The impact of video consultation on interprofessional collaboration and professional roles: a simulation-based study in prehospital stroke chain of care.

Healthcare is often conducted by interprofessional teams. Research has shown that diverse groups with their own terminology and culture greatly influence collaboration and patient safety. Previous studies have focused on interhospital teams, and very little attention has been paid to team collaboration between intrahospital and prehospital care. Addressing this gap, the current study simulated a common and time-critical event for ambulance nurses (AN) that also required contact with a stroke specialist in a hospital. Today such consultations are usually conducted over the phone, this simulation added a video stream from the ambulance to the neurologist on call. The aim of this study was to explore interprofessional collaboration between AN's and neurologists when introducing video-support in the prehospital stroke chain of care. The study took place in Western Sweden. The simulated sessions were video recorded, and the participants were interviewed after the simulation. The results indicate that video has a significant impact on collaboration and can help to facilitate better understanding among different professional groups. The participants found the video to be a valuable complement to verbal information. The result also showed challenges in the form of a loss of patient focused care. Both ANs and neurologists saw the video as benefiting patient safety.

Research on the Current Situation of Emergency Vehicle Management in Sports Medicine and Athletic Hospitals

Objective: To investigate the current state of emergency vehicle management within sports medicine and athletic hospitals, with a focus on hospitals located in Zhejiang Province. This study aims to provide valuable insights and recommendations for enhancing the management of emergency vehicles in the context of sports medicine. Methods: A convenience sampling approach was employed, involving surveys conducted with nurses from a total of 40 sports medicine and athletic hospitals located in 15 cities across Zhejiang Province during the period from April to May 2022. Results: The findings obtained through the questionnaire survey revealed noteworthy aspects. Specifically, 15.89% of the surveyed hospital departments lacked a dedicated pharmacist responsible for regular quality checks of emergency drugs. Furthermore, 55.14% of the respondents expressed concerns about the athlete nurses' level of knowledge regarding rescue drugs and related items. Alarmingly, the study found that 100% of the departments relied solely on manual inventory management for emergency drugs and items, with only 39.39% of them implementing partial information management systems, leading to varying degrees of inventory discrepancies. Conclusion: The study highlights certain shortcomings in the supervision and management systems related to emergency medicines and equipment within sports medicine and athletic hospitals. Additionally, personnel management practices appear to be lacking in some athletic hospitals. (AU)

On the Evaluation of the Ambulance Capacity of the Asian Side of Istanbul in the Case of a Serious Earthquake.

OBJECTIVES: The purpose of this study is to analyze a strategy for the assignment and transportation of injured patients to hospital to decrease the demand on transportation, in both predisaster and postdisaster periods, on the Anatolian side of Istanbul. METHODS: Two approaches are used in this study: a Voronoi diagram, and a heuristic approach to the problem of scheduling. A Voronoi diagram is used to divide the city into 74 regions, where each hospital has a certain region of responsibility. The transportation strategy of 1 hospital is modeled by minimizing the makespan (ie, the maximal completion time) and the work-in-process, which are used as different objectives in scheduling theory. RESULTS: The total waiting time of 100 injured people was minimized to 13,036 min when a total of 3 vehicles was used in the studied region, on the Asian side of Istanbul. The transportation capacity and total operating capacity of the hospitals should be approximately equal. CONCLUSIONS: The people of Istanbul will be in a safer position if the suggested measures are implemented. This is an important consideration, as Istanbul is situated in a region where serious earthquakes are possible at any moment.

Impact of crowding in local ambulance demand on call-to-ambulance scene arrival in out-of-hospital cardiac arrest.

BACKGROUND: Rapid emergency medical service (EMS) response is an important prognostic factor in out-of-hospital cardiac arrest (OHCA). This study aims to evaluate the association between local hourly EMS demand and ambulance response in OHCA. METHODS: OHCA occurring in 24 districts of Seoul from 2013 to 2018 was analyzed. Hourly ambulance demand per ambulance in each local district of patient location at the hour of cardiac arrest was calculated as the crowding index. The crowding index was categorized according to quartiles (1Q: ≤0.43, 2Q: 0.44-0.67, 3Q: 0.68-0.99, 4Q: ≥1.0 calls/h\r/ambulance). The primary outcome was ambulance dispatched within 1 km of the OHCA scene. Multivariable logistic regression analysis was performed to test the association between the local hourly ambulance demand and outcomes. RESULTS: A total of 26,479 patients were analyzed. The rate of ambulance dispatched within 1 km decreased according to the crowding quartile (1Q: 31.3%, 2Q: 30.0%, 3Q: 28.8%, and 4Q: 26.6%). Compared to 1Q, adjusted odds ratios (95% CIs) of dispatch distance within 1 km in 2Q, 3Q, and 4Q were 0.92 (0.86-0.99), 0.86 (0.80-0.94), and 0.77 (0.71-0.84), respectively. CONCLUSION: Crowding in local ambulance demand was associated with less ambulance dispatched within 1 km and delayed response to the scene in OHCA. Strategies to mitigate and adjust to ambulance demand crowding may be considered for better EMS response performance.

