Ozone Efficacy for the Disinfection of Ambulances Used to Transport Patients during the COVID-19 Pandemic in Peru.

We assessed the disinfection efficacy of an ozone generator prototype in ambulances used to transport patients with coronavirus disease (COVID-19). This research consisted of three stages: in vitro tests using microbial indicators, such as Candida albicans, Escherichia coli, Staphylococcus aureus and Salmonella phage, which were experimentally inoculated onto polystyrene crystal surfaces within a 23 m3 enclosure. They were then exposed to ozone at a 25 ppm concentration using the ozone generator (Tecnofood SAC) portable prototype, and the decimal reduction time (D) was estimated for each indicator. The second stage involved the experimental inoculation of the same microbial indicators on a variety of surfaces inside conventional ambulances. The third stage consisted of exploratory field testing in ambulances used to transport patients with suspected COVID-19. During the second and third stages, samples were collected by swabbing different surfaces before and after 25 ppm ozonisation for 30 min. Results suggested that ozone was most effective on Candida albicans (D = 2.65 min), followed by Escherichia coli (D = 3.14 min), Salmonella phage (D = 5.01 min) and Staphylococcus aureus (D = 5.40 min). Up to 5% of the microbes survived following ozonisation of conventional ambulances. Of the 126 surface samples collected from ambulances transporting patients with COVID-19, 7 were positive (5.6%) for SARS-related coronavirus as determined on reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR). Ozone exposure from the ozone generator prototype inside ambulances at a concentration of 25 ppm for 30 min can eliminate gram positive and negative bacteria, yeasts, and viruses.

Experience of ambulance drivers on transfer of suspected or confirmed patients for COVID-19.

OBJECTIVE: To unveil the experience of ambulance drivers regarding the transfer of suspected or confirmed patients for COVID-19. METHOD: Exploratory study with a qualitative approach conducted in October 2021 with 18 drivers from the Northwestern Mesoregion of the State of Ceará-Brazil. The individual interviews occurred virtually, via Google Meet®, and for data processing the IRAMUTEQ® software was used. RESULTS: Six classes were obtained: Feelings experienced during transfers; Concern about contamination of the work team and family members; Therapeutic itinerary, patients' clinical status and increase in the number of transfers; Disinfection of ambulances between transfers of patients with suspected and/or diagnosed COVID-19; Gowning for patient transfers and Psychospiritual aspects of drivers during the pandemic. CONCLUSION: The experience was marked by challenges in adapting to the new routine and procedures during transfers. It was evidenced feelings of fear, insecurity, tension and anguish in the worker's reports.

Challenges and Risks in Out-of-Hospital Transport of Patients During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: Norwegian critical care resources are regionalized making air ambulances transport of suspected or confirmed coronavirus disease 2019 (COVID-19)-positive patients a necessity. We prospectively observed pre- and interhospital transportation of patients with suspected or confirmed COVID-19 in our physician-manned emergency medical services. METHODS: This was a prospective, observational quality assurance study of primary and secondary missions conducted by 2 Norwegian air ambulances during the COVID-19 pandemic. RESULTS: Forty-one (24.1%) were primary missions, whereas 129 (75.9%) were interhospital transports. Most patients (158 [92.9%]) were transported with ground-based vehicles, and 12 (7.1%) were transported by rotor wing aircrafts. One hundred thirty-four of 170 patients (78.8%) were COVID-19 positive at the time of transportation. The median (interquartile range) fraction of inspired oxygen concentration was 0.60 (0.50-0.80), the positive end-expiratory pressure was 11 cm H2O (8-13.5 cm H2O), and the peak inspiratory pressure was 26 cm H2O (22-30 cm H2O). Some degree of elevated treatment challenge was reported in 157 (87.7%) transports, and in 139 (77.7%), the patient risk was considered elevated. The physician stated that some degree of elevated risk for the provider was elevated in 131 (73.2%) of the transports. CONCLUSION: The capacity of the physician-manned emergency medical services to safely transfer patients remains essential to maintain resilient critical care capacity, and the perceived elevated risks should be considered in capacity planning.

