Outcomes of adult patients discharged at scene by emergency medical services.

BACKGROUND: The outcomes of patients who call an ambulance but are discharged at scene reflect the safety and quality of emergency medical service (EMS) care. While previous studies have examined the outcomes of patients discharged at scene, none have specifically focused on paramedic-initiated discharge. This study aims to describe the outcomes of adult patients discharged at scene by paramedics and identify factors associated with 72-hour outcomes. METHODS: This was a retrospective data linkage study on consecutive adult EMS patients discharged at scene by paramedics in Victoria, Australia, between 1 January 2015 and 30 June 2019. Multivariable logistic regression was used to investigate factors associated with EMS recontact, ED presentation, hospital admission and serious adverse events (death, cardiac arrest, category 1 triage or intensive care unit admission) within 72 hours of the initial emergency call. RESULTS: There were 375 758 cases of adults discharged at scene following EMS attendance, of which 222 571 (59.2%) were paramedic-initiated decisions. Of these, 6.8% recontacted EMS, 5.0% presented to ED, 2.4% were admitted to hospital and 0.3% had a serious adverse event in the following 72 hours. The odds of EMS recontact were increased in cases related to mental health (adjusted OR (AOR) 1.41 (95% CI 1.33 to 1.49)), among low-income government concession holders (AOR 1.61 (95% CI 1.55 to 1.67)) and in areas of low socioeconomic advantage (AOR 1.19 (95% CI 1.13 to 1.25)). The odds of hospital admission were increased in cases related to infection (AOR 3.14 (95% CI 2.80 to 3.52)) and pain (AOR 1.93 (95% CI 1.75 to 2.14)). The strongest driver of serious adverse events was an abnormal vital sign (AOR 4.81 (95% CI 3.87 to 5.98)). CONCLUSION: The occurrence of hospital admission and adverse events is rare in those discharged at scene, suggesting generally safe decision-making. However, increased attention to elderly, multimorbid patients or patients with infection and pain is recommended, as is further research examining the use of tools to aid paramedic recognition of potential for deterioration.

Outcomes of people with severe hypoglycaemia requiring prehospital emergency medical services management: a prospective study.

AIMS/HYPOTHESIS: The aim of this work was to investigate clinical outcomes following severe hypoglycaemia requiring prehospital emergency medical services (EMS) management. METHODS: We carried out a prospective, observational study of adults with diabetes attended by prehospital EMS for management of severe hypoglycaemia between April 2016 and July 2017. Information on precipitants, hospitalisation, length of hospital stay and recurrence was collected at 1 and 3 months following the episode of severe hypoglycaemia. Median and logistic regression models examined predictive factors. RESULTS: Five hundred and five adults (61% male, median age 67 years) participated in the study. Fifty-two per cent had type 1 diabetes, 43% type 2 diabetes and 5% were unsure of their diabetes type. Following EMS management of the index episode of severe hypoglycaemia, 50.3% were transported to hospital. Of those transported, 41.3% were admitted to hospital for ongoing management (20.8% of all participants). The following factors predicted hospital admission: older age (OR 1.28 [95% CI 1.02, 1.60] per 10 years), greater number of comorbidities (OR 1.27 [95% CI 1.08, 1.48] per morbidity), moderate-severe injury accompanying the hypoglycaemia (OR 5.24 [95% CI 1.07, 25.8] compared with nil-mild injury) and unknown cause of hypoglycaemia (OR 2.21 [95% CI 1.24, 3.94] compared with known cause). The median (interquartile range) length of hospital stay was 4 (2-7) days. During follow-up, recurrent severe hypoglycaemia attended by prehospital EMS was experienced by 10.7% of participants. Predictive factors of recurrent severe hypoglycaemia in 3 months were decreased HbA1c (OR 1.97 [95% CI 1.27, 3.06] per 10 mmol/mol decrease) and a greater number of antecedent severe hypoglycaemia episodes (OR 1.12 [95% CI 1.03, 1.23] per episode). CONCLUSIONS/INTERPRETATION: Following an episode of severe hypoglycaemia managed by EMS, one-fifth of participants required hospital admission, more likely in those with advancing age, increasing comorbidities and injury and one-tenth required EMS again for severe hypoglycaemia in a 3 month period, more likely in those with a greater number of antecedent episodes and lower HbA1c. Knowledge of these factors associated with admission and recurrence provides an opportunity for development of targeted strategies aimed at prevention of severe hypoglycaemia in those most vulnerable.

