The non-conveyance of trauma patients in Swedish emergency medical services: a retrospective observational study of the trauma population not transported to an emergency department.

INTRODUCTION: Due to a systemic modification in Swedish emergency medical services (EMS) staffing in recent years, the nature of the Swedish EMS has changed. Transport to an emergency department (ED) is no longer the only option. Referrals and non-conveyance form a growing part of EMS assignments. Trauma is one of the most common causes of death and accounts for 17% of Swedish EMS assignments. The aim of this study was to describe the characteristics and clinical outcomes of non-conveyed trauma patients who were assessed, treated and triaged by the EMS to gain a better understanding of, and to optimise, transport and treatment decisions. METHODS: The study had a descriptive, retrospective and epidemiologic design and was conducted by reviewing EMS and hospital records for 837 non-conveyed trauma patients in the southwest of Sweden in 2019. RESULTS: Three in four non-conveyed trauma patients did not seek further medical care within 72 h following EMS assessment. The patients who were admitted to hospital later were often older, had suffered a fall and had a medical history. Half of all the incidents occurred in a domestic environment, and head trauma was the major complaint. Less than 1% of the studied patients died. CONCLUSION: Most of the non-conveyed trauma patients did not seek further medical care after being discharged at the scene. Falling was the most common trauma event, and for the older population, this meant a higher risk of hospital admission. The reasons for falls should therefore be investigated thoroughly prior to non-conveyance decisions. Future studies should focus on the reasons for non-conveyance and measure the morbidity and invalidity outcomes rather than mortality.

Epidemiology of patients assessed for trauma by Swedish ambulance services: a retrospective registry study.

BACKGROUND: There is a lack of knowledge regarding the epidemiology of severe trauma assessed by Swedish emergency medical services (EMS). AIM: To investigate the prevalence of trauma in Sweden assessed by EMS from a national perspective and describe patient demography, aetiology, trauma type, prehospital triage and clinical outcomes. METHODS: Data from two national quality registries, the Swedish Ambulance Registry and the Swedish Trauma Registry (SweTrau) were collected from January 1 to December 31, 2019. Inclusion criteria were an Emergency Symptoms and Signs code equivalent to trauma in the Swedish Ambulance Registry and criteria fulfilled for SweTrau inclusion. Exclusion criteria were patients < 18 years old, those not transported to a hospital and those without a personal identification number. RESULTS: In total, 53,120 patients with trauma were included (14% of primary EMS missions involving a personal identification number). Of those, 2,278 (4.3%) patients (median age: 45 years; 32% women) were reported in SweTrau to have severe or potentially severe trauma (penetrating: 7%, blunt: 93%). In terms of including all causes of trauma, the code for 'trauma alert activation' was most frequent (55%). The most frequent injury mechanism was an injury caused by a car (34%). Most (89%) cases were assigned Priority 1 (life-threatening condition) at the dispatch centre. 62% were regarded as potentially life threatening upon EMS arrival, whereas 29% were assessed as non-life-threatening. Overall, 25% of the patients had new injury severity scores > 15. 12% required invasive treatment, 11% were discharged with severe disability and the 30-day mortality rate was 3.6%. CONCLUSION: In this cross-sectional study, 14% of the primary EMS missions for one year were caused by trauma. However, only a small proportion of these cases are severe injuries, and the risk of severe disabilities and death appears to be limited. The most frequent aetiology of a severe trauma is injury caused by a car, and most severe traumas are blunt. Severe traumas are given the highest priority at the dispatch centre in the vast majority of cases, but nearly one-third of these cases are considered a low priority by the EMS nurse. The latter leaves room for improvement.

[Documentation of prehospital emergency care]. / Över 100 doktorsavhandlingar inom den prehospitala akutsjukvården i Sverige.

