Characteristics, survival and neurological outcome in out-of-hospital cardiac arrest in young adults in Sweden: A nationwide study.

Aim: The aim of this study was to present a comprehensive overview of out-of-hospital cardiac arrests (OHCA) in young adults. Methods: The data set analyzed included all cases of OHCA from 1990 to 2020 in the age-range 16-49 years in the Swedish Registry of Cardiopulmonary Resuscitation (SRCR). OHCA between 2010 and 2020 were analyzed in more detail. Clinical characteristics, survival, neurological outcomes, and long-time trends in survival were studied. Logistic regression was used to study 30-days survival, neurological outcomes and Utstein determinants of survival. Results: Trends were assessed in 11,180 cases. The annual increase in 30-days survival during 1990-2020 was 5.9% with no decline in neurological function among survivors. Odds ratio (OR) for heart disease as the cause was 0.55 (95% CI 0.44 to 0.67) in 2017-2020 compared to 1990-1993. Corresponding ORs for overdoses and suicide attempts were 1.61 (95% CI 1.23-2.13) and 2.06 (95% CI 1.48-2.94), respectively. Exercise related OHCA was noted in roughly 5%. OR for bystander CPR in 2017-2020 vs 1990-1993 was 3.11 (95% CI 2.57 to 3.78); in 2020 88 % received bystander CPR. EMS response time increased from 6 to 10 minutes. Conclusion: Survival has increased 6% annually, resulting in a three-fold increase over 30 years, with stable neurological outcome. EMS response time increased with 66% but the majority now receive bystander CPR. Cardiac arrest due to overdoses and suicide attempts are increasing.

The impact of the three-level collaboration exercise on collaboration and leadership during scenario-based hospital evacuation exercises using flexible surge capacity concept: a mixed method cross-sectional study.

BACKGROUND: Hospitals play a crucial role in responding to disasters and public health emergencies. However, they are also vulnerable to threats such as fire or flooding and can fail to respond or evacuate adequately due to unpreparedness and lack of evacuation measures. The United Nations Office for Disaster Risk Reduction has emphasised the importance of partnerships and capacity building in disaster response. One effective way to improve and develop disaster response is through exercises that focus on collaboration and leadership. This study aimed to examine the effectiveness of using the 3-level collaboration (3LC) exercise in developing collaboration and leadership in districts in Thailand, using the concept of flexible surge capacity (FSC) and its collaborative tool during a hospital evacuation simulation. METHODS: A mixed-method cross-sectional study was conducted with 40 participants recruited from disaster-response organisations and communities. The data from several scenario-based simulations were collected according to the collaborative elements (Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport), in the disaster response education, "Major Incident Medical Management and Support" using self-evaluation survey pre- and post-exercises, and direct observation. RESULTS: The 3LC exercise effectively facilitated participants to gain a mutual understanding of collaboration, leadership, and individual and organisational flexibility. The exercise also identified gaps in communication and the utilisation of available resources. Additionally, the importance of early community engagement was highlighted to build up a flexible surge capacity during hospital evacuation preparedness. CONCLUSIONS: the 3LC exercise is valuable for improving leadership skills and multiagency collaboration by incorporating the collaborative factors of Flexible Surge Capacity concept in hospital evacuation preparedness.

Comparison of the novel WEst coast System for Triage (WEST) with Rapid Emergency Triage and Treatment System (RETTS©): an observational pilot study.