Geographical variation of diabetic emergencies attended by prehospital Emergency Medical Services is associated with measures of ethnicity and socioeconomic status.

Geographical variation of diabetic emergencies attended by prehospital emergency medical services (EMS) and the relationship between area-level social and demographic factors and risk of a diabetic emergency were examined. All cases of hypoglycaemia and hyperglycaemia attended by Ambulance Victoria between 1/01/2009 and 31/12/2015 were tabulated by Local Government Area (LGA). Conditional autoregressive models were used to create smoothed maps of age and gender standardised incidence ratio (SIR) of prehospital EMS attendance for a diabetic emergency. Spatial regression models were used to examine the relationship between risk of a diabetic emergency and area-level factors. The areas with the greatest risk of prehospital EMS attendance for a diabetic emergency were disperse. Area-level factors associated with risk of a prehospital EMS-attended diabetic emergency were socioeconomic status (SIR 0.70 95% CrI [0.51, 0.96]), proportion of overseas-born residents (SIR 2.02 95% CrI [1.37, 2.91]) and motor vehicle access (SIR 1.47 95% CrI [1.08, 1.99]). Recognition of areas of increased risk of prehospital EMS-attended diabetic emergencies may be used to assist prehospital EMS resource planning to meet increased need. In addition, identification of associated factors can be used to target preventative interventions tailored to individual regions to reduce demand.

Utilisation of prehospital emergency medical services for hyperglycaemia: A community-based observational study.

AIMS: This study examines prehospital Emergency Medical Service (EMS) utilisation and patterns of demand for hyperglycaemia management, including characteristics of individuals and factors related to hospital transport. MATERIALS AND METHODS: A state-wide, community-based observational study of all patients requiring prehospital EMS for hyperglycaemia during a 7 year study period (Jan 2009-Dec 2015) using electronic data from the Ambulance Victoria data warehouse was conducted. Pre-specified variables related to patient demographics, comorbidities, examination findings, paramedic treatment and transport outcomes were obtained. Logistic regression was used to assess factors associated with transport to hospital. RESULTS: There were 11,417 cases of hyperglycaemia attended by paramedics during the study period, accounting for 0.3-0.4% of the total annual EMS caseload, and equating to 0.54 attendances per 100 people with diabetes in the state of Victoria, Australia, per year. There was a significant increase in annual utilisation, with a rate ratio of 1.62 between 2009 (2.42 cases per 10,000 population) and 2015 (3.91 cases per 10,000 population). Fifty-one percent of cases had type 2 diabetes, 37% had type 1 diabetes, 4% had diabetes with the type unspecified and 8% had no recorded history of diabetes. Ninety percent of cases were transported to hospital. Factors associated with increased odds of transport to hospital included no known history of diabetes, regional/rural locations, case time between 0600 and <1800 hours, increasing number of comorbidities and increasingly unstable vital sign observations. CONCLUSION: There is substantial utilisation of prehospital EMS for hyperglycaemia. With increased population prevalence of diabetes predicted, further research on opportunities for prevention, as well as optimal management in the prehospital environment is warranted.

Time series modelling to forecast prehospital EMS demand for diabetic emergencies.