The scientific documentation of prehospital emergency care in Sweden is slowly expanding. The first thesis on the value of a mobile coronary care unit was defended in 1982. Since then, at least 106 theses have been defended at 15 educational institutes in Sweden. The theses can be divided into nine different themes, of which acute disease and prognostic factors (n = 30) is the most common, followed in order of frequency by caring, assessment and decision (n = 18), patient and next of kin perspective (n = 14), trauma (n = 1 1), competence, learning, and education (n = 10), care needs, cooperation, and prioritization (n = 10), disaster (n = 7), workers' health and environment (n = 3), and ethics and values (n = 3). The University of Gothenburg had the highest number of theses defended (n = 28), followed by the Karolinska Institute (n = 24) and the University of Umeå (n = 10). The theses were written by 64 nurses, 36 physicians, two public health specialists, one physiotherapist, one priest, one social worker, and one statistician.

Characteristics of a trauma population in an ambulance organisation in Sweden: results from an observational study.

BACKGROUND: Globally, injuries are a major health problem, and in Sweden, injuries are the second most common reason for ambulance dispatch. However, there is a knowledge gap regarding the epidemiology of injuries requiring assessment by emergency medical services (EMS) in Sweden. The aim of the present study was to describe the prehospital population with injuries that have been assessed and treated by EMS. METHODS: A randomly selected retrospective sample was collected from 1 January through 31 December 2019 in a region in southwestern Sweden. Data were collected from ambulance and hospital medical records. RESULTS: Among 153,724 primary assignments, 26,697 (17.4%) were caused by injuries. The study cohort consisted of 5,235 patients, of whom 50.5% were men, and the median age was 63 years. The most common cause of injury was low-energy fall (51.4%), and this was the cause in 77.8% of those aged > 63 years and in 26.7% of those aged ≤ 63 years. The injury mechanism was a motor vehicle in 8.0%, a motorcycle in 2.1% and a bicycle in 4.0%. The most common trauma location was the residential area (55.5% overall; 77.9% in the elderly and 34.0% in the younger group). In the prehospital setting, the most frequent clinical sign was a wound (33.2%), a closed fracture were seen in 18.9% and an open fracture in 1.0%. Pain was reported in 74.9% and 42.9% reported severe pain. Medication was given to 42.4% of patients before arrival in the hospital. The most frequent triage colour according to the RETTS was orange (46.7%), whereas only 4.4% were triaged red. Among all patients, 83.6% were transported to the hospital, and 27.8% received fracture treatment after hospital admission. The overall 30-day mortality rate was 3.4%. CONCLUSION: Among EMS assignments in southwestern Sweden, 17% were caused by injury equally distributed between women and men. More than half of these cases were caused by low-energy falls, and the most common trauma location was a residential area. The majority of the victims had pain upon arrival of the EMS, and a large proportion appeared to have severe pain.

Prehospital assessment of patients with abdominal pain triaged to self-care at home: an observation study.

BACKGROUND: Patients who call for emergency medical services (EMS) due to abdominal pain suffer from a broad spectrum of diseases, some of which are time sensitive. As a result of the introduction of the concept of 'optimal level of care', some patients with abdominal pain are triaged to other levels of care than in an emergency department (ED). We hypothesised that it could be challenging in a patient safety perspective. AIM: This study aims to describe consecutive patients who call for EMS due to abdominal pain and are triaged to self-care by EMS clinicians. METHODS: This was an observational study performed in an EMS organisation in Western Sweden during 2020. The triage tool Rapid Emergency Triage and Treatment System (RETTS), which included Emergency Signs and Symptom (ESS) codes, was used to find medical records where patients with abdominal pain have been triaged to self-care and 194 patients was included in the study. RESULTS: Of total 48,311 ambulance missions, A total of 1747 patients were labelled with ESS code six (abdominal pain), including 223 (12.8%) who were given the code for self-care and 194 who were further assessed by the research group. Of these patients, 32 (16.3%) had a return visit within 96 hours due to the same symptoms and 11 (5.6%) were hospitalised. In six of these patients, the EMS triage was evaluated retrospectively and assessed as inappropriate. These patients had a final diagnosis of ruptured abdominal aneurysm (n = 1), acute appendicitis with peritonitis (n = 2) and acute pancreatitis (n = 3). All these patients required extensive evaluation and different treatments, including acute surgery, antibiotics and fluid therapy. CONCLUSION: Amongst the 1747 patients assessed by EMS due to abdominal pain, 223 (12.8%) were triaged to self-care. Of the 194 patients who were further assessed, 16.3% required a return visit to the ED within 96 hours and 5.6% were hospitalised. Six patients had obvious time-sensitive conditions. Our study highlights the difficulties in the early assessment of abdominal pain and the requirement for an accurate decision support tool.

