Sex-Based Analysis of Treatment, Time Metrics, and Outcomes in Acute Ischemic Stroke Patients Treated in the Netherlands.

INTRODUCTION: Sex disparities in stroke treatment have gained increasing interest, especially since women have worse post-stroke functional outcomes compared with men. Existing studies provide conflicting evidence, with some indicating women have longer delays and less often receive acute treatment, whereas others show no differences between men and women. We aimed to explore sex differences in acute treatment modalities and time metrics of patients with acute ischemic stroke (AIS) in a real-world setting. Second, we examined whether functional outcomes differed by sex and whether this was influenced by treatment timing. METHODS: We analyzed data from the Dutch Acute Stroke Audit, a prospective consecutive registry of AIS patients from 72 hospitals in the Netherlands, between 2017 and 2020. We captured data on type of treatment administered (intravenous thrombolysis [IVT] and endovascular thrombectomy [EVT]), time metrics (onset-to-door time [OTDT], door-to-needle and door-to-groin times), and functional outcomes at 3 months (modified Rankin scale [mRS]). The association between sex and poor outcome (mRS 3-6) was assessed with Cox proportional hazard models stratified by type of treatment and adjusted for age, additionally for National Institutes of Health Stroke Scale (NIHSS) and OTDT. RESULTS: Of the 58,632 patients, 26,941 (46%) were women. Compared with men, women were older (mean age 74.6 vs. 71.0, p < 0.001) and presented with slightly higher NIHSS scores (median 3 [IQR 2-7] vs. 3 [IQR 1-6], p < 0.001). Treatment modalities distribution (no treatment, IVT, EVT) was similar between women and men (64; 29; 10 vs. 63; 30; 9%, p = 0.16). Women had a slightly longer OTDT (median 145 vs. 139 min, p < 0.01). Women had increased odds of poor outcomes (OR 1.49 [95% CI: 1.43-1.56]). This was still statistically significant after adjusting for age and NIHSS score (OR 1.22 [95% CI: 1.16-1.28]). Neither treatment modality nor OTDT had an additional influence on this association. CONCLUSION: In this large real-world registry, we observed no differences in distribution of treatment modalities between sexes. We did find a minor pre-hospital delay in women and worse functional outcomes in women. The minor delay in OTDT does not fully explain the observed worse outcomes in women. Our results provide reassurance that no major sex biases are apparent in acute stroke management throughout participating Dutch centers.

The Danish Nationwide Electrocardiogram (ECG) Cohort.

The electrocardiogram (ECG) is a non-invasive diagnostic tool holding significant clinical importance in the diagnosis and risk stratification of cardiac disease. However, access to large-scale, population-based digital ECG data for research purposes remains limited and challenging. Consequently, we established the Danish Nationwide ECG Cohort to provide data from standard 12-lead digital ECGs in both pre- and in-hospital settings, which can be linked to comprehensive Danish nationwide administrative registers on health and social data with long-term follow-up. The Danish Nationwide ECG Cohort is an open real-world cohort including all patients with at least one digital pre- or in-hospital ECG in Denmark from January 01, 2000, to December 31, 2021. The cohort includes data on standardized and uniform ECG diagnostic statements and ECG measurements including global parameters as well as lead-specific measures of waveform amplitudes, durations, and intervals. Currently, the cohort comprises 2,485,987 unique patients with a median age at the first ECG of 57 years (25th-75th percentiles, 40-71 years; males, 48%), resulting in a total of 11,952,430 ECGs. In conclusion, the Danish Nationwide ECG Cohort represents a novel and extensive population-based digital ECG dataset for cardiovascular research, encompassing both pre- and in-hospital settings. The cohort contains ECG diagnostic statements and ECG measurements that can be linked to various nationwide health and social registers without loss to follow-up.

The feasibility of introducing a whole blood component for traumatic haemorrhage in the UK.