BACKGROUND: Most Swedish emergency departments (ED) use the triage system Rapid Emergency Triage and Treatment System (RETTS©), which over time has proven to prioritize patients to higher triage levels. When many patients are prioritized to high triage levels, challenges with identifying true high-risk patients and increased waiting time for these patients has emerged. In order to achieve a more balanced triage in relation to actual medical risk, the triage system WEst coast System for Triage (WEST) was developed, based on the South African Triage Scale (SATS). The aim of this study was to perform an initial evaluation of the novel emergency triage system WEST compared to the existing RETTS©. METHODS: Both RETTS© and WEST are five level triage systems illustrated by colors. Nurses from each of the three adult EDs of Sahlgrenska University Hospital in Gothenburg and the ambulance service assessed and triaged 1510 patients according to RETTS© and immediately thereafter filled out the WEST triage form. Data from each triage report were analyzed and grouped according to the triage color, chief complaint, and outcome of each patient. Data on discharge categories and events within 72 h were also collected. Data were analyzed with descriptive statistical methods. RESULTS: In general, WEST displayed lower levels of prioritization compared to RETTS©, with no observed impact on patients' medical outcomes. In RETTS© orange triage level, approximately 50% of the patients were down prioritized in WEST to yellow or green triage levels. Also, in the RETTS© yellow triage level, more than 55% were down prioritized to green triage level in WEST. The number of patients who experienced a serious event during the first 72 h was few. Three patients died, these were all prioritized to red triage level in RETTS©. In WEST two of these patients were prioritized to red triage level and one to orange triage level. All these patients were admitted to hospital before deterioration. CONCLUSIONS: WEST may reduce over prioritization at the ED, especially in the orange and yellow triage levels of RETTS©, with no observed increase in medical risk. WEST can be recommended for a clinical comparative study.

[Fewer overtriaged children with PEPP compared to RETTS-p at a Swedish pediatric emergency department]. / Svenskanpassad triage gav färre överprioriteringar på barnakut.

Pediatric Priority Process (PEPP) is a triage system derived from the South African Triage Scale. It was developed by healthcare professionals at the Queen Silvia Children's hospital in Gothenburg. PEPP is a four-level triage system with two parts: vital parameters and warning symptoms. The aim of the study was to compare the amount of overtriage and the specificity for children in need of hospitalization in PEPP compared to RETTS-p. Our study shows that PEPP yields significantly fewer children with a high priority and has a higher specificity than RETTS-p. Senior triage nurses judged PEPP to have a higher accuracy, and the system triages children in need of supplemental oxygen higher than RETTS-p. We conclude that PEPP has high patient safety, and the next step is to implement it at our pediatric emergency department and to continue research for further validation.

Sports nutrition supplements and adverse events - a meta-epidemiological study of case reports specifically addressing causality assessment.

PURPOSE: This meta-epidemiological study aimed to systematically review case reports regarding sports nutrition supplements and adverse events (AEs), specifically addressing the issue of causality assessments. METHODS: Through a systematic literature search we identified all published case reports of AEs associated with sports nutrition supplements between 1 January 2008 and 1 March 2019. Data regarding AEs, suspected supplements, relevant causality assessment factors and the reporting of clinical reasoning and/or systematic causality assessment methods were extracted. RESULTS: In all, 72 publications were included, reporting 134 supplements and 37 different AEs in 97 patients (85% males; median age: 30 years [range: 14-60]). Information regarding previous health and regular prescription drugs was not presented in 30% (29/97) and 46% (45/97) of cases, respectively. In 23% (22/97) of the cases, no alternative cause was mentioned. Clinical reasoning was identified in 63% (61/97), and in 13% (8/61) of these, a systematic causality assessment method was applied. In cases with clinical reasoning, a theoretic rationale (92% vs 78%, P = 0.05), a description of previous cases (90% vs 72%, P = 0.021) and body fluid analysis (18% vs 3%, P = 0.027) were reported to a greater extent. Among cases with clinical reasoning, the application of a systematic causality assessment method captured additional important aspects: use of medication (100% vs 55%, P = 0.015), alcohol use (88% vs 43%, P = 0.020) and illicit drug use (88% vs 40%, P = 0.011). CONCLUSIONS: In published case reports where sports nutrition supplements were suspected to have caused AEs, essential factors for causality assessment were left out in a non-negligible proportion. Clinical reasoning was identified in most cases whereas a systematic causality assessment method was applied in a minority. Factors of importance for causality assessment were reported to a greater extent in cases including clinical reasoning, and the application of a systematic causality assessment method captured additional aspects of importance.

