Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome.

OBJECTIVE: Between 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian's awareness of acute coronary syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia. METHODS: The Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and (1) EMS arrival and (2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics. RESULTS: Between 2003 and 2015, there were 124 632 eligible ED presentations with ACS and 536 148 with U-CP. In patients with ACS, the campaign period was associated with an increase in ED presentations (incidence rate ratio: 1.11; 95% CI 1.07 to 1.15), a decrease in presentations via a GP (adjusted OR (AOR): 0.77; 95% CI 0.70 to 0.86) and an increase in EMS use (AOR: 1.10; 95% CI 1.05 to 1.17). Similar, but smaller associations were seen in U-CP. CONCLUSIONS: The Warning Signs Campaign was associated with improvements in treatment seeking in patients with ACS-including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education needs to focus on improving EMS use in ACS patient groups where use remains low.

Time consumption for non-conveyed patients within emergency medical services (EMS): A one-year prospective descriptive and comparative study in a region of Sweden.

INTRODUCTION: Over time, ambulance assignments have increased in number both nationally and internationally, and a substantial proportion of patients encountered by emergency medical services are assessed as not being in need of services. Non-conveying patients has become a way for emergency medical services clinicians to meet this increasing workload. It has been shown that ambulances can be made available sooner if patients are non-conveyed, but there is no previous research describing the factors that influence the non-conveyance time. STUDY OBJECTIVE: To describe ambulance time consumption and the factors that influence time consumption when patients are non-conveyed. METHODS: A prospective observational review of 2615 non-conveyed patients' ambulance and hospital medical records was conducted using a consecutive sample. Data were analysed with the Kruskal-Wallis test, Mann-Whitney U test and Spearman's rank correlation (rho) for linear correlations. RESULTS: The mean NC time for all ambulance assignments during the study period was 26 minutes, with a median of 25 minutes. The shortest NC time was 4 minutes, and the longest NC time was 73 minutes. NC times were significantly faster during the day than at night. CONCLUSIONS: This study provides new knowledge about time consumption when patients are non-conveyed. Although there are time differences when patients are non-conveyed, the differences observed in this study are small and not of clinical value. Ambulances will most often become available sooner if patients are non-conveyed. Although patients might be eligible for non-conveyance, policy-makers might have to decide when it is appropriate to non-convey patients from time, resource, patient safety and patient-centred care perspectives.

Pre-hospital assistance by ambulance in the context of coronavirus infections.

OBJECTIVE: To reflect on the safe care exercised by the pre-hospital care team by emergency ambulance in times of coronavirus infection. METHOD: A reflection and description of how to provide safe care to the patient and the professional during pre-hospital care in times of coronavirus infection. RESULTS: To ensure the health of all those involved in the care, health professionals who work in pre-hospital care by emergency ambulance should use the recommended Personal Protective Equipment (PPE), such as the use of surgical masks and N95, N99, N100, PFF2 or PFF3, the use of an apron or overall, goggles and face shield, gloves and a hat. The entire team must receive training and demonstrate the ability to use PPE correctly and safely. FINAL CONSIDERATIONS: The professional working in the pre-hospital care by ambulance is exposed to a series of occupational risks that need to be discussed and minimized through professional training.

Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting.

Importance: The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. Objective: To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. Design, Setting, and Participants: This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. Exposures: Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. Main Outcomes and Measures: Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. Results: Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. Conclusions and Relevance: This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.