BACKGROUND: The interest in re-introducing whole blood (WB) transfusion for the management of traumatic major haemorrhage is increasing. However, due to the current leucodepletion filters used in the UK a WB component was not readily available. Instead, an alternative but similar component, leucocyte depleted red cell and plasma (LD-RCP), which provided a unique experience in assessing the feasibility of a WB component was used whilst a WB component was being manufactured. STUDY DESIGN AND METHODS: Between November 2018 and October 2020, LD-RCP replaced RBC as standard of care for all trauma patients with major haemorrhage in London. The aims of the study were to assess (a) deliverability, (b) component wastage and (c) safety. RESULTS: Over the study period a total of 1208 LD-RCP units were delivered, of which 96.5% were delivered 'On Time In Full' (OTIF). Of the 1208 units, 733 (60.68%) were transfused and 475 (39.3%) units were wasted. Component wastage reduced significantly throughout the study (p = 0.001). A total of 177 patients had a blood group recorded, 86 were group O and 91 were non-group O. There was no statistically significantly difference between haemoglobin (p = 0.422), or bilirubin levels (p = 0.084) between group O and non-group O patients. DISCUSSION: It was feasible for NHS Blood and Transplant to deliver LD-RCP on time in full, however component wastage was high due to short shelf life and limited use of the component. Low titre group O LD-RCP units were not associated with clinical evidence of haemolysis.

Helicopter emergency medical services in Iceland between 2018 and 2022-A retrospective study.

BACKGROUND: Helicopter emergency services (HEMS) are widely used to bring medical assistance to individuals that cannot be reached by other means or individuals that have time-critical medical conditions, such as chest pain, stroke or severe trauma. It is a very expensive resource whose use and importance depends on local conditions. The aim of this study was to describe flight and patient characteristics in all HEMS flights done in Iceland, a geographically isolated, mountainous and sparsely populated country, over a 5-year course. METHODS: This retrospective study included all individuals requiring HEMS transportation in Iceland during 2018-2022. The electronic database of the Icelandic Coast Guard was used to identify the individuals and register flight data. Electronic databases from Landspitali and Akureyri hospitals were used to collect clinical variables. Descriptive statistics was applied. RESULTS: The average number of HEMS transports was 3.5/10,000 inhabitants and the median [IQR] activation time and flight times were 30 min [20-42] and 40 min [26-62] respectively. The vast majority of patients were transported to Landspitali Hospital in Reykjavik. More than half of the transports were due to trauma, the most common medical transports were due to chest pain or cardiac arrests. Advanced medical therapy was provided for 66 (10%) of individuals during primary transports, 157 (24%) of individuals were admitted to intensive care, 188 (28%) needed surgery and 53 (7.9%) needed a coronary angiography. CONCLUSION: In Iceland, the number of transports is lower but activation and flight times for HEMS flights are considerably longer than in other Nordic countries, likely due to geographical features and the structure of the service including utilizing helicopters both for HEMS and search and rescue operations. The transport times for some time-sensitive conditions are not within standards set by international studies and guidelines.

Identifying high cholesterol in the ambulance setting: a mixed-methods cohort study to tackle health inequality.

BACKGROUND: Individuals with low socio-economic status (SES) have disproportionate rates of cardio- vascular disease (CVD) but poorer engagement with preventative health. This study aimed to compare characteristics of individuals with and without hyperlipidaemia and describe their health behaviours. METHODS: A mixed-methods study between January and December 2022. Patients aged ≥40 years using the ambulance service with blood pressure of ≥140/90 had their total cholesterol measured using a point of care device. Data including blood pressure, smoking status, National Early Warning Score 2 and clinical frailty scale (CFS) were analysed. RESULTS: Of 203 patients (59% female, mean age 65.7 years), 115 (56.7%) had total cholesterol ≥5.1 mmol/L. Thirty patients (14.8%) sought treatment and received either statins (n = 9; 4.4%), dietary modification (n = 7; 3.4%) or no further intervention (n = 14; 6.9%), whilst 85 patients (41.9%) took no further action. Lower CFS (OR 0.53 [0.31-0.93]) and higher total cholesterol (OR 2.07 [1.03-2.76]) predicted seeking further management. SES was not associated with hyperlipidaemia or likelihood of seeking further management, rather this was dictated by competing co-morbidity, poor health literacy and digital divide. CONCLUSIONS: Undiagnosed hyperlipidaemia exists in patients using the ambulance service, irrespective of SES. Individual and healthcare system factors prevent engagement in cholesterol lowering behaviours.