Improving Machine Learning 30-Day Mortality Prediction by Discounting Surprising Deaths.

BACKGROUND: Machine learning (ML) is an emerging tool for predicting need of end-of-life discussion and palliative care, by using mortality as a proxy. But deaths, unforeseen by emergency physicians at time of the emergency department (ED) visit, might have a weaker association with the ED visit. OBJECTIVES: To develop an ML algorithm that predicts unsurprising deaths within 30 days after ED discharge. METHODS: In this retrospective registry study, we included all ED attendances within the Swedish region of Halland in 2015 and 2016. All registered deaths within 30 days after ED discharge were classified as either "surprising" or "unsurprising" by an adjudicating committee with three senior specialists in emergency medicine. ML algorithms were developed for the death subclasses by using Logistic Regression (LR), Random Forest (RF), and Support Vector Machine (SVM). RESULTS: Of all 30-day deaths (n = 148), 76% (n = 113) were not surprising to the adjudicating committee. The most common diseases were advanced stage cancer, multidisease/frailty, and dementia. By using LR, RF, and SVM, mean area under the receiver operating characteristic curve (ROC-AUC) of unsurprising deaths in the test set were 0.950 (SD 0.008), 0.944 (SD 0.007), and 0.949 (SD 0.007), respectively. For all mortality, the ROC-AUCs for LR, RF, and SVM were 0.924 (SD 0.012), 0.922 (SD 0.009), and 0.931 (SD 0.008). The difference in prediction performance between all and unsurprising death was statistically significant (P < .001) for all three models. CONCLUSION: In patients discharged to home from the ED, three-quarters of all 30-day deaths did not surprise an adjudicating committee with emergency medicine specialists. When only unsurprising deaths were included, ML mortality prediction improved significantly.

The Feasibility of Implementing the Flexible Surge Capacity Concept in Bangkok: Willing Participants and Educational Gaps.

The management of emergencies consists of a chain of actions with the support of staff, stuff, structure, and system, i.e., surge capacity. However, whenever the needs exceed the present resources, there should be flexibility in the system to employ other resources within communities, i.e., flexible surge capacity (FSC). This study aimed to investigate the possibility of creating alternative care facilities (ACFs) to relieve hospitals in Bangkok, Thailand. Using a Swedish questionnaire, quantitative data were compiled from facilities of interest and were completed with qualitative data obtained from interviews with key informants. Increasing interest to take part in a FSC system was identified among those interviewed. All medical facilities indicated an interest in offering minor treatments, while a select few expressed interest in offering psychosocial support or patient stabilization before transport to major hospitals and minor operations. The non-medical facilities interviewed proposed to serve food and provide spaces for the housing of victims. The lack of knowledge and scarcity of medical instruments and materials were some of the barriers to implementing the FSC response system. Despite some shortcomings, FSC seems to be applicable in Thailand. There is a need for educational initiatives, as well as a financial contingency to grant the sustainability of FSC.

Inter-rater reliability of assessments regarding the quality of drug treatment, and drug-related hospital admissions.

