Effect of skill-based educational training for ambulance personnel on neonatal transport for newborn care in coastal South India - a single arm intervention study.

Background: Education of '108' ambulance personnel involved in transporting neonates may improve outcomes. We assessed i) perceptions/practices of '108' ambulance personnel for transporting neonates, ii) clinical parameters of transported neonates at arrival, and iii) outcomes such as survival/mortality and NICU stay (before and after skill-based educational intervention). Methods: We conducted a single-arm intervention study (pre-and post) over 18 months. We assessed the perceptions and practices of 77 ambulance personnel on neonatal transport pre- versus post-intervention. Checklists assessed ambulance equipment availability/usage in both phases. We compared clinical parameters and outcomes of transported neonates between the pre-intervention (n=62) and post-intervention (n=53) phases. We analyzed data using SPSS version 25. Results: Post-intervention, there was a significant reduction in the levels of hypothermia (p < 0.001), hypoglycemia (p=0.010), and prolonged capillary refill time (p=0.042), along with improvement in the use of intravenous fluids (p <0.001), a reduction in the positivity of umbilical swab growth (p=0.002) and in the duration of NICU stay (p = 0.001), significant improvement (p < 0.001) in the perceptions/practices of ambulance personnel towards neonatal transport. There was an improvement in the ambulance equipment availability/usage post-intervention. Conclusions: The perceptions and practices of the '108' ambulance towards transporting neonates had significantly improved post-educational intervention. Further, a significant decrease in hypothermia, hypoglycemia, and duration of NICU stay was seen in neonates transported post-intervention.

A scenario based approach to optimizing cost-effectiveness of physician-staffed Helicopter Emergency Medical Services compared to ground-based Emergency Medical Services in Finland.

OBJECTIVES: Since Helicopter Emergency Medical Services (HEMS) is an expensive resource in terms of unit price compared to ground-based Emergency Medical Service (EMS), it is important to further investigate which methods would allow for the optimization of these services. The aim of this study was to evaluate the cost-effectiveness of physician-staffed HEMS compared to ground-based EMS in developed scenarios with improvements in triage, aviation performance, and the inclusion of ischemic stroke patients. METHODS: Incremental cost-effectiveness ratio (ICER) was assessed by comparing health outcomes and costs of HEMS versus ground-based EMS across six different scenarios. Estimated 30-day mortality and quality-adjusted life years (QALYs) were used to measure health benefits. Quality-of-Life (QoL) was assessed with EuroQoL instrument, and a one-way sensitivity analysis was carried out across different patient groups. Survival estimates were evaluated from the national FinnHEMS database, with cost analysis based on the most recent financial reports. RESULTS: The best outcome was achieved in Scenario 3.1 which included a reduction in over-alerts, aviation performance enhancement, and assessment of ischemic stroke patients. This scenario yielded 1077.07-1436.09 additional QALYs with an ICER of 33,703-44,937 €/QALY. This represented a 27.72% increase in the additional QALYs and a 21.05% reduction in the ICER compared to the current practice. CONCLUSIONS: The cost-effectiveness of HEMS can be highly improved by adding stroke patients into the dispatch criteria, as the overall costs are fixed, and the cost-effectiveness is determined based on the utilization rate of capacity.

Community First Responders' role in the current and future rural health and care workforce: a mixed-methods study.