Construction and validation of checklist for disinfecting ambulances to transport Covid-19 patients / Construcción y validación de checklist para la desinfección de ambulancias para el transporte de pacientes Covid-19 / Construção e validação de checklist para desinfecção de ambulâncias para transporte de pacientes Covid-19

ABSTRACT Objective To build and validate a checklist for disinfecting ambulances transporting patients with Covid-19. Method Methodological study composed by the construction of a checklist and validation by 42 professionals, of which 35 professionals had expertise in patient transport/transfer and seven in hospital infection control. The item with a minimum agreement of 80% was considered valid, based on the Content Validation Index and binomial test. Results The checklist had the steps performed for terminal disinfection of ambulances. It had 54 items, which included the personal protective equipment and used materials, disinfection of the driver's cabin, equipment, and the patient care cabin. The minimum agreement obtained was 85% and the mean of the Content Validation Index was 0.96. Conclusion The checklist was considered valid in terms of content and can be used to disinfect ambulances transporting patients with Covid-19.

RESUMEN Objetivo Construir y validar checklist para desinfectar ambulancias que transportan pacientes con Covid-19. Método Un estudio metodológico compuesto por la construcción de un checklist y validación por 42 profesionales, de los cuales 35 profesionales tenían experiencia en transporte/transferencia de pacientes y siete en control de infecciones hospitalarias. El ítem con un acuerdo mínimo del 80% se consideró válido, según el índice de validación de contenido y la prueba binomial. Resultados El checklist tenía los pasos a seguir para la desinfección terminal de ambulancias. Tenía 54 artículos, que incluían el equipo de protección individual y los materiales utilizados, la desinfección de la cabina del conductor, el equipo y la cabina de atención al paciente. El acuerdo mínimo obtenido fue del 85% y el promedio del Índice de Validación de Contenido fue de 0,96. Conclusión El checklist se consideró válido en términos de contenido y puede usarse para desinfectar ambulancias que transportan pacientes con Covid-19.

RESUMO Objetivo Construir e validar checklist para desinfecção de ambulâncias que transportam pacientes com Covid-19. Método Estudo metodológico composto pela construção de checklist e validação por 42 profissionais, dos quais 35 profissionais possuíam expertise em transporte/transferência de pacientes e sete em controle de infecção hospitalar. Foi considerado válido o item com concordância mínima de 80%, a partir do Índice de Validação de Conteúdo e teste binomial. Resultados O checklist possuiu as etapas que devem ser realizadas para desinfecção terminal das ambulâncias. Possuiu 54 itens, que contemplaram os equipamentos de proteção individual e materiais utilizados, desinfecção da cabine do condutor, dos equipamentos e da cabine de atendimento ao paciente. A concordância mínima obtida foi de 85% e a média do Índice de Validação de Conteúdo foi de 0,96. Conclusão O checklist foi considerado válido quanto ao conteúdo e pode ser utilizado para desinfecção das ambulâncias que transportam pacientes com Covid-19.

Changes in demand for emergency ambulances during a nationwide lockdown that resulted in elimination of COVID-19: an observational study from New Zealand.

OBJECTIVE: To examine the impact of a 5-week national lockdown on ambulance service demand during the COVID-19 pandemic in New Zealand. DESIGN: A descriptive cross-sectional, observational study. SETTING: High-quality data from ambulance electronic clinical records, New Zealand. PARTICIPANTS: Ambulance records were obtained from 588 690 attendances during pre-lockdown (prior to 17 February 2020) and from 36 238 records during the lockdown period (23 March to 26 April 2020). MAIN OUTCOME MEASURES: Ambulance service utilisation during lockdown was compared with pre-lockdown: (a) descriptive analyses of ambulance events and proportions of event types for each period, (b) absolute rates of ambulance attendance (event types/week) for each period. RESULTS: During lockdown, ambulance patients were more likely to be attended at home and less likely to be aged between 16 and 25 years. There was a significant increase in the proportion of lower acuity patients (Status 3 and Status 4) attended (p<0.001) and a corresponding increase in patients not transported from scene (p<0.001). Road traffic crashes (p<0.001) and alcohol-related incidents (p<0.001) significantly decreased. There was a decrease in the absolute number of weekly ambulance attendances (ratio (95% CI), 0.89 (0.87 to 0.91), p<0.001), attendances to respiratory conditions (0.74 (0.61 to 0.86), p=0.01), and trauma (0.81 (0.77 to 0.85), p<0.001). However, there was a significant increase in ambulance attendances for mental health conditions (1.37 (1.22 to 1.51), p=0.005). CONCLUSIONS: Despite the relative absence of COVID-19 in the community during the 5-week nationwide lockdown, there were significant differences in ambulance utilisation during this period. The lockdown was associated with an increase in ambulance attendances for mental health conditions and is of concern. In considering future lockdowns, the potential implications on a population's mental well-being will need to be seriously considered against the benefits of elimination of virus transmission.