A Systematic Review of Associations and Predictors for Job Satisfaction and Work Engagement in Prehospital Emergency Medical Services-Challenges for the Future.

Ambulance services are changing, and the SARS-CoV-2 pandemic has been a major challenge in the past three years. Job satisfaction and work engagement are important characteristics for a healthy organization and success in one's profession. The purpose of the current systematic review was to evaluate the predictors of job satisfaction and work engagement in prehospital emergency medical service personnel. Electronic databases, such as PubMed, Ovid Medline, Cochrane Library, Scopus, Web of Science, PsycINFO, PSYNDEX, and Embase, were utilized in this review. Predictors (ß coefficient, odds ratio, rho) of higher job satisfaction and work engagement were examined. Only prehospital emergency medical service personnel were considered. The review included 10 studies worldwide with 8358 prehospital emergency medical service personnel (24.9% female). The main predictor for job satisfaction was supervisors' support. Other predictors were younger or middle age and work experience. Emotional exhaustion and depersonalization, as burnout dimensions, were negative predictors for higher job satisfaction or work engagement. Quality demands for health care systems are a significant challenge for future emergency medical services. The psychological and physical strengthening of employees is necessary and includes constant supervision of managers or facilitators.

COVID-19 as a risk factor for long-term mortality in patients managed by the emergency medical system: A prospective, multicenter, ambulance-based cohort study.

Introduction: COVID-19 has initially been studied in terms of an acute-phase disease, although recently more attention has been given to the long-term consequences. In this study, we examined COVID-19 as an independent risk factor for long-term mortality in patients with acute illness treated by EMS (emergency medical services) who have previously had the disease against those who have not had the disease. Methods: A prospective, multicenter, ambulance-based, ongoing study was performed with adult patients with acute disease managed by EMS and transferred with high priority to the emergency department (ED) as study subjects. The study involved six advanced life support units, 38 basic life support units, and five emergency departments from Spain. Sociodemographic inputs, baseline vital signs, pre-hospital blood tests, and comorbidities, including COVID-19, were collected. The main outcome was long-term mortality, which was classified into 1-year all-cause mortality and 1-year in- and out-of-hospital mortality. To compare both the patients with COVID-19 vs. patients without COVID-19 and to compare survival vs non-survival, two main statistical analyses were performed, namely, a longitudinal analysis (Cox regression) and a logistic regression analysis. Results: Between 12 March 2020 and 30 September 2021, a total of 3,107 patients were included in the study, with 2,594 patients without COVID-19 and 513 patients previously suffering from COVID-19. The mortality rate was higher in patients with COVID-19 than in patients without COVID-19 (31.8 vs. 17.9%). A logistic regression showed that patients previously diagnosed with COVID-19 presented higher rates of nursing home residency, a higher number of breaths per minute, and suffering from connective disease, dementia, and congestive heart failure. The longitudinal analysis showed that COVID-19 was a risk factor for mortality [hazard ratio 1.33 (1.10-1.61); p < 0.001]. Conclusion: The COVID-19 group presented an almost double mortality rate compared with the non-COVID-19 group. The final model adjusted for confusion factors suggested that COVID-19 was a risk factor for long-term mortality.

Not only COVID-19 disease impacts ambulance emergency demands but also lockdowns and quarantines.