Time for a prehospital-modified sequential organ failure assessment score: An ambulance-Based cohort study.

BACKGROUND: To adapt the Sequential Organ Failure Assessment (SOFA) score to fit the prehospital care needs; to do that, the SOFA was modified by replacing platelets and bilirubin, by lactate, and tested this modified SOFA (mSOFA) score in its prognostic capacity to assess the mortality-risk at 2 days since the first Emergency Medical Service (EMS) contact. METHODS: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of adults with acute diseases, referred to two tertiary care hospitals (Spain), between January 1st and December 31st, 2020. The discriminative power of the predictive variable was assessed through a prediction model trained using the derivation cohort and evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) on the validation cohort. RESULTS: A total of 1114 participants comprised two separated cohorts recruited from 15 ambulance stations. The 2-day mortality rate (from any cause) was 5.9% (66 cases). The predictive validity of the mSOFA score was assessed by the calculation of the AUC of ROC in the validation cohort, resulting in an AUC of 0.946 (95% CI, 0.913-0.978, p < .001), with a positive likelihood ratio was 23.3 (95% CI, 0.32-46.2). CONCLUSIONS: Scoring systems are now a reality in prehospital care, and the mSOFA score assesses multiorgan dysfunction in a simple and agile manner either bedside or en route. Patients with acute disease and an mSOFA score greater than 6 points transferred with high priority by EMS represent a high early mortality group. TRIAL REGISTRATION: ISRCTN48326533, Registered Octuber 312,019, Prospectively registered (doi:https://doi.org/10.1186/ISRCTN48326533).

Collective Critical Care Ambulance: an innovative transportation of critical care patients by bus in COVID-19 pandemic response.

BACKGROUND: During the COVID-19 pandemic, as the number of available Intensive Care beds in France did not meet the needs, it appeared necessary to transfer a large number of patients from the most affected areas to the less ones. Mass transportation resources were deemed necessary. To achieve that goal, the concept of a Collective Critical Care Ambulance (CCCA) was proposed in the form of a long-distance bus re-designed and equipped to accommodate up to six intensive care patients and allow Advanced Life Support (ALS) techniques to be performed while en route. METHODS: The expected benefit of the CCCA, when compared to ALS ambulances accommodating a single patient, was to reduce the resources requirements, in particular by a lower personnel headcount for several patients being transferred to the same destination. A foreseen prospect, comparing to other collective transportation vectors such as airplanes, was the door-to-door capability, minimalizing patients' handovers for safety concerns and time efficiency. With the project of a short-distance transfer of several Intensive Care Unit (ICU) patients together, the opportunity came to test the CCCA under real-life conditions and evaluate safely its technical feasibility and impact in time and resources saving, before it could be proposed for longer distances. RESULTS: Four COVID-19 patients were transported over 37 km. All patients were intubated and under controlled ventilation. One of them was under Norepinephrine support. Mean loading time was 1 min 39 s. Transportation time was 29 min. At destination, the mean unloading time was 1 min 15 s. No serious adverse effect, in particular regarding hemodynamic instability or ventilation disorder, has been observed. No harmful incident has occurred. CONCLUSIONS: It was a very instructive test. Collective medical evacuation by bus for critically ill patients under controlled ventilation is suitable and easy to implement. Design, ALS equipment, power autonomy, safety and resources saving, open the way for carrying up to 6 ICU-patients over a long distance. The CCCA could bring a real added-value in an epidemic context and could also be helpful in many other events generating multiple victims such as an armed conflict, a terrorist attack or a natural disaster.

Evaluation of the emergency medical system in an area following lifting of the mandatory evacuation order after the Fukushima Daiichi Nuclear Power Plant accident: A retrospective cross-sectional observational study.