Background: Community First Responders are trained volunteers dispatched by ambulance services to potentially life-threatening emergencies such as cardiac arrest in the first vital minutes to provide care until highly skilled ambulance staff arrive. Community First Responder schemes were first introduced to support ambulance services in rural communities, where access to prehospital emergency care is more likely to be delayed. Evidence is lacking on their contribution to rural healthcare provision, how care is provided and how this might be improved. Objectives: We aimed to describe Community First Responder activities, organisation, costs of provision and outcomes of care together with perceptions and views of patients, public, Community First Responders, ambulance service staff and commissioners of their current and future role including innovations in the rural health and care workforce. Design: We used a mixed-methods design, using a lens of pragmatism and the 'actor', 'behaviour change' and 'causal pathway' framework to integrate quantitative routine and qualitative (policy, guideline and protocol documents with stakeholder interview) data from 6 of 10 English ambulance services. We identified potential innovations in Community First Responder provision and prioritised these using a modified nominal group technique. Patients and public were involved throughout the study. Results: In 4.5 million incidents from six English regional ambulance services during 2019, pre COVID-19 pandemic, Community First Responders attended first a higher proportion of calls in rural areas (almost 4% of calls) than in urban areas (around 1.5%). They were significantly more likely to be called out to rural (vs. urban) areas and to attend older (vs. younger), white (vs. minority ethnic) people in more affluent (vs. deprived) areas with cardiorespiratory and neurological (vs. other emergency) conditions for higher-priority emergency or urgent (category 1 and 2 compared with category 3, 4 or 5) calls but did also attend lower-category calls for conditions such as falls. We examined 10 documents from seven ambulance services. Ambulance policies and protocols integrated Community First Responders into ambulance service structures to achieve the safe and effective operation of volunteers. Costs, mainly for training, equipment and support, varied widely but were not always clearly delineated. Community First Responders enabled a faster prehospital response time. There was no clear benefit in out-of-hospital cardiac arrest outcomes. A specific Community First Responder falls response reduced ambulance attendances and was potentially cost saving. We conducted semistructured interviews with 47 different stakeholders engaged in Community First Responder functions. This showed the trajectory of becoming a Community First Responder, the Community First Responder role, governance and practice, and the positive views of Community First Responders from stakeholders despite public lack of understanding of their role. Community First Responders' scope of practice varied between ambulance services and had developed into new areas. Innovations prioritised at the consensus workshop were changes in processes and structures and an expanded scope of practice supported by training, which included counselling, peer support, better communication with the control room, navigation and communication technology, and specific mandatory and standardised training for Community First Responders. Limitations: Missing data and small numbers of interviews in some stakeholder groups (patients, commissioners) are sources of bias. Future research: Future research should include a robust evaluation of innovations involving Community First Responders. Trial registration: This trial is registered as ClinicalTrials.gov, NCT04279262. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR127920) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 18. See the NIHR Funding and Awards website for further award information.

Community First Responders are volunteers who attend emergencies, particularly in rural areas, and provide help until the ambulance arrives. We aimed to describe Community First Responder activities, costs and effects and get the views of the public, Community First Responders, ambulance staff and commissioners on the current and future role of Community First Responders. Our study design combined different approaches. We examined routine ambulance patient information, reviewed ambulance policies and guidelines, and gathered information from interviews to make sense of our findings. Through interviews we learned about ways that the work of Community First Responders had been enhanced or could be improved. In a 1-day workshop, a group of lay and professional experts ranked in order of importance ideas about future developments involving Community First Responders. Community First Responders arrived before ambulance staff for a higher proportion of calls in rural than in urban areas. They attended people with various conditions, including breathing problems, chest pain, stroke, drowsiness, diabetes and falls, and usually the highest-priority emergencies but also lower-priority calls. Policies aimed to ensure that Community First Responders provided safe, effective care. Costs, mainly used for management, training and equipment, were sometimes incomplete or inaccurate and varied widely between services. Community First Responders attending meant faster responses and positive experiences for those patients and relatives interviewed. A Community First Responder scheme responding to people who had fallen at home led to fewer ambulances attending and possible financial savings. Survival among people attended because their heart had stopped was no better when Community First Responders arrived early. Interviews revealed why and how Community First Responders volunteered and were trained, what they did and how they felt. Interviewees were largely positive about Community First Responders. Improvements suggested included support from colleagues or counsellors, better communication with ambulance services, technology for communication and locating patients, and better training. Community First Responders have benefits in terms of response times and patient care. Future improvements should be evaluated.

Ambulance clinician use of capillary blood ketone meters to improve emergency hyperglycaemia care: A stepped-wedged controlled, mixed-methods feasibility study.