Assessing the impact of pre-hospital airway management on severe traumatic Brain injury: A systematic review and Meta-analysis.

OBJECTIVE: This study aimed to assess the impact of establishing a pre-hospital definitive airway on mortality and morbidity compared with no prehospital airway in cases of severe traumatic brain injury (TBI). BACKGROUND: Traumatic brain injury (TBI) is a global health concern that is associated with substantial morbidity and mortality. Prehospital intubation (PHI) has been proposed as a potential life-saving intervention for patients with severe TBI to mitigate secondary insults, such as hypoxemia and hypercapnia. However, their impact on patient outcomes remains controversial. METHODS: A systematic review and meta-analysis were conducted to assess the effects of prehospital intubation versus no prehospital intubation on morbidity and mortality in patients with severe TBI, adhering to the PRISMA guidelines. RESULTS: 24 studies, comprising 56,543 patients, indicated no significant difference in mortality between pre-hospital and In-hospital Intubation (OR 0.89, 95% CI 0.65-1.23, p = 0.48), although substantial heterogeneity was noted. Morbidity analysis also showed no significant difference (OR 0.83, 95% CI 0.43-1.63, p = 0.59). These findings underscore the need for cautious interpretation due to heterogeneity and the influence of specific studies on the results. CONCLUSION: In summary, an initial assessment did not reveal any apparent disparity in mortality rates between individuals who received prehospital intubation and those who did not. However, subsequent analyses and randomized controlled trials (RCTs) demonstrated that patients who underwent prehospital intubation had a reduced risk of death and morbidity. The dependence on biased observational studies and the need for further replicated RCTs to validate these findings are evident. Despite the intricacy of the matter, it is crucial to intervene during severe airway impairment.

Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting.

BACKGROUND: In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock. METHODS: From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed. RESULTS: Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95]. CONCLUSION: In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.

Challenges of pre-hospital emergency care at Addis Ababa Fire and Disaster Risk Management Commission, Addis Ababa, Ethiopia: a qualitative study.

BACKGROUND: A challenge to pre-hospital emergency care is any barrier or obstacle that impedes quality pre-hospital care or impacts community pre-hospital utilization. The Addis Ababa Fire and Disaster Risk Management Commission (AAFDRMC) provides pre-hospital emergency services in Addis Ababa, Ethiopia. These services operate under a government-funded organization that delivers free emergency services, including out-of-hospital medical care and transportation to the most appropriate health facility. This study aimed to assess the challenges of pre-hospital emergency care at the Addis Ababa Fire and Disaster Risk Management Commission in Addis Ababa, Ethiopia. METHODS: A qualitative descriptive study was conducted from November 20 to December 4, 2022. Data were collected through in-depth, semi-structured interviews with 21 experienced individuals in the field of pre-hospital emergency care, who were selected using purposeful sampling. A thematic analysis method was used to analyze the data. RESULTS: This study includes twenty-one participants working at the Addis Ababa Fire and Disaster Risk Management Commission. Three major themes emerged. The themes that arose were the participants' perspectives on the challenges of pre-hospital emergency care in Addis Ababa, Ethiopia. CONCLUSION AND RECOMMENDATION: The Fire and Disaster Risk Management Commission faces numerous challenges in providing quality pre-hospital emergency care in Addis Ababa. Respondents stated that infrastructure, communication, and resources were the main causes of pre-hospital emergency care challenges. There has to be more focus on emergency management in light of infrastructure reform, planning, staff training, and education, recruiting additional professional power, improving communication, and making pre-hospital emergency care an independent organization in the city.

Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study.

BACKGROUND: Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors. METHODS: We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay. RESULTS: In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908). CONCLUSIONS: Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.

Pre-hospital management and patient-related factors affecting access to the surgical care of appendicitis - a survey study.