ABSTRACT: Following the lifting of the evacuation order due to the Fukushima Daiichi Nuclear Power Plant accident, the medical demand and emergency medical system (EMS) in the area where the evacuation orders were lifted have not been well-investigated. This study aimed to evaluate the emergency transportation in such areas and compare the differences with areas that had minimal impact.Using the local EMS transport records, the characteristics of patients who were transferred by an EMS vehicle in Minamisoma City were collected between July 12, 2016 and July 31, 2018, and were compared between former evacuation zones and outside the evacuation zones in the city.The number of emergency transports in the study period in Minamisoma City were 325 cases in the area where the evacuation orders were lifted and 4307 cases in the other areas. The total EMS time was significantly longer in the area where the evacuation order was lifted (48 ±â€Š16 minutes) than in the other areas (40 ±â€Š15 minutes) (P < .001). In the analysis of each component of EMS times, the transport time, which is the time from departure from the patient's location to arrival at a hospital, was significantly longer in the former evacuation zone than in the other areas (16 ±â€Š9 vs 9 ±â€Š9 minutes, P < .001), suggesting that transport time contributed to the longer EMS response times.In areas where the evacuation orders were lifted, the EMS transport time was significantly longer than that in the area outside the former evacuation zone; correspondingly, the total EMS time significantly increased in the former evacuation zone. A plausible reason for this may be the closure of local medical facilities following the evacuation order after the nuclear accident.

COVID-19 pandemic and STEMI: pathway activation and outcomes from the pan-London heart attack group.

OBJECTIVES: To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19. METHODS: We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes RESULTS: There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19. CONCLUSION: These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

Air and ground ambulance location-allocation-routing problem for designing a temporary emergency management system after a disaster.

Disasters cause a huge number of injured patients in a short time while existing emergency facilities encountered devastation and cannot respond properly. Here, the importance of implementing temporary emergency management becomes clear. This study aims to locate some temporary emergency stations across the area by maximal covering after a disaster. Furthermore, a multi-mode fleet is used for transferring patients using different modes of transportation (e.g. helicopter ambulance and bus ambulance). Since the type of patients may change over periods, medical servers can displace among temporary emergency stations dynamically according to disaster severity. For this purpose, a new bi-objective dynamic location-helicopter ambulance allocation-ambulance routing model with multi-medical servers is presented. The first objective function minimizes the operational costs related to the newly designed Emergency Medical Service along with the rate of human loss. The second objective function minimizes the critical time spent before the medical treatment. To validate the developed model, the augmented ε-constraint method is used and applied for the Tehran city, which shows the applicability of the model. Finally, two meta-heuristic algorithms are customized for large-sized problems, and the related results are compared based on multi-objective algorithms' performance comparison metrics to find the more efficient one.

Characteristics of paediatric patients with altered conscious state attended by road ambulances in a metropolitan area - An 8 year observational study.

BACKGROUND: Out-of-hospital paediatric emergencies represent are rare and little is known about characteristics of paediatric patients with severe illness. This study seeks to describe the paediatric population with altered conscious state. METHODS: A retrospective electronic data review was conducted of paediatric patients (≤ 4 years) attended by road ambulances between January 2006 and December 2013. Patients with a Glasgow Coma Scale (GCS) score ≤9 were included. RESULTS: A total of 4533 children were included in the study, 55.9% of which were male. The majority of patients (48.7%) were between one and four years old. Pre-existing neurologic conditions were identified in 26.8% of patients. Seizures were the most common reason for emergency call (68.7%) and were more frequent in children 1-4 years (80.4%) than in <1 year (32.6%), 5-8 years (75.3%) or 9-14 years (53.9%, p < 0.001). Vital signs (heart rate, systolic blood pressure, oxygen saturation, GCS) improved or remained stable from time of first contact with Emergency Medical Service (EMS) to arrival at hospital. CONCLUSIONS: Seizure was the most common reason for ambulance attendances to children with altered conscious state, and most frequently occurred in preschool children. Pre-existing conditions were frequent. Vital signs and level of conscious stateof patients improved during paramedic management.

Innovations in Prehospital Stroke Management Utilizing Mobile Stroke Units.

Using a representative case, this article discusses prehospital innovations for patients with acute large vessel occlusion ischemic stroke, including mobile stroke unit care supported by advanced field imaging.

Evaluative Research of Technologies for Prehospital Communication and Coordination: a Systematic Review.