Pain in the Prehospital Setting in Rwanda: Results of a Mixed-Methods Quality Improvement Project.

Introduction: Pain is a universal human experience tied to an individual's health but difficult to understand. It is especially important in health emergencies. We performed a two-step quality improvement project to assess pain management by the SAMU ambulance service in Kigali, Rwanda, examining how pain is assessed and treated by ambulance staff to facilitate development of standardized guidelines of pain management in the prehospital setting, which did not exist at the time of the study. Materials and Methods: Deidentified ambulance service records from December 2012 to May 2016 were analyzed descriptively for patient demographics, emergency conditions, pain assessment, and medications given. Then, anonymized, semistructured interviews of ambulance staff were conducted until thematic saturation was achieved. Data were analyzed using a grounded theory approach. Results: SAMU managed 11,161 patients over the study period, of which 6,168 (55%) were documented as reporting pain and 5,010 (45%) received pain medications. Men had greater odds of receiving pain medications compared to women (OR = 3.8, 95% CI (3.5, 4.1), p < 0.01). Twenty interviews were conducted with SAMU staff. They indicated that patients communicate pain in different ways. They reported using informal ways to measure pain or a standardized granular numeric scale. The SAMU team reviewed these results and developed plans to modify practices. Conclusions: We reviewed the existing quality of pain management in the prehospital setting in Kigali, Rwanda, assessed the SAMU staff's perceptions of pain, and facilitated standardization of prehospital pain management through context-specific guidelines.

Todos Contra o Coronavírus #7 Desinfecção da Viatura: técnica correta

Confira vídeos produzidos pela Secretaria de Estado da Saúde em parceria com a Defesa Civil de Santa Catarina com orientações para profissionais de saúde.

A Comparison of Probabilistic and Deterministic Match Strategies for Linking Prehospital and in-Hospital Stroke Registry Data.

BACKGROUND: Understanding and improving EMS stroke care requires linking data from both the prehospital and hospital settings. In the US, such data is collected in separate de-identified registries that cannot be directly linked due to lack of a common, unique patient identifier. In the absence of unique patient identifiers two common approaches to linking databases are deterministic matching, which uses combinations of non-unique matching variables to define matches, and probabilistic matching, which generates estimates of match probability based on the degree of similarity between records. This analysis seeks to compare these two approaches for matching EMS and stroke registry data. METHODS: Stroke cases transported by EMS to Michigan hospitals participating in the Michigan Coverdell Acute Stroke Registry were linked to records from Michigan's EMS Information System (MI-EMSIS) between January 2018 and June 2019. Destination hospital, date-of-service, patient age, date-of-birth, and sex were used to perform deterministic and probabilistic linkages. Match rates and representativeness of the matched samples were compared between the two matching strategies. Multivariable logistic regression was used to identify characteristics associated with successful matching. RESULTS: During the 18-month study period there were 8,828 EMS transported confirmed stroke cases in the registry and 620,907 EMS transports to 38 Coverdell registry-participating hospitals. The probabilistic match linked 5985 (67.7%) strokes to EMS records; the deterministic match linked 4012 (45.5%). Within each strategy the characteristics of matched and unmatched cases were similar, with the exception that deterministically matched cases were less likely to be older than 89 (adjusted odds ratio [aOR]=0.3), white (aOR=0.8), and more likely to have subarachnoid hemorrhage (aOR=1.4) than unmatched cases. CONCLUSION: Probabilistic matching resulted in higher match rates and a more representative sample of EMS transported strokes, suggesting it may be superior in assessing EMS stroke care compared to a deterministic approach.