BACKGROUND: The pandemic has impacted both patients infected by the SARS-CoV-2 virus and patients who seek emergency assistance due to other health issues. Changes in emergency demands are expected to have occurred during the pandemic, the objective of this investigation is to characterize the changes in ambulance emergency demands during the first year of the COVID-19 pandemic in the Vaud State of Switzerland. The goal of this research is to identify the collateral effects of the COVID-19 pandemic on emergency demands. To do so, this study quantifies the differences in health issues, level of severity, and patients' sociodemographic characteristics (age, location, gender) prior to and during the outbreak. METHOD: This is a retrospective, descriptive and comparative statistical analysis of all ambulance emergency missions from 2018 to 2020 (n = 107,150) in the State of Vaud in Switzerland. Variables analyzed were the number of ambulance missions, patient age and gender, health issues, severity (NACA scores), number of non-transports, mission times and locations. Variables were compared between prepandemic and pandemic situations across years and months. Comparative analysis used bivariate analysis, χ2 test, Student's t test, and Mann‒Whitney U test. RESULTS: The pandemic has had two major impacts on the population's emergency demands. The first appears to be due to COVID-19, with an increase in respiratory distress cases that doubled in November 2020. The second relates to the implementation of lockdown and quarantine measures for the population and the closures of restaurants and bars. These might explain the decrease in both the number of traumas and intoxications, reaching more than 25% and 28%, respectively. An increase in prehospital emergency demands by the older population, which accounted for 53% of all demands in 2020, is measured. CONCLUSION: Collateral effects occurred during 2020 and were not only due to the pandemic but also due to protective measures deployed relative to the population. This work suggests that more targeted reflections and interventions concerning the most vulnerable group, the population of people 65 and older, should be of high priority. Gaining generalizable knowledge from the COVID-19 pandemic in prehospital settings is critical for the management of future pandemics or other unexpected disasters.

Risk of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) acquisition during ambulance transport: A retrospective propensity-score-matched cohort analysis.

OBJECTIVE: To estimate the relative risk (RR) of developing methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization or infection within 30 days of ambulance transport. METHODS: We performed a retrospective cohort study of patients with a principal diagnosis of chest pain presenting to our emergency department (ED) over a 4-year period. Patients were included if they presented from and were discharged to nonhealthcare locations without being admitted. Encounters were stratified by arrival mechanism: ambulance versus private vehicle. We performed propensity score matching and multivariable logistic regression to estimate the RR for the primary outcome. RESULTS: In total, 321,229 patients had ED encounters during the study period. After applying inclusion criteria and propensity score matching, there were 11,324 patients: 3,903 in the ambulance group and 7,421 in the unexposed group. Among them, 12 patients (0.11%) had the outcome of interest, including 9 (0.08%) with MRSA and 3 (0.03%) with VRE. The 30-day prevalence of MRSA or VRE was larger in the ambulance group than in the unexposed group: 8 (0.20%) and 4 (0.05%), respectively (P = .02). Patients who presented to the ED via ambulance were almost 4 times more likely to have MRSA or VRE within 30 days of their encounter (RR, 3.72; 95% CI, 1.09-12.71; P = .04). CONCLUSIONS: Our cohort study is the first to demonstrate an association between ambulance exposure and pathogen incidence, representing the first step in evaluating medical-transport-associated infection burden to eventually develop interventions to address it.

Adverse outcomes of GHB use: Analysis of ambulance attendances in metropolitan and regional Victoria.

BACKGROUND: Gamma-hydroxybutyrate (GHB) use and attributable harms have been increasing in Australia, however changes over time, including the impact of COVID-19 lockdowns and restrictions on harms requiring an ambulance attendance, are unknown. This study utilised a novel population-based surveillance system to identify the types of GHB-related harms between January 2018 and 31 December 2021 in Victoria, Australia. METHODS: A cross-sectional, retrospective analysis of all GHB-related ambulance attendances between January 2018 and 31 December 2021 in Victoria, Australia was undertaken. Paramedic clinical notes and Glasgow Coma Scale scores were used to assess conscious state. Event codes were classified using dispatch information available in the database. Crude rates (per 100,000 population) and descriptive analyses were calculated for metropolitan and regional settings. Adjusted Odds ratios (aOR) with 95% confidence intervals [95% CI] were used to assess the relationship between GCS severity and polysubstance combinations with GHB. RESULTS: There were 6,836 ambulance attendances for GHB recorded during the study period. A statistically significant increase in GHB-related attendance numbers was observed State-wide in 2019 (n = 1,402, p<0.001) and 2020 (n = 2,622, p<0.001), when comparing year on year attendances. While both numbers and rates (per 100,000 population) of GHB-related attendances were significantly lower in regional areas, significant increases were evident in both metropolitan and regional areas in 2019 and 2020 (both p<0.001). Attendances involving GHB and alcohol had higher odds of a severe GCS score (aOR:1.25; 95%: 1.04-1.49; p<0.019). A high proportion of GHB-attendances involved harms of significant concern including: overdose (56%) and a loss of, or altered state of consciousness (45%). CONCLUSIONS: We observed increases in GHB-related ambulance attendances over time in both metropolitan and regional areas, placing a significant burden on ambulance services. Our study demonstrates the value of using ambulance surveillance to obtain representative data on acute GHB-related harms.