Satisfaction among non-conveyed patients and significant others when discharged at the scene by the ambulance service: an exploratory cross-sectional survey.

BACKGROUND: The ambulance service is facing an increased number of calls and ambulance assignments. Between 12 and 42% of all assignments result in non-conveyance to the Accident and Emergency Department. However, there is limited knowledge regarding satisfaction among patients and significant others when patients are assessed as non-urgent and discharged at the scene. Therefore, the aim of the study was to explore and compare satisfaction with the ambulance service among patients and significant others when the patient was discharged at the scene. METHODS: The present study was designed as a cross-sectional exploratory survey with a consecutive sample employing the Consumer Emergency Care Satisfaction Scale questionnaire on patients and significant others. RESULTS: A total of 162 questionnaires were analysed, 87 patients and 75 significant others. Overall, satisfaction was high with no significant difference between patients and significant others, although 17-19% were dissatisfied with the discharge information. CONCLUSIONS: Generally, patients and significant others are satisfied with the care provided by the Ambulance Service when discharged at the scene and thus not conveyed the Accident and Emergency Department. The participants were especially satisfied with Specialist Ambulance Nurses' interpersonal skills, e.g., making time and providing thorough information. Guidelines for assignments involving non-conveyance, as well as information, instructions and what to expect when discharged at the scene can be improved.

Suboptimal prehospital decision- making for referral to alternative levels of care - frequency, measurement, acceptance rate and room for improvement.

BACKGROUND: The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from "time-sensitive conditions" delaying diagnosis and treatment. Thus, four questions arise: 1) How often are time-sensitive cases referred to primary care or self-care advice? 2) How can we measure and define the level of inappropriate clinical decision-making? 3) What is acceptable? 4) How to increase patient safety? MAIN TEXT: To what extent time-sensitive cases are non-conveyed varies. About 5-25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1-3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%. The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome. In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories. There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another. CONCLUSION: A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.

[The role of prehospital emergency care in Sweden has changed - patient safety has become a key issue]. / Den prehospitala akutsjukvården i Sverige har stora utmaningar.

Prehospital emergency care in Sweden has undergone dramatic changes in recent decades from the role of being a primary transport organization to a more differentiated approach to health care. The Swedish prehospital emergency nurse must therefore today make prehospital assessments to be able to decide whether patients should be transported to hospital with ¼fast-track« or sent to primary care or stay at home with advice on self-care. Therefore, ¼patient safety« has become a key issue and primary data indicate that there is a risk of a potential adverse event in approximately four percent of the primary assignments. Computer based decision support tools are under development and time-sensitive conditions need to be defined. We also need to further develop symptom-relieving therapy and the possibility of starting causal therapy already on the spot. Future perspectives include the use of biochemical markers as well as simple X-ray examinations to further improve pre-hospital assessment.

Fascia iliaca compartment block (FICB) as pain treatment in older persons with suspected hip fractures in prehospital emergency care - A comparative pilot study.

BACKGROUND: Older persons with a suspected hip fracture and suffering considerable pain are common patients in the emergency medical services (EMS). Pain treatment needs to be improved and fascia iliaca compartment block (FICB) can be one option. The purpose of this paper was to analyse prehospital pain in patients with a suspected hip fracture under EMS care and to compare standard treatment and FICB. METHODS: An evaluation of a retrospective case-control study comprising 135 patients from a pilot project with FICB in an EMS organisation in Sweden. The control patients were matched with FICB patients. Pain was assessed on the arrival of the EMS and on arrival in hospital. RESULTS: In all, 27 patients received FICB and 108 had standard pain treatment. There was a significant reduction in pain in both groups. However, there was a more marked reduction in pain among patients who received FICB than in the control group. So, for static pain, 56% experienced a reduction in pain in the FICB group versus 30% among controls (p < 0.01). The corresponding values for dynamic pain were 85% and 59% (p < 0.01). CONCLUSION: FICB can be a good supplement to standard prehospital pain treatment in patients with suspected hip fractures.