AIMS: To investigate inter-rater agreement on the quality of drug treatment, and the relationship between the drug treatment and hospital admission. METHODS: Three specialist physicians and two resident physicians determined, independently and in consensus, the quality of drug treatment from an overall medical perspective, and its association with admission, in 30 randomly selected patients (50% female, median age 72 years) admitted to Sahlgrenska University Hospital, Sweden, in April 2018. The inter-rater agreement was evaluated with Gwet's agreement coefficient (AC1 ). RESULTS: In all, 200 (95%) out of 210 drugs at admission and 238 (97%) out of 245 drugs at discharge were assessed as reasonable drug treatment by all assessors. Conversely, none of the drugs at admission, and two at discharge, were assessed as unreasonable drug treatment by all assessors (AC1 : 0.88 and 0.94 [all], 0.86 and 0.95 [specialists], 0.92 and 0.92 [residents], respectively). The assessments regarding the association between the drug treatment and the hospital admission (not related or main/contributory reason) were consistent between the assessors for 16 out of 30 patients (AC1 : 0.67 [all], 0.74 [specialists], 0.54 [residents]). In none of the three cases where the hospital admission was considered possibly attributable to a prescribing error did the assessors make consistent assessments. CONCLUSIONS: As the inter-rater agreement ranged between weak and almost perfect, the reliability of assessments of drug treatment quality, as well as adverse consequences, appears to be a methodological concern. To yield acceptably reliable results regarding both drug treatment aspects at issue, specialist physicians should be involved.

Likelihood of admission to hospital from the emergency department is not universally associated with hospital bed occupancy at the time of admission.

BACKGROUND: The decision to admit into the hospital from the emergency department (ED) is considered to be important and challenging. The aim was to assess whether previously published results suggesting an association between hospital bed occupancy and likelihood of hospital admission from the ED can be reproduced in a different study population. METHODS: A retrospective cohort study of attendances at two Swedish EDs in 2015 was performed. Admission to hospital was assessed in relation to hospital bed occupancy together with other clinically relevant variables. Hospital bed occupancy was categorized and univariate and multivariate logistic regression were performed. RESULTS: In total 89,503 patient attendances were included in the final analysis. Of those, 29.1% resulted in admission within 24 h. The mean hospital bed occupancy by the hour of the two hospitals was 87.1% (SD 7.6). In both the univariate and multivariate analysis, odds ratio for admission within 24 h from the ED did not decrease significantly with an increasing hospital bed occupancy. CONCLUSIONS: A negative association between admission to hospital and occupancy level, as reported elsewhere, was not replicated. This suggests that the previously shown association might not be universal but may vary across sites due to setting specific circumstances.

Reasons for longer LOS at the emergency departments: Practical, patient-centred, medical, or cultural?

Emergency department (ED) overcrowding is caused by external and/or internal factors. One critical internal factor, leading to longer length of stay (LOS) at ED (eg, frequent ED users), is the physician's uncertainty in management of patients with unclear diagnosis and or complex medical history. The aim of this study was to identify whether the causes of physicians' uncertainty was practical, patient-centred, medical, or cultural. Using earlier published dimensions of uncertainty, 18 physicians were asked to reply to a template by choosing a relevant dimension that causes a delay in assessment of a known complex patient. This stage was completed by interviews through which participants had an opportunity to express their concerns and critical thoughts, if any. The data obtained from the template were collected and analysed. The interviews were recorded and transcribed verbatim. The results of the template indicated medical dimension as the main factor in delayed assessment of a complex patient. However, this finding was challenged by the results of the interviews, which indicated higher impact of personal/routines/cultural dimension (eg, being afraid of criticism, reprimand, and gossip or feelings of guilt). Although medical, patient-centred, and practical issues are important causes of longer LOS at ED, physicians' working and professional environment may have a higher impact than previously perceived. The uncertainty caused by interpersonal, organisational, and cultural issues within a clinic/hospital seems to influence the physician's ability to make decisions and thus a patient's medical outcome.

Drug adherence in treatment resistant and in controlled hypertension-Results from the Swedish Primary Care Cardiovascular Database (SPCCD).

