert in 80% of the patients, as opposed to LTS-D which was easy to insert in 51% of the patients. CONCLUSIONS: Overall success rate was significantly higher and the difficulty in insertion was significantly lower in the I-gel group compared to the LTS-D in patients with OHCA.

Introducing fairness in Norwegian air ambulance base location planning.

BACKGROUND: A primary task of the Norwegian helicopter emergency medical services (HEMS) is to provide advanced medical care to the critical ill and injured outside of hospitals. Where HEMS bases are located, directly influences who in the population can be reached within a given response time threshold and who cannot. When studying the locations of bases, the focus is often on efficiency, that is, maximizing the total number of people that can be reached within a given set time. This approach is known to benefit people living in densely populated areas, such as cities, over people living in remote areas. The most efficient solution is thus typically not necessarily a fair one. This study aims to incorporate fairness in finding optimal air ambulance base locations. METHODS: We solve multiple advanced mathematical optimization models to determine optimal helicopter base locations, with different optimization criteria related to the level of aversion to inequality, including the utilitarian, Bernoulli-Nash and iso-elastic social welfare functions. This is the first study to use the latter social welfare function for HEMS. RESULTS: Focusing on efficiency, a utilitarian objective function focuses on covering the larger cities in Norway, leaving parts of Norway largely uncovered. Including fairness by rather using an iso-elastic social welfare function in the optimization avoids leaving whole areas uncovered and in particular increases service levels in the north of Norway. CONCLUSIONS: Including fairness in determining optimal HEMS base locations has great impact on population coverage, in particular when the number of base locations is not enough to give full coverage of the country. As results differ depending on the mathematical objective, the work shows the importance of not only looking for optimal solutions, but also raising the essential question of 'optimal with respect to what'.

Developing Quality Indicators for Helicopter Emergency Medical Services Coordination in Norwegian Emergency Medical Communication Centrals: A Consensus Process.

OBJECTIVE: Efforts to optimize the use, availability, and safety of helicopter emergency medical services (HEMS) is important. A lack of consistent and comprehensive flight dispatch procedures and a lack of use of safety technology are recurring safety problems. Reports after several major incidents pointed toward a possible gain by coordinating Norwegian HEMS from regional emergency medical communication centrals. Our objective was to develop and implement relevant quality indicators before such implementation in central Norway. METHODS: We recruited an expert panel of 24 persons representing Norwegian health authorities, emergency medical communication centrals, and HEMS bases and performed a 3-step e-mail-based Delphi process to develop relevant quality indicators. Each indicator was assessed according to their feasibility, rankability, actionability, and variability. To reach a consensus, a median score of 5 or more on a 6-point Likert scale in step 3 was needed. RESULTS: A total of 61 quality indicators were proposed. Of the 14 indicators that reached a consensus, 12 of these were considered process indicators, and 2 were bordering to outcome indicators. CONCLUSION: We applied a Delphi process method to develop quality indicators for HEMS coordination and flight following. An experienced and heterogeneous expert panel suggested and reached a consensus on which quality indicators should be applied.

Improper monitoring and deviations from physiologic treatment goals in patients with brain injury in the early phases of emergency care.

Severe traumatic brain injury (TBI), out-of-hospital cardiac arrest (OHCA) and intracerebral- and subarachnoid hemorrhage (ICH/SAH) are conditions associated with high mortality and morbidity. The aim of this study was to investigate the feasibility of obtaining continuous physiologic data and to identify possible harmful physiological deviations in these patients, in the early phases of emergency care. Patients with ICH/SAH, OHCA and severe TBI treated by the Physician-staffed Emergency Medical Service (P-EMS) between September and December 2016 were included. Physiological data were obtained from site of injury/illness, during transport, in the emergency department (ED) and until 3 h after admittance to the intensive care unit. Physiological deviations were based on predefined target values within each 5-min interval. 13 patients were included in the study, of which 38% survived. All patients experienced one or more episodes of hypoxia, 38% experienced episodes of hypercapnia and 46% experienced episodes of hypotension. The mean proportion of time without any monitoring in the pre-hospital phase was 29%, 47% and 56% for SpO2, end-tidal CO2 and systolic blood pressure, respectively. For the ED these proportions were 57%, 71% and 56%, respectively. Continuous physiological data was not possible to obtain in this study of critically ill and injured patients with brain injury. The patients had frequent deviations in blood pressure, SpO2 and end tidal CO2-levels, and measurements were frequently missing. There is a potential for improved monitoring as a tool for quality improvement in pre-hospital critical care.