National Ambulance Surveillance System: A novel method using coded Australian ambulance clinical records to monitor self-harm and mental health-related morbidity.

Self-harm and mental health are inter-related issues that substantially contribute to the global burden of disease. However, measurement of these issues at the population level is problematic. Statistics on suicide can be captured in national cause of death data collected as part of the coroner's review process, however, there is a significant time-lag in the availability of such data, and by definition, these sources do not include non-fatal incidents. Although survey, emergency department, and hospitalisation data present alternative information sources to measure self-harm, such data do not include the richness of information available at the point of incident. This paper describes the mental health and self-harm modules within the National Ambulance Surveillance System (NASS), a unique Australian system for monitoring and mapping mental health and self-harm. Data are sourced from paramedic electronic patient care records provided by Australian state and territory-based ambulance services. A team of specialised research assistants use a purpose-built system to manually scrutinise and code these records. Specific details of each incident are coded, including mental health symptoms and relevant risk indicators, as well as the type, intent, and method of self-harm. NASS provides almost 90 output variables related to self-harm (i.e., type of behaviour, self-injurious intent, and method) and mental health (e.g., mental health symptoms) in the 24 hours preceding each attendance, as well as demographics, temporal and geospatial characteristics, clinical outcomes, co-occurring substance use, and self-reported medical and psychiatric history. NASS provides internationally unique data on self-harm and mental health, with direct implications for translational research, public policy, and clinical practice. This methodology could be replicated in other countries with universal ambulance service provision to inform health policy and service planning.

Exploring the need for and application of human factors and ergonomics in ambulance design: Overcoming the barriers with technical standards.

Ergonomic risk factors, such as excessive physical effort, awkward postures or repetitive movements, were the leading causes of injuries amongst EMS workers in the United States, of which 90% were attributed to lifting, carrying, or transferring a patient and/or equipment. Although the essential tasks of patient handling, transport, and care cannot be eliminated, the design of ambulances and associated equipment is modifiable. Our aims were to identify the extent of Human Factors and Ergonomic (HFE) considerations in existing ambulance design standards/regulations, and describe how HFE and the standards/regulations were applied in the EMS system. Through an extensive environmental scan of jurisdictionally relevant standards/regulations and key informant interviews, our findings demonstrated that existing standards/regulations had limited considerations for HFE. As a result, HFE principles continue to be considered reactively through retrofit rather than proactively in upstream design. We recommend that performance-based HFE requirements be integrated directly into ambulance design standards.

The effect of emergency medical system transport time on in route clinical decline in a rural system.