PURPOSE: To assess drug adherence in patients treated with ≥3 antihypertensive drug classes, with both controlled and uncontrolled blood pressure and describe associated factors for nonadherence. METHODS: Patients with hypertension, without cardiovascular comorbidity, aged >30 years treated with ≥3 antihypertensive drug classes were followed for 2 years. Both patients with treatment resistant hypertension (TRH) and patients with controlled hypertension were included. Clinical data were derived from a primary care database. Pharmacy refill data from the Swedish Prescribed drug registry was used to calculate proportion of days covered (PDC). Patients with a PDC level ≥ 80% were included. RESULTS: We found 5846 patients treated ≥3 antihypertensive drug classes, 3508 with TRH (blood pressure ≥ 140/90), and 2338 with controlled blood pressure (<140/90 mm Hg). TRH patients were older (69.1 vs 65.8 years, P < .0001) but had less diabetes (28.5 vs 31.7%, P < .009) compared with patients with controlled blood pressure. The proportion of patients with PDC ≥ 80% declined with 11% during the first year in both groups. Having diabetes was associated with staying adherent at 1 year (RR 0.82; 95% CI, 0.68-0.98) whilst being born outside Europe was associated with nonadherence at one and (RR 2.05; 95% CI, 1.49-2.82). CONCLUSIONS: Patients with multiple antihypertensive drug therapy had similar decline in adherence over time regardless of initial blood pressure control. Diabetes was associated with better adherence, which may imply that the structured caregiving of these patients enhances antihypertensive drug treatment.

Cardiovascular outcome in treatment-resistant hypertension: results from the Swedish Primary Care Cardiovascular Database (SPCCD).

OBJECTIVE: To assess cardiovascular outcome in patients with treatment-resistant hypertension (TRH) compared with patients with nontreatment-resistant hypertension (HTN). METHODS: Cohort study with data from 2006 to 2012 derived from the Swedish Primary Care Cardiovascular Database with hypertensive patients aged at least 30 years. TRH was defined as blood pressure at least 140/90 mmHg despite medication adherence to three or more dispensed antihypertensive drug classes. Patients with cardiovascular comorbidity were excluded. The association between TRH and cardiovascular events with adjustment for important confounders was analyzed. RESULTS: We included 4317 TRH patients and 32 282 HTN patients. TRH patients (61% women) were older (70 vs. 66 years), had higher SBP (152 vs. 141 mmHg) and more diabetes (30 vs. 20%) (P < 0.001 for all) compared with HTN patients. Mean follow-up time was 4.3 years. In the adjusted analysis, TRH patients had an increased risk for total mortality [hazard ratio 1.12; 95% confidence interval (CI), 1.03-1.23], cardiovascular mortality (hazard ratio 1.20; 95% CI, 1.03-1.40) and incident heart failure (hazard ratio 1.34; 95% CI, 1.17-1.54) but not for incident stroke (hazard ratio 1.03; 95% CI, 0.90-1.19) or transitoric ischemic attack (hazard ratio 1.12; 95% CI, 0.86-1.46) compared with HTN patients. CONCLUSION: Patients with TRH have a poor prognosis beyond blood pressure level, compared with hypertensive patients without TRH. In particular, the high risk for heart failure is of clinical importance and merits further investigation.

Prevalence of treatment-resistant hypertension and important associated factors-results from the Swedish Primary Care Cardiovascular Database.

We aimed to describe the prevalence, treatment, and associated comorbidity of treatment-resistant hypertension (TRH). This registry-based cohort study from The Swedish Primary Care Cardiovascular Database assessed 53,090 hypertensive patients attending primary care. Patients adherent to antihypertensive treatment measured by pharmacy fills and with proportion of days covered ≥80% were included. The prevalence of TRH was 17% when considering all current TRH definitions. Adherence to mineralocorticoid receptor antagonists differed between TRH- and non-TRH patients (8 vs. 4%). Higher frequencies (prevalence ratio and 95% confidence intervals) of diabetes mellitus (1.59, 1.53-1.66), heart failure (1.55, 1.48-1.64), atrial fibrillation (1.33, 1.27-1.40), ischemic heart disease (1.25, 1.20-1.30), and chronic kidney disease (1.38, 1.23-1.54) were seen in patients with TRH compared to patients without TRH. These findings, in a population with valid data on medication adherence, emphasize a broad preventive approach for these high-risk patients.