Prehospital Stressors: A Cross-sectional Study of Norwegian Helicopter Emergency Medical Physicians.

OBJECTIVE: Personnel working in helicopter emergency medical services (HEMS) and search and rescue (SAR) are exposed to environmental stressors, which may impair performance. The aim of this survey was to study the extent HEMS and SAR physicians report the influence of specific danger-based and non-danger-based stressors. METHODS: The study was performed as a cross-sectional, anonymous, Web-based (Questback AS, Bogstadveien 54, 0366 Oslo, Norway) survey of Norwegian HEMS and SAR physicians between December 2, 2019, and February 25, 2020. RESULTS: Of the recipients, 119 (79.3%) responded. In helicopter operations, 33.6% (n = 40) reported involvement in a minor accident and 44.5% (n = 53) a near accident. In the rapid response car, 26.1% (n = 31) reported near accidents, whereas 26.9% (32) reported this in an ambulance. Of physicians, 20.2% (n = 24) received verbal abuse or threats during the last 12 months. When on call, 50.4% (n = 60) of physicians reported sometimes or often being influenced by fatigue. CONCLUSION: This study shows that Norwegian HEMS and SAR physicians are exposed to several stressors of both a danger-based and non-danger-based nature, especially regarding accidents, threatening patient behavior, and fatigue. Very serious incidents appear to be seldom, and job satisfaction is high.

Community paramedicine-cost-benefit analysis and safety with paramedical emergency services in rural areas: scoping review protocol.

INTRODUCTION: Community paramedicine models have been developed around the world in response to demographic changes, healthcare system needs and reforms. The traditional role of the paramedic has primarily been to provide emergency medical response and transportation of patients to nearby medical facilities. As a response to healthcare service gaps in underserved communities and the growing professionalisation of the workforce, the role of community paramedicine has evolved as a new model of care. A community paramedicine model in one region might address other healthcare needs than a model in another region. Various terms are also in use for community paramedicine providers, with no consensus on the definition for community paramedics, although the definition used by the International Roundtable on Community Paramedicine has been widely accepted. We aimed to examine the current knowledge and possibly identify gaps in the research/knowledge base for cost-benefit analysis and safety concerning community paramedicine in rural areas using a scoping review methodology. METHODS AND ANALYSIS: This scoping review will follow the methodology developed by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. In October 2020, we will search electronic databases (MEDLINE via PubMed, CINAHL, Cochrane and Embase) and the reference lists of key studies to identify studies for inclusion. The selection process is in two steps. First, two reviewers will independently screen identified articles for title and abstracts and, second, perform a full-text review of eligible studies for inclusion. Studies focusing on community paramedicine in rural areas, which include cost-benefit analysis or safety evaluation, will be included. ETHICS AND DISSEMINATION: The data used are available from publicly secondary sources, therefore this study will not require ethical review. The results will be disseminated through peer-reviewed publication.

Undertriage in trauma: an ignored quality indicator?

BACKGROUND: Early identification of life-threatening injuries is essential to reduce morbidity and mortality in trauma patients. Failure to detect severe injury may cause delayed diagnosis and therapeutic interventions and is associated with increased morbidity. A national trauma system will contribute to ensure the optimal care for seriously injured patients throughout the treatment chain by, among other things, defining a sensitive triage tool for identifying severe injury and contribute to correct treatment destination. In 2017, a National trauma plan was implemented in Norway and several quality indicators were recommended to ensure an evaluation of potential gaps between achieved and desired quality, and thereby highlighting areas with potential for quality improvement. With this commentary, we want to draw attention to, what we believe is, an ignoring of an important quality indicator: undertriage in trauma. MAIN BODY: Severely injured patients not met by a trauma team is commonly referred to as undertriage. An undertriage rate below 5 % is an internationally recognized quality indicator in trauma care and is emphasized in the Norwegian national trauma plan. However, whether hospitals measure and report data about undertriage, have received little attention. Therefore, a national survey was performed among Norwegian hospitals, where thirty-seven of forty trauma receiving hospitals contributed. The results of the survey showed that only half of Norwegian trauma hospitals were capable of providing these data. The results of this survey show that currently the national trauma system is not equipped to obtain important data on an important and specific quality indicator. An ongoing discussion at a national level is how to define severe injury, which may alter future definitions on undertriage. CONCLUSIONS: Knowledge of undertriage in trauma is important to enhance patient safety, increase the precision of the triage tool and provide valuable learning information to individual hospitals and prehospital services. Currently only half of Norwegian hospitals who receive trauma patients report undertriage rates and unfortunately, only few hospital administrators request these data.