AIM: To determine whether it was feasible, safe and acceptable for ambulance clinicians to use capillary blood ketone meters for 'high-risk' diabetic ketoacidosis (DKA) recognition and fluid initiation, to inform the need for a full-powered, multi-centre trial. METHODS: Adopting a stepped-wedge controlled design, participants with hyperglycaemia (capillary blood glucose >11.0 mmol/L) or diabetes and unwell were recruited. 'High-risk' DKA intervention participants (capillary blood ketones ≥3.0 mmol/L) received paramedic-led fluid therapy. Participant demographic and clinical data were collated from ambulance and hospital care records. Twenty ambulance and Emergency Department clinicians were interviewed to understand their hyperglycaemia and DKA care experiences. RESULTS: In this study, 388 participants were recruited (Control: n = 203; Intervention: n = 185). Most presented with hyperglycaemia, and incidence of type 1 and type 2 diabetes was 18.5% and 74.3%, respectively. Ketone meter use facilitated 'high-risk' DKA identification (control: 2.5%, n = 5; intervention: 6.5%, n = 12) and was associated with improved hospital pre-alerting. Ambulance clinicians appeared to have a high index of suspicion for hospital-diagnosed DKA participants. One third (33.3%; n = 3) of Control and almost half (45.5%; n = 5) of Intervention DKA participants received pre-hospital fluid therapy. Key interview themes included clinical assessment, ambulance DKA fluid therapy, clinical handovers; decision support tool; hospital DKA management; barriers to hospital DKA care. CONCLUSIONS: Ambulance capillary blood ketone meter use was deemed feasible, safe and acceptable. Opportunities for improved clinical decision making, support and safety-netting, as well as in-hospital DKA care, were recognised. As participant recruitment was below progression threshold, it is recommended that future-related research considers alternative trial designs. CLINICALTRIALS: gov: NCT04940897.

Confronting mobile phone signal coverage and helicopter emergency medical service travel time: A geospatial analysis in the northwest macro-region of Paraná State, Brazil.

OBJECTIVE: The aim of this study was to conduct a detailed geospatial analysis of mobile phone signal coverage in the northwest macro-region of Paraná State, Brazil, seeking to identify areas where limitations in coverage may be related to lengthy travel times of the helicopter emergency medical service (HEMS) for the assistance of victims of road traffic injuries (RTIs). METHODS: An observational study was conducted to examine mobile phone signal coverage and HEMS travel times from 2017 to 2021. HEMS travel times were categorized into four groups: T1 (0-15 min), T2 (16-30 min), T3 (31-45 min), and T4 (over 45 min). Empirical Bayesian Kriging was used to map areas with low mobile signal coverage. The Kruskal-Wallis test and Dwass-Steel-Critchlow-Fligner comparative analyses were performed to explore how mobile signal coverage relates to HEMS travel times to RTI locations. RESULTS: There were 470 occurrences of RTIs attended by HEMS, of which 108 (23%) resulted in on-site fatalities. Among these deaths, 47 (26.85%) occurred in areas with low mobile phone signal coverage ("shadow areas"). Low mobile phone signal coverage identified at 175 (37.24%) RTIs locations, was unevenly distributed across the macro-region. The lowest medians of mobile signal quality were predominantly found in areas with HEMS travel times exceeding 30 min, corresponding to signal strength values of -98.44 (T3) and -100.75 (T4) dBm. This scenario represents a challenge for effective communication to activate HEMS. In the multiple comparison analysis among travel time groups, significant differences were observed between T1 and T2 (p < 0.001), T1 and T3 (p < 0.001), T1 and T4 (p < 0.001), and T2 and T3 (p < 0.001), indicating a potential association between lower mobile phone signal coverage and longer HEMS travel times. CONCLUSION: It can be concluded that poor mobile phone signals in remote areas can hinder HEMS activation, potentially delaying the start of treatment for RTIs. Identification of the shadow areas can help communication and health managers in designing and implementing the necessary changes to improve mobile phone signal coverage and consequently reduce delays in the initial response to RTIs.

Front of neck airway in Finnish helicopter emergency medical services.

INTRODUCTION: An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS). MATERIALS AND METHODS: This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed. RESULTS: A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1). CONCLUSION: The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.

Development of examination objectives for the Korean paramedic and emergency medical technician examination: a survey study.