Cognitive status following a hip fracture and its association with postoperative mortality and activities of daily living: A prospective comparative study of two prehospital emergency care procedures.

INTRODUCTION: Early assessment of hip fracture patients' cognitive function is important for preventing pre- and postoperative complications. The aim of this study was twofold: (1) to assess prehospital cognitive function in hip fracture patients and establish whether cognitive status differs pre- and postoperatively between prehospital fast track care (PFTC) and the traditional emergency department (ED) pathway and (2) whether preoperative cognitive function is associated with postoperative mortality and activities of daily living (ADL) ability. METHODS: Three hundred and ninety one hip fracture patients were prospectively included. The Short Portable Mental Status Questionnaire (SPMSQ) was used prehospital, at the orthopaedic ward and three days postoperatively. ADL was followed up after four months. RESULTS: No difference in patients' cognitive function was observed between PFTC and ED. Four-month mortality was 37% for patients with dementia, 21% for those with cognitive impairment and 10% for patients without cognitive impariment. Only 26% of patients with dementia and 47% with cognitive impairment had full ADL ability, compared with 70% of patients with intact cognitive function (p < 0.001). CONCLUSION: PFTC did not influence hip fracture patients' cognitive function. Patients with prehospital cognitive impairment had a poor outcome in terms of mortality and ADL, indicating the need for special care interventions.

It was not a hip fracture - you were lucky this time - or perhaps not! A prospective study of clinical outcomes in patients with low-energy pelvic fractures and hip contusions.

INTRODUCTION: Prehospital and hospital emergency care guidelines have been developed for patients with suspected hip fracture. Initial radiography can identify a number of patients with other injuries, generally pelvic fractures and hip contusions. Little is known about the prognosis for these patients. The aim of this study is twofold: i) to investigate the injury pattern of patients assessed in prehospital emergency care as suffering from a suspected hip fracture and ii) to compare clinical outcomes between patients with verified hip fracture (HF) and those with other hip injuries (OHI). METHOD: The study design was prospective. Older patients with suspected HF after low-energy trauma were identified in prehospital emergency care. Injury type was determined by radiological imaging. Comparisons of length of stay, adverse events, repeated prehospital emergency care and mortality were made between verified HF and OHI cases. RESULTS: 449 patients were included, 400 in the HF and 149 in the OHI group (86 hip contusions, 46 pelvic fractures and 17 other injuries/diseases). The HF group had a significantly longer hospital stay (9.5 days vs. 6.3 for the OHI group; p < 0.001) and more adverse events while in hospital (34% vs. 19%; p < 0.001). We found no evidence that the groups differed with regard to other outcomes: mortality during hospital stay (4% vs. 2%, p = 0.42), at 4 (16% vs. 13%; p = 0.35) and 12 months (21 vs. 23%; p = 0.64), the proportion that experienced an adverse event (24% vs. 22%; p = 0.65) and the proportion that required another ambulance transport within 6 months after discharge (40% vs. 34%; p = 0.16). The results were not strongly affected by adjustments for possible confounders. CONCLUSION: Older patients who suffer a low-energy pelvic fracture or a hip contusion are common in prehospital and hospital emergency care. These patients need attention as they have poor outcomes in terms of adverse events, mortality and recurrent need for ambulance transport after discharge from hospital. While individualized multidisciplinary care is recommended for hip fracture patients, it might also be suitable for other geriatric hip injuries.

Patient satisfaction with prehospital emergency care following a hip fracture: a prospective questionnaire-based study.