Increases in Ambulance Call Volume Are an Early Warning Sign of Major COVID-19 Surges in Children.

Background: Infectious diseases, including COVID-19, have a severe impact on child health globally. We investigated whether emergency medical service (EMS) calls are a bellwether for future COVID-19 caseloads. We elaborated on geographical hotspots and socioeconomic risk factors. Methods: All EMS calls for suspected infectious disease in the pediatric population (under 18 years of age) in Rhode Island between 1 March 2018 and 28 February 2022 were included in this quasi-experimental ecological study. The first of March 2020 was the beginning of the COVID-19 pandemic. We used the 2020 census tract and the most recent COVID-19 data. We investigated associations between pediatric EMS calls and positive COVID-19 tests with time series analysis and identified geographical clusters using local indicators of spatial association. Economic risk factors were examined using Poisson regression. Results: We included 980 pediatric ambulance calls. Calls during the omicron wave were significantly associated with increases in positive COVID-19 tests one week later (p < 0.001). Lower median household income (IRR 0.99, 95% CI [0.99, 0.99]; p < 0.001) and a higher child poverty rate (IRR 1.02, 95% CI [1.02, 1.02]; p < 0.001) were associated with increased EMS calls. Neighborhood hotspots changed over time. Conclusion: Ambulance calls might be a predictor for major surges of COVID-19 in children.

The experiences and perceptions of wellbeing provision among English ambulance services staff: a multi-method qualitative study.

BACKGROUND: NHS ambulance service staff are at risk of poor physical and mental wellbeing because of the likelihood of encountering stressful and traumatic incidents. While reducing sickness absence and improving wellbeing support to ambulance staff is a key NHS priority, few studies have empirically documented a national picture to inform policy and service re-design. The study aimed to understand how ambulance service trusts in England deal with staff health and wellbeing, as well as how the staff perceive and use wellbeing services. METHODS: To achieve our aim, we undertook semi-structured telephone interviews with health and wellbeing leads and patient-facing ambulance staff, as well as undertaking documentary analysis of ambulance trust policies on wellbeing. The study was conducted both before and during the UK first COVID-19 pandemic wave. The University of Lincoln ethics committee and the Health Research Authority (HRA) granted ethical approval. Overall, we analysed 57 staff wellbeing policy documents across all Trusts. Additionally, we interviewed a Health and Wellbeing Lead in eight Trusts as well as 25 ambulance and control room staff across three Trusts. RESULTS: The study highlighted clear variations between organisational and individual actions to support wellbeing across Trust policies. Wellbeing leads acknowledged real 'tensions' between individual and organisational responsibility for wellbeing. Behaviour changes around diet and exercise were perceived to have a positive effect on the overall mental health of their workforce. Wellbeing leads generally agreed that mental health was given primacy over other wellbeing initiatives. Variable experiences of health and wellbeing support were partly contingent on the levels of management support, impacted by organisational culture and service delivery challenges for staff. CONCLUSION: Ambulance service work can impact upon physical and mental health, which necessitates effective support for staff mental health and wellbeing. Increasing the knowledge of line managers around the availability of services could improve engagement.