BACKGROUND AND AIMS: Long pre-hospital delay substantially increases the likelihood of perforated appendicitis. This study aimed to find patient-related factors affecting this delay. METHODS: A survey was conducted for patients with acute appendicitis after appendectomy. The participants were asked about their path to the surgical center and socioeconomic status. Variables affecting delays and the rate of complicated appendicitis were analyzed. RESULTS: The study included 510 patients; 157 (31%) had complicated appendicitis with a median prehospital delay of 42 h. In patients with uncomplicated appendicitis, the delay was 21 h, p < .001. Forty-six (29%) patients with complicated appendicitis were not referred to the hospital after the first doctor's visit. The multivariate analysis discovered factors associated with long pre-hospital delay: age 40-64 years (OR 1.63 (95% CI 1.06-2.52); compared to age 18-39), age more than 64 years (OR 2.84 (95% CI 1.18-6.80); compared to age 18-39), loss of appetite (OR 2.86 (95% CI 1.64-4.98)), fever (OR 1.66 (95% CI 1.08-2.57)), non-referral by helpline nurse (OR 2.02 (95% CI 1.15-3.53)) and non-referral at first doctors visit (OR 2.16 (95% CI 1.32-3.53)). Age 40-64 years (OR 2.41 (95% CI 1.50-3.88)), age more than 64 years (OR 8.79 (95% CI 2.19-35.36)), fever (OR 1.83 (95% CI 1.15-2.89)) and non-referral at first doctors visit (OR 1.90 (95% CI 1.14-3.14)) were also risk factors for complicated appendicitis. CONCLUSIONS: Advanced age, fever and failure to suspect acute appendicitis in primary care are associated with prolonged pre-hospital delay and complicated appendicitis.

Rule-out of non-ST-segment elevation acute coronary syndrome by a single, pre-hospital troponin measurement: a randomized trial.

AIMS: Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are routinely transferred to the emergency department (ED). A clinical risk score with point-of-care (POC) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ED evaluation is unnecessary. The aim was to assess safety and healthcare costs of a pre-hospital rule-out strategy using a POC troponin measurement in low-risk suspected NSTE-ACS patients. METHODS AND RESULTS: This investigator-initiated, randomized clinical trial was conducted in five ambulance regions in the Netherlands. Suspected NSTE-ACS patients with HEAR (History, ECG, Age, Risk factors) score ≤3 were randomized to pre-hospital rule-out with POC troponin measurement or direct transfer to the ED. The sample size calculation was based on the primary outcome of 30-day healthcare costs. Secondary outcome was safety, defined as 30-day major adverse cardiac events (MACE), consisting of ACS, unplanned revascularization or all-cause death. : A total of 863 participants were randomized. Healthcare costs were significantly lower in the pre-hospital strategy (€1349 ± €2051 vs. €1960 ± €1808) with a mean difference of €611 [95% confidence interval (CI): 353-869; P < 0.001]. In the total population, MACE were comparable between groups [3.9% (17/434) in pre-hospital strategy vs. 3.7% (16/429) in ED strategy; P = 0.89]. In the ruled-out ACS population, MACE were very low [0.5% (2/419) vs. 1.0% (4/417)], with a risk difference of -0.5% (95% CI -1.6%-0.7%; P = 0.41) in favour of the pre-hospital strategy. CONCLUSION: Pre-hospital rule-out of ACS with a POC troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of MACE was low in both strategies. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT05466591 and International Clinical Trials Registry Platform id NTR 7346.

Pre-hospital symptom clusters and symptom network analysis in decompensated cirrhotic patients: A cross-sectional study.