BACKGROUND: The emergency medical system (EMS) Field Triage Decision Scheme (FTDS) exists to direct certain injured patients to high-level care facilities. In rural states, this may require long transport durations, with uncertainty about the effects on clinical decline. We investigate adherence to the FTDS and the effect of transport duration on clinical decline in helicopter emergency medical system (HEMS) and ground emergency medical system (GEMS) transport in the Commonwealth of Kentucky. METHODS: This institutional review board-approved study retrospectively analyzed deidentified data from the 2017 National EMS Information System for Kentucky. Patients were classified using step 1 FTDS criteria (respiratory rate [RR], <10 or >29 breaths per minute; systolic blood pressure (SBP), <90 mm Hg; or Glasgow Coma Scale [GCS] score, <14 points), by mode of transport (HEMS or GEMS), and by arrival at an appropriate center (levels I-III trauma center). Clinical decline was defined in both groups as an in route decrease in GCS of 2 points or greater, a SBP decrease of 1 SD or greater into or within the low range, an RR increase of 1 SD or greater into or within the high range, or an RR decrease of 1 SD or greater into or within the low range. RESULTS: Almost half (46.3%) of step 1 patients were transported to an inappropriate center; the most common reason recorded was "closest facility" (57.8%). The percent of step 1 patients who declined in route increased with prehospital time in both HEMS and GEMS (p < 0.001). Overall, 12.2% of step 1 patients declined during transport, most commonly because of decreasing GCS (median change, -5 points; interquartile range, -3 to -9, in GCS declining patients). Helicopter EMS patients were more likely to meet step 1 criteria at the scene (29.9% vs. 5.8% GEMS, p < 0.001) and to decline (27.8% vs. 6.1% GEMS, p < 0.001). CONCLUSION: This study demonstrates that, in a rural state, injured patients meeting FTDS step 1 criteria reach levels I to III trauma centers only about half the time. The FTDS step 1 criteria identified patients at higher risk of further prehospital clinical decline. Rather than decline after 1 hour, these data show that an increasing proportion of patients experience clinical decline throughout prehospital transport. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Limpieza y desinfección de ambulancias luego de transportar un paciente confirmado con COVID-19 / Cleaning and disinfection of ambulances after transporting a confirmed patient with COVID-19