BACKGROUND: Older patients with a hip fracture require specialized emergency care and their first healthcare encounter before arriving at the hospital is often with the ambulance service. Since 2005 there has been a registered nurse on the crew of every ambulance in Sweden in order to provide prehospital emergency care and to prepare the patients for hospitalization. It is important to investigate patient satisfaction with prehospital emergency care following a hip fracture to ensure that their expectations of good care are met.The aim of this study was to investigate patient satisfaction with prehospital emergency care following a hip fracture by comparing two similar emergency care contexts. METHODS: The study was conducted using the Consumer Emergency Care Satisfaction Scale (CECSS) on patients treated for hip fracture in prehospital emergency care. The data were collected within a randomized controlled study for the purpose of comparing prehospital fast track care (PFTC) and the traditional type of transport to an accident and emergency department (A&E). RESULTS: Questionnaire data from 287 patients, 188 women (66%) and 99 men (34%) with a mean age of 80.9 years, were analysed. More than 80% of the patients selected the most positive response alternatives, but 16% were dissatisfied with the nursing information provided. Patients in PFTC responded more positively on specific caring behaviour than those transported to the A&E department in the traditional way. CONCLUSION: Patient satisfaction with prehospital emergency care following a hip fracture is an important outcome and this study highlights the fact that patients expressed a high level of satisfaction with the prehospital emergency care provided by ambulance nurses in both care contexts under study. However, some areas need to be improved in terms of nursing information.

Early prehospital assessment of non-urgent patients and outcomes at the appropriate level of care: A prospective exploratory study.

INTRODUCTION: The Ambulance Organization of Sweden provides qualified medical assessment and treatment by ambulance nurses based on patient needs regarding appropriate levels of care. A new model for patients with non-urgent medical conditions has been introduced. The main objective of this study was to examine early prehospital assessment of non-urgent patients, and its impact on the choice of the appropriate level of care. METHODS: The study design was a 1-year, prospective study, involving an ambulance district in southwestern Sweden with a population of 78,000. Eligible patients were from18years of age, assessed as priority GREEN by Rapid Emergency Triage and Treatment System (RETTS). Ambulance nurses contacted primary care physicians on decisions on whether a patient should be transported to a primary healthcare unit or an A&E. Data was collected from electronic health records from April 2014 to July 2015. A comparison was made with a retrospective control group without consulting a physician concerning the appropriate level of care. RESULTS: 394 patients were included, 184 in the intervention group, and 210 in the control group. There were statistically significant differences in favor of the study group (p<0.001) regarding no transport, or transport and admission to an A&E. The groups did not differ significantly regarding transport to a primary care unit. CONCLUSION: This prehospital assessment model indicates a decrease in ambulance transports to an A&E and admissions to a hospital ward. Collaboration between ambulance nurses and primary physicians affects the decision for the appropriate level of care for patients with a non-urgent condition.

Early Assessment of Patient's Medical Condition in Ambulance Care Affects the Level of Care of Non Urgent Patients.

The Rapid Emergency Triage and Treatment System (RETTS) is used by the Swedish ambulance care organization for assessment of patients medical condition. The aim of the present study was to evaluate prehospital assessment in collaboration with the ambulance nurse and primary health care physicians. If the patient's condition was priority GREEN by RETTS then the ambulance nurse decided to contact the primary care physicians for a dialogue and together they decided which level of care was the most appropriate for the patient's condition.

Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial.

INTRODUCTION: Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality. METHODS: The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group). RESULTS: Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p<0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p=0.07); proportion operated within 24h (79% PFTC, 75% A&E; p=0.34); length of stay (p=0.34); post-operative complications (p=0.75); and 4 month mortality (18% PFTC, 15% A&E p=0.58). CONCLUSION: PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded.

Fast-track care for patients with suspected hip fracture.

Patients over 65 years of age with suspected hip fracture following low-energy trauma often wait a long time for examinations, X-rays, tests and surgery. There may be a connection between long waiting times and complications, including severe pain, mental confusion, infection, pressure sores, and longer hospital stays. This study examines whether implementing prehospital preoperative procedures might lead to reduced waiting times, less postoperative pain, fewer complications and shorter length of care for this patient group. To "fast-track" care for hip fracture patients, the ambulance nurse starts the preoperative procedure (usually performed in the accident and emergency department [A&E]) and transfers patients directly to radiology, bypassing A&E. Results from the fast-track care group were compared to results from a control group, who had been admitted to A&E in the usual way. The study group experienced fewer complications and shorter hospital stays compared to the control group. This finding suggests that fast-track care for hip fracture patients can minimise complications, heighten priorities, and decrease overall length of care. Greater awareness of risk factors for hip fracture patients amongst hospital staff leads to improved patient care. Fast-track care may also decrease the workload in A&E and thus release more time for other patients.