Various technologies have been designed and developed to support communication and coordination between the field and hospital during a medical emergency. The usability issues and human factors entailed in these new technologies are important to their application and effectiveness, suggesting the need to examine this information in a systematic review. The systematic review aims to synthesize the user-centered evaluative research of prehospital communication technologies. We conducted a systematic literature search in four databases (Medline, Cochrane, Embase, and Web of Science) for articles published between the years 2000 and 2019. We included articles that evaluated the technologies developed for supporting prehospital communication and collaboration, and were published in English. A total of 918 articles were retrieved and screened, with 17 articles included for in-depth analysis. Two authors conducted independent screens and reviews of the articles using a list of inclusion/exclusion criteria and defined factors. The types of technology of reviewed articles included ambulance-based telemedicine, wearable, handheld, and Internet of Things (IoT) devices. Even though these technologies have demonstrated high levels of user acceptance, the reviewed studies noted a variety of challenges faced by emergency care providers, which were grouped into three categories-technical, usability, and organizational challenges. Our review also highlighted the paucity of evaluative research of prehospital communication technologies and the lack of user engagement throughout system design process. Based on the results, we discuss the importance of adopting user-centered design approaches and accounting for three social-technical factors in designing technologies for time-critical medical settings, including cognitive and physical stressor, workflow, and context. This systematic review presents an overview of key evaluative research of prehospital communication technologies. The paucity of evaluative research in prehospital communication technology and challenges faced in adopting advanced technological solutions in emergency care highlight the need to adopt user-centered design and take into account socio-technical issues at the point of system design.

Using clinical based vignettes to further develop a mass gathering event triage tool.

BACKGROUND: Previously published triage tools for use at mass gathering events (MGE) lack real-world validation. Non-health care professionals, such as first aiders, first responders, and advanced responders often undertake a triage role at MGEs. This research aimed to determine consistency in the decision-making of a MGE triage tool. METHOD: Volunteer members of St John Ambulance Australia were recruited. Surveys included participant demographics and real-world clinical vignettes. Participants determined a triage category based on the vignettes and supplied triage tool. Demographics were analysed using descriptive statistics and responses to vignettes were analysed using Fleiss Kappa [p-bar]. RESULTS: There were 110 participants, the majority male (60%), having completed a Bachelor or higher degree (53.6%), and were non-health care professionals (70%). Of the vignettes, there was a slightly better than moderate agreement (items: 18, p-bar: 0.55). There was an excellent level of agreeance for the resuscitation category (items: 3, b-par 0.69), and moderate level of agreeance for the urgent (items: 10, b-par 0.52) and minor (items: 5, b-par 0.52) categories. CONCLUSIONS: This research demonstrated similar findings to that of emergency department triage tool validation. Multi-country, multi-site, multi-type, real-world testing at MGEs is the next step to progress the development of this tool.

Stakeholder opinion on the proposal to introduce 'treat and referral' into the Irish emergency medical service.

BACKGROUND: The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call, regardless of acuity, to an emergency department (ED). A proposal to introduce Treat and Referral, an established care pathway in some jurisdictions, is under active consideration in Ireland. This will present a significant change. Stakeholder engagement is recognised as an essential component of management of such change. This study has conducted a multicentre, cross-sectional survey exploring opinions on the introduction of Treat and Referral among key Irish stakeholders; consultants in emergency medicine, paramedics and advanced paramedics. METHODS: Public-sector consultants in emergency medicine (EM), registered paramedics and advanced paramedics, in Ireland at the time of the study, were invited to complete an on-line survey. RESULTS: A significant finding was that 90% of both cohorts (EM consultants and registered paramedic practitioners) support written after-care instructions being given to referred patients, that > 83% agree that Treat and Referral will reduce unnecessary ambulance journeys and that 70% are in favour of their own family member being offered Treat and Referral. Consensus was reached between respondents that Treat and Referral would improve care and increase clinical judgement of practitioners. Differences were identified in relation to the increased availability of ambulances locally, that only adults should be included, and that research was required to extend Treat and Referral beyond the index conditions. There was no consensus on whether general practitioners (GPs) should be directly informed. CONCLUSIONS: This study identified that the Irish healthcare practitioners surveyed are supportive of the introduction of Treat and Referral into Ireland. It also affords healthcare policymakers the opportunity to address the concerns raised, in particular the clinical level which will be targeted for inclusion in this extended scope of practice.