PURPOSE: The duties of paramedics and emergency medical technicians (P&EMTs) are continuously changing due to developments in medical systems. This study presents evaluation goals for P&EMTs by analyzing their work, especially the tasks that new P&EMTs (with less than 3 years' experience) find difficult, to foster the training of P&EMTs who could adapt to emergency situations after graduation. METHODS: A questionnaire was created based on prior job analyses of P&EMTs. The survey questions were reviewed through focus group interviews, from which 253 task elements were derived. A survey was conducted from July 10, 2023 to October 13, 2023 on the frequency, importance, and difficulty of the 6 occupations in which P&EMTs were employed. RESULTS: The P&EMTs' most common tasks involved obtaining patients' medical histories and measuring vital signs, whereas the most important task was cardiopulmonary resuscitation (CPR). The task elements that the P&EMTs found most difficult were newborn delivery and infant CPR. New paramedics reported that treating patients with fractures, poisoning, and childhood fever was difficult, while new EMTs reported that they had difficulty keeping diaries, managing ambulances, and controlling infection. CONCLUSION: Communication was the most important item for P&EMTs, whereas CPR was the most important skill. It is important for P&EMTs to have knowledge of all tasks; however, they also need to master frequently performed tasks and those that pose difficulties in the field. By deriving goals for evaluating P&EMTs, changes could be made to their education, thereby making it possible to train more capable P&EMTs.

A standard operating procedure for prehospital anaesthesia and its effect on mortality-An observational study.

BACKGROUND: Prehospital anaesthesia is a complex intervention performed for critically ill patients. To minimise complications, a standard operating procedure (SOP) outlining the process is considered valuable. We investigated the implementation of an SOP for prehospital anaesthesia in helicopter emergency medical services (HEMS). METHODS: We performed a retrospective observational study of patients receiving prehospital anaesthesia by Finnish HEMS from January 2012 to August 2019. The intervention studied was the implementation of an SOP at two of the five bases during 2015-2016. Patients were stratified according to whether they were anaesthetised before, during or after implementation and the primary outcomes were 1- and 30-day mortality. Secondary outcomes included anaesthesia quality indicators. Confounding factors was assessed via logistic regression. RESULTS: A total of 3902 tracheal intubations were performed without an SOP, 430 during implementation and 1525 after implementation. The SOP had a significant effect on 1-day mortality during implementation with an odds ratio (OR) of 0.56, 95% confidence interval (95% CI) 0.37-0.81 and a further trend towards benefit after implementation (OR 0.84, 95% CI 0.68-1.04), but no difference in 30-day mortality (OR after implementation 1.10, 95% CI 0.92-1.30). Implementation of an SOP improved first-pass success rate from 87.3% to 96.5%, p < 0.001. CONCLUSION: Implementation of an SOP for prehospital anaesthesia was associated with a trend towards lower 1-day mortality and an improved first-pass success but did not affect 30-day mortality. Despite this, we advocate prehospital systems to consider implementation of a prehospital anaesthesia SOP as immediate performance markers improved significantly.

Experiences and perceptions of nurses and air ambulance service providers in carrying out aeromedical evacuations in Indonesia: A qualitative research.

Background: Basic non-military flight nurse training is essential for enhancing nurses' competency in conducting aeromedical evacuations. Trained nurses possessing flight nurse proficiency are indispensable for ensuring stable patient conditions amidst the unique physical, physiological, and psychological challenges encountered during flights. Objective: This study aimed to describe the experiences and perceptions of nurses and air ambulance service providers regarding aeromedical evacuations. Methods: This study employed a qualitative descriptive design. Data were gathered from February to July 2023 through semi-structured online interviews with seven nurses and air ambulance service providers engaged in aeromedical evacuation. Content analysis was utilized to interpret the interview data. Results: Seven themes were generated: 1) Experiences in aeromedical evacuation experiences, 2) Challenges faced by nurses and air ambulance service providers during aeromedical evacuations, 3) Essential knowledge for nurses involved in aeromedical evacuations, 4) Efforts to improve nurses' knowledge and skills, 5) Leveling of flight nurse training, 6) Flight nurse training methods, and 7) Flight nurse training evaluation strategies. Conclusion: Nurses and air ambulance service providers acknowledge the significant influence of the flight environment on changes in patient conditions during aeromedical evacuations. To effectively manage alterations in patient conditions during flights, healthcare workers equipped with aviation health competency are imperative. One approach to enhancing the competency of healthcare workers is through flight nurse training. The findings from this study serve as a valuable resource for policymakers and health-related institutions endeavoring to formulate aeromedical evacuation strategies.

When do medical operators choose to use, or not use, video in emergency calls? A case study.