AIMS: To generate pre-hospital symptom networks, explore core, bridge and sentinel symptoms, identify pre-hospital symptom clusters and analyse relationship between influencing factors and symptom clusters in decompensated cirrhosis patients. DESIGN: A cross-sectional study design using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. METHODS: Demographical, physiological, psychological and sociological characteristics and the pre-hospital symptoms of 292 decompensated cirrhotic patients were collected from October 2021 to March 2023 in China. Frequencies, percentages, means, standard deviations, independent samples t-tests, one-way analysis of variance, exploratory factor analysis, multiple stepwise regression analysis and network analysis were used for data analysis. RESULTS: 'I don't look like myself' and itching were core and bridge symptoms, while bloating and lack of energy were sentinel symptoms in decompensated cirrhotic patients. Monthly family income, anxiety, depression, social support and disease duration influenced the neuropsychological symptom cluster, with worrying as the strongest predictor symptom. Influential factors for cirrhosis-specific symptom cluster included Child-Pugh class, monthly family income, disease duration, anxiety and depression, with itching being the strongest predictor symptom. Monthly family income, disease duration and depression were influential factors for gastrointestinal symptom cluster, with loss of appetite as the strongest predictor symptom. CONCLUSIONS: Neuropsychological, cirrhosis-specific and gastrointestinal symptom clusters were formed in decompensated cirrhotic patients. Through network analysis, direct connections between symptoms, symptom clusters and their influencing factors were revealed, thereby offering clinicians a foundation for effectively managing patients' pre-hospital symptoms. IMPACT: Decompensated cirrhosis patients commonly have multiple symptoms, while the management of pre-hospital symptoms is often suboptimal. This study identified neuropsychological, cirrhosis-specific, gastrointestinal symptom clusters and recognized core, bridge and sentinel symptoms in these patients. It also revealed the most prominent symptoms within each cluster. This provides insight into the hierarchy of symptoms, improving symptom management in decompensated cirrhosis. PATIENT AND PUBLIC INVOLVEMENT: There was no patient or public involvement.

Workshop-based training of pre-hospital emergency technicians for acute psychiatric patients: benefits and drawbacks.

BACKGROUND: Pre-hospital emergency technicians are crucial in managing patients with acute psychiatric symptoms. They must quickly assess the condition, make a primary diagnosis, and refer the patient to the appropriate treatment center. Insufficient skills in these situations can cause serious harm. Educating technicians on dealing with these patients may enhance their knowledge and skills; however, we do not know the extent and longevity of this improvement and which areas are affected. This study investigates the impact of training on pre-hospital emergency technicians' knowledge and skills. METHODS: This quasi-experimental study involved pre-hospital emergency technicians in Robat Karim and Nasim Shahr counties from December 2022 to January 2022. The technicians received workshops on interacting with psychiatric patients. The training topics included the basic principles of coping with a psychiatric patient. They also covered a step-by-step approach to dealing with an aggressive patient, dealing with a patient threatening suicide, managing agitation, managing a patient suffering from panic attacks, and finally dealing with a delirious patient. A pre-test assessed their baseline knowledge and skills, followed by a post-test after training and another test three months later. The test results were analyzed. RESULTS: This study involved forty male participants ranging in age from 25 to 44 and with work experience ranging from five to twenty years. As a result of training in dealing with acute psychiatric patients, technicians developed significant skills and knowledge immediately after training, and these improvements remained significant three months after training. Nevertheless, the correct answers decreased during the three-month follow-up compared to the pre-test. Education was less effective at managing panic, delirium, and agitation. CONCLUSION: In conclusion, technicians' knowledge and skills can be effectively enhanced through training; however, the impact diminishes with time. Theories and practical methods, periodic repetition, and real-world internships are the best ways to maximize training effectiveness.

Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age-disaggregated analysis.

BACKGROUND: Tranexamic acid (TXA) decreases mortality in injured patients and should be administered as soon as possible. Despite international guidelines recommending TXA in the prehospital setting, its use remains low. The aim of this study was to assess the prehospital administration of TXA for injured patients in a Swiss region. METHODS: We conducted a retrospective observational study in Switzerland between 2018 and 2021. Inclusion criteria were injured patients ≥18 years for whom an ambulance or helicopter was dispatched. The exclusion criterion was minor injury defined by a National Advisory Committee for Aeronautics score <3. The primary outcome was the proportion of patients treated with TXA according to guidelines. The European guidelines were represented by the risk of death from bleeding (calculated retrospectively using the Bleeding Audit for Trauma and Triage (BATT) score). Factors impacting the likelihood of receiving TXA were assessed by multivariate analysis. RESULTS: Of 13 944 patients included in the study, 2401 (17.2%) were considered at risk of death from bleeding. Among these, 257 (11%) received prehospital TXA. This represented 38% of those meeting US guidelines. For European guidelines, the treatment rate increased with the risk of death from bleeding: 6% (95% CI 4.4% to 7.0%) for low risk (BATT score 3-4); 13% (95% CI 11.1% to 15.9%) for intermediate risk (BATT score 5-7); and 21% (95% CI 17.6% to 25.6%) for high risk (BATT score ≥8) (p<0.01). Women and the elderly were treated less often than men and younger patients, irrespective of the risk of death from bleeding and the mechanism of injury. CONCLUSION: The proportion of injured patients receiving TXA in the prehospital setting of the State of Vaud in Switzerland was low, with even lower rates for women and older patients. The reasons for this undertreatment are probably multifactorial and would require specific studies to clarify and correct them.