Perceived feasibility, facilitators and barriers to incorporating point-of-care testing for SARS-CoV-2 into emergency medical services by ambulance service staff: a survey-based approach.

OBJECTIVES: This body of work aimed to elicit ambulance service staff's perceptions on the barriers and facilitators to adoption, and clinical utility of incorporating rapid SARS-CoV-2 testing during ambulance assessments. DESIGN: A mixed-methods survey-based project using a framework analysis method to organise qualitative data. SETTING: Emergency and non-emergency care ambulatory services in the UK were approached to take part. PARTICIPANTS: Current, practising members of the UK ambulance service (paramedics, technicians, assistants and other staff) were included in this body of work. RESULTS: Survey 1: 226 responses were collected between 3 December 2020 and 11 January 2021, 179 (79.2%) of which were completed in full. While the majority of respondents indicated that an ambulance-based testing strategy was feasible in concept (143/190, 75.3%), major barriers to adoption were noted. Many open-ended responses cited concerns regarding misuse of the service by the general public and other healthcare services, timing and conveyance issues, and increased workloads, alongside training and safety concerns. Survey 2: 26 responses were received between 8 February 2021 and 22 February 2021 to this follow-up survey. Survey 2 revealed conveyance decision-making, and risk stratification to be the most frequently prioritised use cases among ambulance service staff. Optimal test characteristics for clinical adoption according to respondents were; accuracy (above 90% sensitivity and specificity), rapidity (<30 min time to results) and ease of sample acquisition. CONCLUSIONS: The majority of commercially available lateral flow devices are unlikely to be supported by paramedics as their duty of care requires both rapid and accurate results that can inform clinical decision making in an emergency situation. Further investigation is needed to define acceptable test characteristics and criteria required for ambulance service staff to be confident and supportive of deployment of a SARS-CoV-2 test in an emergency care setting.

SARS-CoV-2 Contamination of Ambulance Surfaces and Effectiveness of Routine Decontamination Procedure: A Classic Hygiene Lesson for A Novel Pathogen.

The efficacy of standard operating procedures (SOPs) for the decontamination of ambulances against SARS-CoV-2 has been debated. In Italy, the differential use of ambulances was implemented by regional health authorities, with selected vehicles being used exclusively for transporting COVID-19 patients. We investigated the presence of SARS-CoV-2 on high-touch surfaces in ambulances to assess contamination dynamics and the effectiveness of decontamination SOPs. Four high-touch surfaces were sampled before and after decontamination (T0; T1). The gloves of the EMS crew chief were also sampled. RNA extraction was performed with a commercial kit, followed by RT-qPCR molecular detection of SARS-CoV-2. A total of 11 transports were considered. Seven transports had at least one positive sample; all were related to a COVID-19 patient. Three of the negative transports had dealt with COVID-19 case, and one had dealt with a COVID-19-negative patient. One door handle and one oxygen knob were positive at T0, with negative T1 swabs. The monitors were positive in 5 transports at T0, yet they were never positive at T1. Three stretcher handles tested positive at T0, and two of them also at T1, possibly having bypassed decontamination during personnel dismounting. Gloves were contaminated in five transports, in which 1 to 3 additional samples (monitor, knob, stretcher) resulted as positive. Overall, the efficacy of decontamination SOPs was confirmed under the unprecedented conditions of the COVID-19 emergency. However, the importance of correct hand-hygiene and glove-disposal should be further emphasized through the dedicated training of EMS personnel.

Ten Years of the Nepal Ambulance Service: Successful and Sustainable Efforts.