BackgroundAn evaluation report for a pilot project on the use of video in medical emergency calls between the caller and medical operator indicates that video is only used in 4% of phone calls to the emergency medical communication centre (EMCC). Furthermore, the report found that in half of these cases, the use of video did not alter the assessment made by the medical operator at the EMCC.We aimed to describe the reasons for when and why medical operators choose to use or not use video in emergency calls. METHOD: The study was conducted in a Norwegian EMCC, employing a thematic analysis of notes from medical operators responding to emergency calls regarding the use of video. RESULT: Informants reported 19 cases where video was used and 46 cases where it was not used. When video was used, three main themes appeared: 'unclear situation or patient condition', 'visible problem' and 'children'. When video was not used the following themes emerged: 'cannot be executed/technical problems', 'does not follow instructions', 'perceived as unnecessary'. Video was mostly used in cases where the medical operators were uncertain about the situation or the patients' conditions. CONCLUSION: The results indicate that medical operators were selective in choosing when to use video. In cases where operators employed video, it provided a better understanding of the situation, potentially enhancing the basis for decision-making.

Mortality after paediatric emergency calls for patients with or without pre-existing comorbidity: a nationwide population based cohort study.

BACKGROUND: Life-threatening conditions are infrequent in children. Current literature in paediatric prehospital research is centred around trauma and paediatric out-of-hospital cardiac arrests (POHCA). The aims of this study were to (1) outline the distribution of trauma, POHCA or other medical symptoms among survivors and non-survivors after paediatric emergency calls, and (2) to investigate these clinical presentations' association with mortality in children with and without pre-existing comorbidity, respectively. METHODS: Nationwide population-based cohort study including ground and helicopter emergency medical services in Denmark for six consecutive years (2016-2021). The study included all calls to the emergency number 1-1-2 regarding children ≤ 15 years (N = 121,230). Interhospital transfers were excluded, and 1,143 patients were lost to follow-up. Cox regressions were performed with trauma or medical symptoms as exposure and 7-day mortality as the outcome, stratified by 'Comorbidity', 'Severe chronic comorbidity' and 'None' based on previous healthcare visits. RESULTS: Mortality analysis included 76,956 unique patients (median age 5 (1-12) years). Annual all-cause mortality rate was 7 per 100,000 children ≤ 15 years. For non-survivors without any pre-existing comorbidity (n = 121), reasons for emergency calls were trauma 18.2%, POHCA 46.3% or other medical symptoms 28.9%, whereas the distribution among the 134 non-survivors with any comorbidity was 7.5%, 27.6% and 55.2%, respectively. Compared to trauma patients, age- and sex-adjusted hazard ratio for patients with calls regarding medical symptoms besides POHCA was 0.8 [0.4;1.3] for patients without comorbidity, 1.1 [0.5;2.2] for patients with comorbidity and 6.1 [0.8;44.7] for patients with severe chronic comorbidity. CONCLUSION: In both non-survivors with and without comorbidity, a considerable proportion of emergency calls had been made because of various medical symptoms, not because of trauma or POHCA. This outline of diagnoses and mortality following paediatric emergency calls can be used for directing paediatric in-service training in emergency medical services.

Identifying prehospital trauma patients from ambulance patient care records; comparing two methods using linked data in New South Wales, Australia.

BACKGROUND: Linked datasets for trauma system monitoring should ideally follow patients from the prehospital scene to hospital admission and post-discharge. Having a well-defined cohort when using administrative datasets is essential because they must capture the representative population. Unlike hospital electronic health records (EHR), ambulance patient-care records lack access to sources beyond immediate clinical notes. Relying on a limited set of variables to define a study population might result in missed patient inclusion. We aimed to compare two methods of identifying prehospital trauma patients: one using only those documented under a trauma protocol and another incorporating additional data elements from ambulance patient care records. METHODS: We analyzed data from six routinely collected administrative datasets from 2015 to 2018, including ambulance patient-care records, aeromedical data, emergency department visits, hospitalizations, rehabilitation outcomes, and death records. Three prehospital trauma cohorts were created: an Extended-T-protocol cohort (patients transported under a trauma protocol and/or patients with prespecified criteria from structured data fields), T-protocol cohort (only patients documented as transported under a trauma protocol) and non-T-protocol (extended-T-protocol population not in the T-protocol cohort). Patient-encounter characteristics, mortality, clinical and post-hospital discharge outcomes were compared. A conservative p-value of 0.01 was considered significant RESULTS: Of 1 038 263 patient-encounters included in the extended-T-population 814 729 (78.5 %) were transported, with 438 893 (53.9 %) documented as a T-protocol patient. Half (49.6 %) of the non-T-protocol sub-cohort had an International Classification of Disease 10th edition injury or external cause code, indicating 79644 missed patients when a T-protocol-only definition was used. The non-T-protocol sub-cohort also identified additional patients with intubation, prehospital blood transfusion and positive eFAST. A higher proportion of non-T protocol patients than T-protocol patients were admitted to the ICU (4.6% vs 3.6 %), ventilated (1.8% vs 1.3 %), received in-hospital transfusion (7.9 vs 6.8 %) or died (1.8% vs 1.3 %). Urgent trauma surgery was similar between groups (1.3% vs 1.4 %). CONCLUSION: The extended-T-population definition identified 50 % more admitted patients with an ICD-10-AM code consistent with an injury, including patients with severe trauma. Developing an EHR phenotype incorporating multiple data fields of ambulance-transported trauma patients for use with linked data may avoid missing these patients.