Prehospital identification of acute ischaemic stroke with large vessel occlusion: a retrospective study from western Norway.

BACKGROUND: In 2019, the emergency medical services (EMS) covering the western Norway Regional Health Authority area implemented its version of the prehospital clinical criteria G-FAST (Gaze deviation, Facial palsy, Arm weakness, Visual loss, Speech disturbance) to detect acute ischaemic stroke (AIS) with large vessel occlusion (LVO). For patients with gaze deviation and at least one other G-FAST symptom, a primary stroke centre (PSC) may be bypassed and the patient taken directly to a comprehensive stroke centre (CSC) for rapid endovascular treatment (EVT) evaluation. The study aim was to investigate the efficacy of the G-FAST criteria for LVO patient selection and direct transfer to a CSC. METHODS: This retrospective study included patients with code-red emergency medical communication centre (EMCC) stroke suspicion ambulance dispatch between August to December 2020. Stroke suspicion was defined as having at least one G-FAST symptom at EMS arrival. We obtained patient data from dispatches from EMCCs, EMS records and local EVT registries. Clinical features, CT images, and reperfusion treatment were recorded. The test characteristics for gaze deviation plus one other G-FAST symptom in detecting LVO were determined. RESULTS: Among 643 patients, 59 were diagnosed with LVO at hospital arrival. In this group, seven fulfilled the G-FAST criteria for direct transport to a CSC at EMS arrival on scene, resulting in a sensitivity of 12% (95% CI 5% to 23%). The specificity was 99.66% (95% CI 98.77% to 99.96%), the positive predictive value 78%, and the negative predictive value 92%. EVT was performed in 64% (38/59) of LVO cases. Median time from PSC arrival to start of EVT at a CSC was 163 min. CONCLUSION: The use of local G-FAST prehospital criteria by EMS personnel to identify patients with AIS with LVO is not suitable for selection of patients with LVO for direct transfer to a CSC.

Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study.

BACKGROUND: Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS: Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS: Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS: Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.

Performance of 21 Early Warning System scores in predicting in-hospital deterioration among undifferentiated admitted patients managed by ambulance services.

BACKGROUND: The optimal Early Warning System (EWS) scores for identifying patients at risk of clinical deterioration among those transported by ambulance services remain uncertain. This retrospective study compared the performance of 21 EWS scores to predict clinical deterioration using vital signs (VS) measured in the prehospital or emergency department (ED) setting. METHODS: Adult patients transported to a single ED by ambulances and subsequently admitted to the hospital between 1 January 2019 and 18 April 2019 were eligible for inclusion. The primary outcome was 30-day mortality; secondary outcomes included 3-day mortality, admission to intensive care or coronary care units, length of hospital stay and emergency call activations. The discriminative ability of the EWS scores was assessed using the area under the receiver operating characteristic curve (AUROC). Subanalyses compared the performance of EWS scores between surgical and medical patient types. RESULTS: Of 1414 patients, 995 (70.4%) (53.1% male, mean age 68.7±17.5 years) were included. In the ED setting, 30-day mortality was best predicted by VitalPAC EWS (AUROC 0.71, 95% CI (0.65 to 0.77)) and National Early Warning Score (0.709 (0.65 to 0.77)). All EWS scores calculated in the prehospital setting had AUROC <0.70. Rapid Emergency Medicine Score (0.83 (0.73 to 0.92)) and New Zealand EWS (0.88 (0.81 to 0.95)) best predicted 3-day mortality in the prehospital and ED settings, respectively. EWS scores calculated using either prehospital or ED VS were more effective in predicting 3-day mortality in surgical patients, whereas 30-day mortality was best predicted in medical patients. Among the EWS scores that achieved AUROC ≥0.70, no statistically significant differences were detected in their discriminatory abilities to identify patients at risk of clinical deterioration. CONCLUSIONS: EWS scores better predict 3-day as opposed to 30-day mortality and are more accurate when estimated using VS measured in the ED. The discriminatory performance of EWS scores in identifying patients at higher risk of clinical deterioration may vary by patient type.