We describe the evolution of the nonprofit Nepal Ambulance Service (NAS) in a narrative of its 10-y history, presenting geographical, social, cultural, and financial considerations that permeated the development of NAS. We gathered narrative information from the NAS leadership and partners to detail key organizational considerations regarding the implementation and maintenance of the prehospital system in Nepal. We describe the response of NAS to the 2015 earthquake and summarize transport data for 6 mo before and 6 mo after the event. The data collected included the date and time of calls received, time to ambulance dispatch, on-scene time, time to arrival at the hospital, time until the ambulance crew was back in service, patient age and sex, chief complaints, and work shift time of the ambulance crew. To characterize the time to response and transport after the 2015 earthquake, we present the means and standard deviations of the time intervals. There was an overall increase in calls and, specifically, trauma-related calls after the 2015 earthquake. The time from a call placed to dispatch was stable, approximately 2 min, throughout the period, whereas the time from dispatch to the scene and arrival at the scene varied widely. We discuss the response to coronavirus disease 2019 (COVID-19). The NAS provided care to 1230 patients with COVID-19. The descriptive data show how well NAS responded to a major national disaster and the recent pandemic.

Why do ambulance employees (not) seek organisational help for mental health support? A mixed-methods systematic review protocol of organisational support available and barriers/facilitators to uptake.

INTRODUCTION: The COVID-19 pandemic is exacerbating a wide range of symptoms of poor mental health among emergency medical service (EMS) ambulance populations. Evidence suggests that using organisational support can improve employee outcomes and in turn, patient outcomes. Understanding why EMS staff do and do not use support services is therefore critical to improving uptake, ensuring equitable access, and potentially influencing workforce well-being, organisational sustainability and patient care delivery. This systematic review aims to identify what support is available and any perceived barriers and facilitators to accessing and utilising organisational support. METHODS AND ANALYSIS: Searches performed between 18 February 2022 and 23 February 2022 will be used to identify studies that report barriers and facilitators to EMS employee support among all government/state commissioned EMS ambulance systems. Electronic databases, AMED, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, EMBASE, EMCARE, HMIC, Medline and PsycINFO will be searched. All relevant English-language studies of adult employees of government/state commissioned EMS ambulance organisations published since December 2004 will be screened and relevant data extracted by two independent reviewers. A third reviewer will resolve any disagreements.The primary outcome is the identification of perceived barriers or facilitators to EMS staff using organisational support for mental health. The secondary outcome is the identification of supportive interventions offered through or by ambulance trusts. Study selection will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the methodological quality of included studies will be appraised by administering rating checklists. A narrative synthesis will be conducted to report qualitative and quantitative data and will include population characteristics, methodological approach and information about barriers and facilitators. ETHICS AND DISSEMINATION: Ethical approval is not required because only available published data will be analysed. Findings will be disseminated through peer-reviewed publication and conference presentation. PROSPERO REGISTRATION NUMBER: CRD42022299650.

"See us as humans. Speak to us with respect. Listen to us." A qualitative study on UK ambulance staff requirements of leadership while working during the COVID-19 pandemic.

BACKGROUND: The COVID-19 Ambulance Response Assessment (CARA) study aimed to enable the experiences of UK frontline ambulance staff working during the first wave of the pandemic to be heard. Specifically, CARA aimed to assess feelings of preparedness and well-being and to collect suggestions for beneficial leadership support. METHODS: Three online surveys were sequentially presented between April and October 2020. Overall, 18 questions elicited free-text responses that were analysed qualitatively using an inductive thematic approach. FINDINGS: Analysis of 14 237 responses revealed participants' goals and their requirements of leadership to enable those goals to be achieved. A large number of participants expressed low confidence and anxiety resulting from disagreement, inconsistency and an absence of transparency related to policy implementation. Some staff struggled with large quantities of written correspondence and many desired more face-to-face training and an opportunity to communicate with policymakers. Suggestions were made on how best to allocate resources to reduce operational demands and maintain service delivery, and a need to learn from current events in order to plan for the future was stressed. To further support well-being, staff wanted leadership to understand and empathise with their working conditions, to work to reduce the risks and if required, to facilitate access to appropriate therapeutic interventions. CONCLUSIONS: This study demonstrates that ambulance staff desire both inclusive and compassionate leadership. Leadership should aim to engage in honest dialogue and attentive listening. Resultant learning can then inform policy development and resource allocation to effectively support both service delivery and staff well-being.