INTRODUCCIÓN: La ambulancia es un transporte sanitario esencial para proporcionar asistencia médica de emergencia o de soporte vital básico en situaciones de atención primario como interhospitalario. Este medio a su vez está equipada de materiales sanitarios y del personal sanitario abordo quienes prestan asistencia de acuerdo a las necesidades de atención en situaciones de emergencia. Asimismo, es importante señalar que muchos hospitales cuentan con un servicio propio para el traslado de los pacientes, por lo tanto, se requiere de la disponibilidad del manejo de los procedimientos de desinfección y limpieza de la ambulancia, principalmente para evitar la propagación del COVID-19. Los profesionales de la salud están capacitados para prestar la atención médica a los pacientes en casos sospechosos y confirmados, de esta manera es muy importante que el personal esté capacitado y entrenado para desinfectar y limpiar la ambulancia, para garantizar la seguridad de los pacientes y su equipo de profesionales a bordo. Estudios recientes han permitido evidenciar que las superficies de las ambulancias están frecuentemente contaminadas con microorganismos. (2,24) Por ello, la desinfección es una parte importante de cualquier procedimiento de control y prevención de infecciones. Ante la crisis de COVID-19 a nivel mundial, el seguir procedimientos de limpieza y desinfección de ambulancias es vital para reducir la carga biológica del SARS-CoV-2 y evitar más infectados (3) una vez que un paciente con sospecha de COVID-19 ha sido transportado. El SARS-CoV-2 tiene una envoltura lipídica, por lo que una amplia gama de desinfectantes resulta muy efectiva, para asegurar una completa y adecuada desinfección de todas las superficies expuestas, equipos y áreas de contacto, antes de volver a las tareas operativas normales. En la actualidad existen diversos protocolos efectivos de limpieza y desinfección para este entorno de atención primaria de emergencia. En varios países, se ha estado trabajando en la elaboración de protocolos y guías con procedimientos precisos para desinfectar y limpiar la ambulancia. A partir de estos instrumentos, señalamos las pautas generales seguidas por dichos países como medida de prevención y control, en relación a los procedimientos seguidos para la desinfección de ambulancias. MÉTODOS: Se realizó una revisión narrativa de las principales bases de datos de investigación, documentos, artículos y guías relacionadas a los procedimientos de limpieza y desinfección de ambulancias durante y después del transporte de algún caso sospechoso o confirmado de COVID-19. En este documento se incluyó principalmente información científica actualizada de los departamentos gubernamentales de los países del reino unido como GOB.UK, la guía de prevención y control de infecciones en entornos sanitarios, como también, la guía de fideicomisos de ambulancias y recomendaciones de la Organización Mundial de la Salud (OMS). Sobre los procedimientos de limpieza y desinfección de las ambulancias después del transporte de un paciente con COVID-19, se revisaron las recomendaciones más actuales del Centro para el Control y Prevención de Enfermedades de los Estados Unidos (CDC), también se incluyeron textos de la guía de prevención y control de infecciones para COVID-19 enlos entornos sanitarios del Centro Europeo de Prevención y Control de Enfermedades (ECDC), y el manual de bioseguridad para prestadores de servicios de salud que brinden atención en salud ante la eventual introducción del nuevo coronavirus (ncov-2019) a Colombia. Esta revisión incluye, además, información técnica respecto a la atención primaria ante el nuevo coronavirus y algunas recomendaciones de limpieza y desinfección de vehículos de transporte del equipo de EMS como la guía recientemente actualizada por el equipo de trabajo sobre coronavirus de la asociación Internacional de Jebes de Bomberos (International Association of Fire Chiefs - IAFC). RESULTADOS: Existe la urgencia internacional para contener el virus y prevenir su propagación. Es factible que el personal de salud de primera línea, como los que conforman el equipo de ambulancias para el traslado de pacientes sospechosos o confirmados por SARS-Cov-2, estén potencialmente expuestos al contagio. (12) Por ello, es necesario que cada entidad sanitaria mantenga un estándar de bioseguridad para el procedimiento de limpieza y desinfección de ambulancias, manteniendo un protocolo que ayude a prevenir los riesgos de infección para el personal de salud de esta área. Actualmente conocemos que, la transmisión de SARS-Cov-2, se da por medio de las gotitas respiratorias (14) y que al ser liberadas alcanzan hasta un metro de distancia pueden depositarse en diferentes superficies y aun permanecer activas Para ello, una amplia gama de productos biocidas están disponibles para desinfectar superficies en diferentes ámbitos sanitarios y en las ambulancias. (5,15). Kampf y col. han observado que otros coronavirus, por ejemplo, SARS y MERS, pueden persistir en superficies inanimadas como metal, vidrio o plástico por hasta 9 días, pero pueden ser desactivados eficientemente por procedimientos de desinfección con etanol al 62­71%, peróxido de hidrógeno al 0.5%, o hipoclorito de sodio al 0.1% dentro de 1 min. Otros agentes biocidas como el cloruro de benzalconio al 0.05% a 0.2% o digluconato de clorhexidina al 0.02% fueron menos eficaces. (16,17) Duan y col. encontraron que la irradiación con luz ultra violeta (LUV) durante 60 minutos en varios coronavirus en medio cultivo dio como resultado niveles indetectables de infectividad viral. Un estudio cuasi-experimental Iraní, realizó toma de muestras antes y después de la desinfección en la cabina delantera, equipo médico y parte trasera de ambulancias para determinar contaminaciones microbianas, para ello utilizó la solución "Cloruro de didecildimetilamonio, alquil dimetil bencil amonio, una base de compuestos de amonio cuaternario de quinta generación y biguanidas"; demostrando su acción bactericida hasta en un 100% luego de la desinfección, por lo que el producto resultó ser eficaz en la eliminación de bacterias. El mismo estudio revela la limitación de no haber podido probar tal eficacia en virus, hongos o esporas. No existen estudios específicos referidos a la efectividad y seguridad de diversos desinfectantes para la descontaminación de las ambulancias y sus equipos biomédicos por SARS-CoV-2. Las medidas adoptadas por diferentes países se basan en las recomendaciones de la OMS, CDC y de países de alta vigilancia epidemiológica. Es importante mencionar que, estas recomendaciones tienen como fuente de información las experiencias referidas al SARS-CoV y MERS-CoV y los diferentes estudios que encontraron que en superficies inanimadas los agentes biocidas comúnmente utilizados como desinfectantes, obtuvieron alta eficacia contra estos vírus. La OMS/OPS recomienda el uso de desinfectantes como el hipoclorito de sodio, amonio cuaternario, peróxido de hidrogeno, etanol y clorhexidina; en el área intrahospitalaria (incluyendo las ambulancias); pero dependiendo de las áreas específicas del entorno, estas podrán variar de concentración y dilución. Estos desinfectantes presentan actividad frente a la mayoría de los virus, incluyendo coronavirus y SARS, siempre que sean preparados de acuerdo con las instrucciones del fabricante (los virus con envoltura como el coronavirus son más susceptibles a los detergentes que los virus no envueltos). El adecuado uso de antisépticos y desinfectantes, es una herramienta esencial para evitar la diseminación de agentes infecciosos y el control de infecciones asociadas a la atención de salud. Por ello, es imprescindible seguir las recomendaciones de entidades de alta vigilancia epidemiológica y valorar la evidencia científica. CONCLUSIONES: Este documento proporciona información para la limpieza y desinfección de ambulancias, brindada por entidades de alta vigilancia epidemiológica contra infecciones emergentes, basados en evidencia científica, para los servicios de emergencia sanitaria que dispongan de ambulancias destinadas para el transporte de casos sospechosos y confirmados de COVID-19. No existen estudios específicos referidos a la efectividad y seguridad de diversos desinfectantes para la descontaminación de las ambulancias y sus equipos biomédicos por SARS-Cov-2, la información referida se ha realizado en base a las recomendaciones de la OMS, CDC y de países de alta vigilancia epidemiológica, basados en la contención del SARS-CoV y MERS-CoV emergentes en el pasado. Estudios científicos revelaron que los coronavirus humanos, SARS-CoV y MERS-CoV pueden persistir en superficies inanimadas, pero se pueden inactivar eficientemente mediante desinfección con hipoclorito de sodio al 0,1%, etanol al 62-71% (pequeñas superficies), peróxido de hidrógeno al 0,5% en 1 minuto. Sin embargo, biocidas como el cloruro de benzalconio al 0,05­0,2% o el digluconato de clorhexidina al 0,02% son menos efectivos.

Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion.

INTRODUCTION: In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs. METHODS: The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative. RESULTS: Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS. CONCLUSION: This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.

Effectiveness of the Mobile Emergency Medical Services (SAMU): use of interrupted time series.

OBJECTIVE: To evaluate the performance of the Mobile Emergency Medical Services (SAMU) in the ABC Region, using myocardial infarction as tracer condition. METHODS: The analysis of interrupted time series was the approach chosen to test immediate and gradual effects of the intervention on the study population. The research comprised adjusted monthly time series of the hospital mortality rate by myocardial infarction in the period between 2000 and 2011. Data were extracted from the Mortality Information System (SIM), using segmented regression analysis to evaluate the level and trend of the intervention before and after its implementation. To strengthen the internal validity of the study, a control region was included. RESULTS: The analysis of interrupted time series showed a reduction of 0.04 deaths per 100,000 inhabitants in the mortality rate compared to the underlying trend since the implementation of the Emergency Medical Services (p = 0.0040; 95%CI: -0.0816 - -0.0162) and a reduction in the level of 2.89 deaths per 100,000 inhabitants (p = 0.0001; 95%CI: -4.3293 - -1.4623), both with statistical significance. Regarding the control region, Baixada Santista, the difference in the result trend between intervention outcome and post-intervention control of -0.0639 deaths per 100,000 inhabitants was statistically significant (p = 0.0031; 95%CI: -0.1060 - -0.0219). We cannot exclude confounders, but we limited their presence in the study by including control region series. CONCLUSIONS: Although the analysis of interrupted time series has limitations, this modeling can be useful for analyzing the performance of policies and programs. Even though the intervention studied is not a condition that in itself implies effectiveness, the latter would not be present without the former, which, integrated with other conditions, generates a positive result. SAMU is a strategy that must be expanded when formulating and consolidating policies focusing on emergency care.

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.

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.