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

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

How do emergency departments respond to ambulance pre-alert calls? A qualitative exploration of the management of pre-alerts in UK emergency departments.

BACKGROUND: Calls to emergency departments (EDs) from ambulances to alert them to a critical case being transported to that facility that requires a special response ('pre-alerts') have been shown to improve outcomes for patients requiring immediate time-critical treatment (eg, stroke). However, little is known about their usefulness for other patients and the processes involved in ED responses to them. This study aimed to understand how pre-alerts influence patient care in the ED. METHODS: We undertook non-participant observation (162 hours, 143 pre-alerts) and semi-structured interviews with staff (n=40) in six UK EDs between August 2022 and April 2023 focusing on how ED staff respond to pre-alert calls and what influences their response. Observation notes and interview transcripts were imported into NVivo and analysed using a thematic approach. RESULTS: Pre-alert calls involved significant time and resources for ED staff but they were valued as they enabled staff to prepare for a patient's arrival (practically and psychologically). High demand and handover delays at ED created additional pre-alerts due to ambulance clinician concerns about the impact of long waits on patients.Despite the risk of pre-alert fatigue from calls for patients considered not to require a special response, ED clinicians appreciated timely pre-alert information, perceiving a higher risk from underalerting than overalerting. Variation in ED response was influenced by individual and organisational factors, particularly the resources available at the time of pre-alert. Unclear ED processes for receiving, documenting and sharing information about pre-alerts increased the risk of information loss. CONCLUSION: Improving processes for receiving and sharing pre-alert information may help ED clinicians prepare appropriately for incoming patients. Alternative routes for ambulance clinicians to seek advice on borderline pre-alert patients may help to improve the appropriateness of pre-alerts.

Triage in major incidents: development and external validation of novel machine learning-derived primary and secondary triage tools.

BACKGROUND: Major incidents (MIs) are an important cause of death and disability. Triage tools are crucial to identifying priority 1 (P1) patients-those needing time-critical, life-saving interventions. Existing expert opinion-derived tools have limited evidence supporting their use. This study employs machine learning (ML) to develop and validate models for novel primary and secondary triage tools. METHODS: Adults (16+ years) from the UK Trauma Audit and Research Network (TARN) registry (January 2008-December 2017) served as surrogates for MI victims, with P1 patients identified using predefined criteria. The TARN database was split chronologically into model training and testing (70:30) datasets. Input variables included physiological parameters, age, mechanism and anatomical location of injury. Random forest, extreme gradient boosted tree, logistic regression and decision tree models were trained to predict P1 status, and compared with existing tools (Battlefield Casualty Drills (BCD) Triage Sieve, CareFlight, Modified Physiological Triage Tool, MPTT-24, MSTART, National Ambulance Resilience Unit Triage Sieve and RAMP). Primary and secondary candidate models were selected; the latter was externally validated on patients from the UK military's Joint Theatre Trauma Registry (JTTR). RESULTS: Models were internally tested in 57 979 TARN patients. The best existing tool was the BCD Triage Sieve (sensitivity 68.2%, area under the receiver operating curve (AUC) 0.688). Inability to breathe spontaneously, presence of chest injury and mental status were most predictive of P1 status. A decision tree model including these three variables exhibited the best test characteristics (sensitivity 73.0%, AUC 0.782), forming the candidate primary tool. The proposed secondary tool (sensitivity 77.9%, AUC 0.817), applicable via a portable device, includes a fourth variable (injury mechanism). This performed favourably on external validation (sensitivity of 97.6%, AUC 0.778) in 5956 JTTR patients. CONCLUSION: Novel triage tools developed using ML outperform existing tools in a nationally representative trauma population. The proposed primary tool requires external validation prior to consideration for practical use. The secondary tool demonstrates good external validity and may be used to support decision-making by healthcare workers responding to MIs.