BACKGROUND: Acute diabetic emergencies are often managed by prehospital Emergency Medical Services (EMS). The projected growth in prevalence of diabetes is likely to result in rising demand for prehospital EMS that are already under pressure. The aims of this study were to model the temporal trends and provide forecasts of prehospital attendances for diabetic emergencies. METHODS: A time series analysis on monthly cases of hypoglycemia and hyperglycemia was conducted using data from the Ambulance Victoria (AV) electronic database between 2009 and 2015. Using the seasonal autoregressive integrated moving average (SARIMA) modelling process, different models were evaluated. The most parsimonious model with the highest accuracy was selected. RESULTS: Forty-one thousand four hundred fifty-four prehospital diabetic emergencies were attended over a seven-year period with an increase in the annual median monthly caseload between 2009 (484.5) and 2015 (549.5). Hypoglycemia (70%) and people with type 1 diabetes (48%) accounted for most attendances. The SARIMA (0,1,0,12) model provided the best fit, with a MAPE of 4.2% and predicts a monthly caseload of approximately 740 by the end of 2017. CONCLUSIONS: Prehospital EMS demand for diabetic emergencies is increasing. SARIMA time series models are a valuable tool to allow forecasting of future caseload with high accuracy and predict increasing cases of prehospital diabetic emergencies into the future. The model generated by this study may be used by service providers to allow appropriate planning and resource allocation of EMS for diabetic emergencies.

Effect of diabetes and pre-hospital blood glucose level on survival and recovery after out-of-hospital cardiac arrest.

OBJECTIVE: Diabetes mellitus and blood glucose level (BGL) are emerging as important prognosticators of outcome in critically ill patients. We evaluated the effect of diabetes and pre-hospital BGL on survival to hospital discharge and on 12-month functional recovery after out-of-hospital cardiac arrest (OHCA). DESIGN, SETTING AND PARTICIPANTS: We performed a retrospective analysis of data from a statewide cardiac arrest registry in Victoria, Australia. We included 11 873 adult patients who had had an OHCA of presumed cardiac aetiology between 1 January 2007 and 30 June 2015. Of these, 2438 (20.5%) had documented diabetes. MAIN OUTCOME MEASURES: Survival to hospital discharge and 12-month functional recovery, measured using the Extended Glasgow Outcome Scale. RESULTS: Crude survival to hospital discharge differed among patients with and without diabetes (6.8% v 13.4%; P < 0.001). Diabetes significantly reduced the odds of survival to hospital discharge for patients presenting with a shockable rhythm (adjusted odds ratio [OR], 0.57; 95% CI, 0.38-0.86; P = 0.007) and reduced the odds of good 12-month functional recovery for patients discharged alive (OR, 0.57; 95% CI, 0.35-0.95; P = 0.03). In contrast, a mild-to-moderate elevation of pre-hospital BGL (8.0- 15.9 mmol/L) was present in 695 of 1319 patients with available data (52.7%) and was associated with improved survival and functional recovery outcomes, which were independent of diabetes status. CONCLUSIONS: Diabetes affects at least one in five patients who have had an OHCA and is associated with poorer survival and 12-month functional recovery after OHCA. In comparison, an elevated pre-hospital BGL is common in the peri-arrest period and may be associated with improved outcomes.

Utilisation of emergency medical services for severe hypoglycaemia: An unrecognised health care burden.

AIMS: Diabetes is associated with several acute, life-threatening complications yet there are limited data on the utilisation of prehospital services for their management. This study aimed to examine the utilisation of emergency medical services (EMS) for prehospital hypoglycaemia, including patient characteristics and factors related to hospital transportation. METHODS: An observational study of patients requiring EMS for hypoglycaemia across Victoria, Australia over three years was conducted. Pre-specified data including patient demographics, comorbidities, examination findings and transport outcomes were obtained. Logistic regression was used to assess factors associated with transportation. RESULTS: During the study period, 12,411 hypoglycaemia events were attended by paramedics for people with diabetes. The majority were individuals with type 1 diabetes (58.8%), followed by type 2 diabetes (35.2%) and unspecified diabetes type (5.9%). Thirty-eight percent of patients were transported to hospital by EMS following hypoglycaemia. Factors associated with transport by EMS included extremes of age (<15 and >75years), female gender, type 2 diabetes, event at a nursing home or hospital/community clinic, presence of comorbidities and time of day. CONCLUSIONS: Examination of the utilisation of EMS for hypoglycaemia has identified a previously unquantified need for emergency care for people with diabetes as well as factors related to hospital transportation.