Heat-related mortality and ambulance transport after a power outage in the Tokyo metropolitan area.

Background: Air conditioners can prevent heat-related illness and mortality, but the increased use of air conditioners may enhance susceptibility to heat-related illnesses during large-scale power failures. Here, we examined the risks of heat-related illness ambulance transport (HIAT) and mortality associated with typhoon-related electricity reduction (ER) in the summer months in the Tokyo metropolitan area. Methods: We conducted event study analyses to compare temperature-HIAT and mortality associations before and after the power outage (July to September 2019). To better understand the role of temperature during the power outage, we then examined whether the temperature-HIAT and mortality associations were modified by different power outage levels (0%, 10%, and 20% ER). We computed the ratios of relative risks to compare the risks associated with various ER values to the risks associated without ER. Results: We analyzed the data of 14,912 HIAT cases and 74,064 deaths. Overall, 93,200 power outage cases were observed when the typhoon hit. Event study results showed that the incidence rate ratio was 2.01 (95% confidence interval [CI] = 1.42, 2.84) with effects enduring up to 6 days, and 1.11 (95% CI = 1.02, 1.22) for mortality on the first 3 days after the typhoon hit. Comparing 20% to 0% ER, the ratios of relative risks of heat exposure were 2.32 (95% CI = 1.41, 3.82) for HIAT and 0.95 (95% CI = 0.75, 1.22) for mortality. Conclusions: A 20% ER was associated with a two-fold greater risk of HIAT because of summer heat during the power outage, but there was little evidence for the association with all-cause mortality.

Development and internal validation of an algorithm for estimating mortality in patients encountered by physician-staffed helicopter emergency medical services.

BACKGROUND: Severity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm. METHODS: We conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets. RESULTS: After exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023). CONCLUSIONS: Based on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.

Can the Emergency Medical Service (EMS) System Help in Improving the Healthcare Access - Evidence from Maharashtra EMS.

Background: For many people in the remote regions of India, medical help is inaccessible as 66% of rural Indians do not have access to critical medicine and 31% of the population travel more than 30 km seeking health care in rural India. Timely non-availability of doctors in healthcare facilities, especially in primary health centers (PHCs), leads to more dependency on the private healthcare practitioners for the out-patient department services. This needs immediate attention. Materials and Methods: The healthcare authority in Maharashtra has allowed doctors in 108 emergency ambulances to provide consulting services. The current study is based on the total consultations managed by the doctors on-board on the 108 ambulances in the state of Maharashtra in the years 2020, 2021, and 2022. The data are procured from the state-run Emergency Response Centre, and the analysis is done by using the basic statistical technique in MS Excel and SPSS16.0. Results: More than 9.35 lakh medical consultations were provided with an average 856 consultations per ambulance in the year 2022, showing a significant growth of 452% over the consultations in 2020. The base location of the 32% ambulance (298) in the PHCs has improved the round the clock accessibility in 16% of the total PHCs in the state of Maharashtra. Conclusion: The availability of the doctors in the state-run emergency ambulances for general healthcare services has improved the adherence of Indian Public Health Standards, and such practice must be examined for implementation in other states.

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study.