Two-Tiered Ambulance Dispatch and Redeployment considering Patient Severity Classification Errors.

A two-tiered ambulance system, consisting of advanced and basic life support for emergency and nonemergency patient care, respectively, can provide a cost-efficient emergency medical service. However, such a system requires accurate classification of patient severity to avoid complications. Thus, this study considers a two-tiered ambulance dispatch and redeployment problem in which the average patient severity classification errors are known. This study builds on previous research into the ambulance dispatch and redeployment problem by additionally considering multiple types of patients and ambulances, and patient classification errors. We formulate this dynamic decision-making problem as a semi-Markov decision process and propose a mini-batch monotone-approximate dynamic programming (ADP) algorithm to solve the problem within a reasonable computation time. Computational experiments using realistic system dynamics based on historical data from Seoul reveal that the proposed approach and algorithm reduce the risk level index (RLI) for all patients by an average of 11.2% compared to the greedy policy. In this numerical study, we identify the influence of certain system parameters such as the percentage of advanced-life support units among all ambulances and patient classification errors. A key finding is that an increase in undertriage rates has a greater negative effect on patient RLI than an increase in overtriage rates. The proposed algorithm delivers an efficient two-tiered ambulance management strategy. Furthermore, our findings could provide useful guidelines for practitioners, enabling them to classify patient severity in order to minimize undertriage rates.

What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom.

BACKGROUND: Emergency ambulance services are integral to providing a service for those with unplanned urgent and life-threatening health conditions. However, high use of the service by a small minority of patients is a concern. Our objectives were to describe: service-wide and local policies or pathways for people classified as Frequent Caller; call volume; and results of any audit or evaluation. METHOD: We conducted a national survey of current practice in ambulance services in relation to the management of people who call the emergency ambulance service frequently using a structured questionnaire for completion by email and telephone interview. We analysed responses using a descriptive and thematic approach. RESULTS: Twelve of 13 UK ambulance services responded. Most services used nationally agreed definitions for 'Frequent Caller', with 600-900 people meeting this classification each month. Service-wide policies were in place, with local variations. Models of care varied from within-service care where calls are flagged in the call centre; contact made with callers; and their General Practitioner (GP) with an aim of discouraging further calls, to case management through cross-service, multi-disciplinary team meetings aiming to resolve callers' needs. Although data were available related to volume of calls and number of callers meeting the threshold for definition as Frequent Caller, no formal audits or evaluations were reported. CONCLUSIONS: Ambulance services are under pressure to meet challenging response times for high acuity patients. Tensions are apparent in the provision of care to patients who have complex needs and call frequently. Multi-disciplinary case management approaches may help to provide appropriate care, and reduce demand on emergency services. However, there is currently inadequate evidence to inform commissioning, policy or practice development.

Needs assessment of emergency medical and rescue services in Abuja/Nigeria and environs.

BACKGROUND: Nigeria is ranked second highest in the rate of road accidents and other emergencies (Deaths, disabilities) among 193 countries of the world. There is therefore the need for analyzing Emergency Medical Rescue Services (EMRS) in the country to identify options for improvement. METHOD: The study was conducted from February, 2016 to March, 2017 in three EMRS organizations (FRSC, NEMA and MAITAMA Hospital) located in Abuja. The structure, resources, process of EMRS activities and outcome (delay times, case fatality as well as victims and service-providers satisfaction with services) were assessed through observation, time measurements and interviews. RESULTS: FRSC and NEMA offers (Road Traffic Injury) RTI and Disaster services, the ambulances consist of Intensive Care Unit(ICU) buses, Helicopters, Speed boats, motorbikes and other specialized vehicles. Mortality and morbidity recorded for 2016 was 1.1 and 2% respectively. MAITAMA is a specialist centre that offers general medical services. A total number 1227(88.8%) lives were saved during the observational period by three organizations, 60(4.9%) deaths, 132 (9.6%) disabilities, 793 (57.2%) NCDs and 593(42.8%) RTI. CONCLUSION: Non-communicable diseases (NCDs) cause many deaths and morbidities in the developing world compared to infectious diseases. There is need for total revamping and education of EMRS institutions in Nigeria and Low- Middle Income Countries (LMICs). Abuja and its surroundings suffers from delays in rapid emergency services, lack of adequate awareness, functional ambulances, minimal specialists and inadequate consumables lead to the loss of many lives.