Background: Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department. Objectives: To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment. Design: Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness. Setting: Two ambulance services and four acute hospitals in England. Participants: Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded. Interventions: Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation. Main outcome measures: Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained. Results: Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed. Limitations: We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling. Conclusions: No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis. Study registration: This study is registered as Research Registry (reference: researchregistry5268). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

Sepsis is a life-threatening condition in which an abnormal response to infection causes heart, lung or kidney failure. People with sepsis need urgent treatment. They need to be prioritised at the emergency department rather than waiting in the queue. Paramedics attempt to identify people with possible sepsis using an early warning score (based on simple measurements, such as blood pressure and heart rate) alongside their impression of the patient's diagnosis. They can then alert the hospital to assess the patient quickly. However, an inaccurate early warning score might miss cases of sepsis or unnecessarily prioritise people without sepsis. We aimed to measure how accurately early warning scores identified people with sepsis when used alongside paramedic diagnostic impression. We collected data from 71,204 people that two ambulance services transported to four different hospitals in 2019. We recorded paramedic diagnostic impressions and calculated early warning scores for each patient. At one hospital, we linked ambulance records to hospital records and identified who had sepsis. We then calculated the accuracy of using the scores alongside diagnostic impression to diagnose sepsis. Finally, we used modelling to predict how many patients (with and without sepsis) paramedics would prioritise using different strategies based on early warning scores and diagnostic impression. We found that none of the currently available early warning scores were ideal. When they were applied to all patients, they prioritised too many people. When they were only applied to patients whom the paramedics thought had infection, they missed many cases of sepsis. The NEWS2, score, which ambulance services already use, was as good as or better than all the other scores we studied. We found that using the NEWS2, score in people with a paramedic impression of infection could achieve a reasonable balance between prioritising too many patients and avoiding missing patients with sepsis.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients.

BACKGROUND: Mobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability. METHOD: Following a pilot study, we developed a 4-level prehospital mobility score based of the question"How much help did the patient need to be mobilized to the ambulance trolley". Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020-May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics. RESULTS: We included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1). Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86). CONCLUSION: We developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers.

"Mind the gap": An exploratory qualitative study of paramedics' experiences attending older adults who fall in Western Australia.

PURPOSE: To explore paramedics' experiences and perspectives about attending and managing older adults who had fallen. PROCEDURES: This qualitative, exploratory study used a purposive sample of paramedics in Western Australia. Participants had at least one year of clinical experience. Semi-structured interviews were undertaken. Data were analysed via an inductive thematic approach. FINDINGS: Fourteen paramedics were interviewed (Median age: 38 years, n = 5 females). The main theme identified that experiences were positive when attending patients with high-acuity medical problems or injuries following falls because binary decision-making (transport vs non-transport) was appropriate. Themes highlighted that decision-making for low-acuity falls attendances was a complex balance between 1) patient context, 2) risk management, 3) paramedic reactions, and 4) the lack of alternate referral pathways available. Experiences could be stressful and frustrating when attending falls call-outs for older adults with no injuries or medical problems. Participants concurred that when transport to hospital was not required there were no available, alternative pathways to refer onwards for appropriate health or social care. CONCLUSION: Attending low-acuity call-outs for falls was often frustrating and required complex decision-making, with gaps in services identified. Further exploration of alternative referral pathways for health care for pre-hospital management of adults who fall is required.

The role of emergency medical services in the management of in-hospital emergencies: Causes and outcomes of emergency calls - A descriptive retrospective register-based study.

BACKGROUND: Medical emergency teams (METs) are in place in some hospitals in Finland to respond to critical emergency events. However, in hospitals without dedicated METs, staff are instructed to call emergency medical services (EMS) to deal with emergencies. This study examined the reasons for calling EMS to hospitals and the outcomes of these calls. METHODS: Descriptive retrospective register-based study of the response and management of in-hospital emergencies by EMS in the wellbeing services county of Southwest Finland. Patient care reports of the EMS and those of the hospitals were analysed. RESULTS: In total, 138 medical emergencies managed by EMS were included in this study. 108 of these related to patients, and 25 related to hospital personnel. Cardiac arrest (n = 36) and a reduced level of consciousness (n = 29) were the most common in-hospital emergencies. In 68% of in-hospital emergencies managed by the EMS team, after calling 112, hospital personnel implemented various treatment measures. In 72% of cases, follow-up treatment was required. CONCLUSIONS: Hospital personnel are able to initiate medical measures in emergencies, even when no MET is available. Although EMS are important in responding to in-hospital emergencies, they seem to be performing the same role as METs.