Continuous chest compressions are associated with higher peak inspiratory pressures when compared to 30:2 in an experimental cardiac arrest model.

BACKGROUND: Ventilation during cardiopulmonary resuscitation (CPR) has long been a part of the standard treatment during cardiac arrests. Ventilation is usually given either during continuous chest compressions (CCC) or during a short pause after every 30 chest compressions (30:2). There is limited knowledge of how ventilation is delivered if it effects the hemodynamics and if it plays a role in the occurrence of lung injuries. The aim of this study was to compare ventilation parameters, hemodynamics, blood gases and lung injuries during experimental CPR given with CCC and 30:2 in a porcine model. METHODS: Sixteen pigs weighing approximately 33 kg were randomized to either receive CPR with CCC or 30:2. Ventricular fibrillation was induced by passing an electrical current through the heart. CPR was started after 3 min and given for 20 min. Chest compressions were provided mechanically with a chest compression device and ventilations were delivered manually with a self-inflating bag and 12 l/min of oxygen. During the experiment, ventilation parameters and hemodynamics were sampled continuously, and arterial blood gases were taken every five minutes. After euthanasia and cessation of CPR, the lungs and heart were removed in block and visually examined followed by sampling of lung tissue which were examined using microscopy. RESULTS: In the CCC group and the 30:2 group, peak inspiratory pressure (PIP) was 58.6 and 35.1 cmH2O (p < 0.001), minute volume (MV) 2189.6 and 1267.1 ml (p < 0.001), peak expired carbon dioxide (PECO2) 28.6 and 39.4 mmHg (p = 0.020), partial pressure of carbon dioxide (PaCO2) 50.2 and 61.1 mmHg (p = 0.013) and pH 7.3 and 7.2 (p = 0.029), respectively. Central venous pressure (CVP) decreased more over time in the 30:2 group (p = 0.023). All lungs were injured, but there were no differences between the groups. CONCLUSIONS: Ventilation during CCC resulted in a higher PIP, MV and pH and lower PECO2 and PaCO2, showing that ventilation mode during CPR can affect ventilation parameters and blood gases.

Enhanced Therapeutic Effects of 177Lu-DOTA-M5A in Combination with Heat Shock Protein 90 Inhibitor Onalespib in Colorectal Cancer Xenografts.

Carcinoembryonic antigen (CEA) has emerged as an attractive target for theranostic applications in colorectal cancers (CRCs). In the present study, the humanized anti-CEA antibody hT84.66-M5A (M5A) was labeled with 177Lu for potential CRC therapy. Moreover, the novel combination of 177Lu-DOTA-M5A with the heat shock protein 90 inhibitor onalespib, suggested to mediate radiosensitizing properties, was assessed in vivo for the first time. M5A antibody uptake and therapeutic effects, alone or in combination with onalespib, were assessed in human CRC xenografts and visualized using SPECT/CT imaging. Although both 177Lu-DOTA-M5A and onalespib monotherapies effectively reduced tumor growth rates, the combination therapy demonstrated the most substantial impact, achieving a fourfold reduction in tumor growth compared to the control group. Median survival increased by 33% compared to 177Lu-DOTA-M5A alone, and tripled compared to control and onalespib groups. Importantly, combination therapy yielded comparable or superior effects to the double dose of 177Lu-DOTA-M5A monotherapy. 177Lu-DOTA-M5A increased apoptotic cell levels, indicating its potential to induce tumor cell death. These findings show promise for 177Lu-DOTA-M5A as a CRC therapeutic agent, and its combination with onalespib could significantly enhance treatment efficacy. Further in vivo studies are warranted to validate these findings fully and explore the treatment's potential for clinical use.

The Impact of the Swedish Care Coordination Act on Hospital Readmission and Length-of-Stay among Multi-Morbid Elderly Patients: A Controlled Interrupted Time Series Analysis.

Coordinating follow-up care after discharge from hospital is critical to ensuring good outcomes for patients, but is difficult when multiple care providers are involved. In 2018, Sweden adopted the Care Coordination Act, which modified economic incentives to reduce discharge delays and mandated a discharge planning process for patients requiring post-discharge social- or primary care services. This study evaluates the impact of this reform on hospital length-of-stay and unplanned readmissions among multi-morbid elderly patients. Interrupted time series analysis of all in-patient care episodes involving multi-morbid elderly patients in Sweden from 2015 - 2019 (n = 2 386 039) was performed. Secondary analyses using case-mix adjustment and controlled interrupted time series analysis were employed to assess for bias. Average length of stay decreased during the post-reform period, corresponding to 248 521 saved care days. Unplanned readmissions meanwhile increased, corresponding to 7 572 excess unplanned readmissions. While reductions in length-of-stay were concentrated among patients targeted by the reform, increases in readmission rates were similar in patients not targeted by the reform, indicating potential confounding. The reform thus appears to have achieved its goal of decreasing in-patient length of stay, but a robust effect on readmissions, outpatient visits, or mortality was not found. This may be due to lackluster implementation or an ineffective mandated intervention.

Soft law and individual responsibility: a review of the Swedish policy response to COVID-19.

Sweden's coronavirus disease 2019 (COVID-19) response, initially based largely on voluntary measures, has evoked strong reactions nationally and internationally. In this study, we describe Sweden's national policy response with regard to the general public, the community and the health care system, with a focus on how the response changed from March 2020 to June 2021. A number of factors contributed to Sweden's choice of policy response, including its existing legal framework, independent expert agencies and its decentralized, multi-level health care governance system. Challenges to the health- and elder care system during the pandemic, such as the need to increase intensive care- and testing capacity, and to ensure the safety of the elderly were addressed largely at the regional and local levels, with national authorities assuming a primarily coordinative role. Although the overall response based on voluntary compliance has persisted, the national government started to take a more prominent role in public messaging, and in enacting legally binding restrictions during subsequent waves of the pandemic. This study illustrates that not only policy responses, but also the fundamental structure of the health- and elder care system and its governance should be considered when evaluating the impact of the COVID-19 pandemic.

Better safe than sorry: Registered nurses' strategies for handling difficult calls to emergency medical dispatch centres - An interview study.

AIMS AND OBJECTIVES: To describe strategies employed by registered nurses for handling difficult calls to emergency medical dispatch centres. BACKGROUND: At emergency medical dispatch centres, registered nurses encounter a range of difficult calls in their clinical practice. They often use clinical decision support systems, but these may be of limited help if the caller is for instance abusive or has limited language proficiency. Much can be learnt from strategies developed by registered nurses for handling difficult calls. DESIGN: A descriptive qualitative study was conducted. METHODS: A purposeful sample of 24 registered nurses from three different emergency medical dispatch centres were interviewed. The transcribed interviews were analysed using qualitative content analysis. The COREQ checklist was applied. RESULTS: An overarching theme was established: "Using one's nursing competence and available resources for a safe outcome", based on three sub-themes: Use one's own professional and personal resources, Use resources within the organisation and Use external resources. The themes in turn consist of ten categories. CONCLUSIONS: Registered nurses employed a range of strategies to deal with difficult calls, often in combination. They used their personal resources, resources within their own organisation, and collaboration partners to make safe triage decisions and use resources wisely. The effectiveness of these strategies, however, remains unknown. When registered nurses were unable to rule out a high-acuity condition, they used safety-netting and sent an ambulance. Evaluating current strategies and making strategies explicit could further improve the ability of nurses to handle difficult calls. RELEVANCE TO CLINICAL PRACTICE: The strategies described by registered nurses for handling difficult calls to EMDCs included using a consecutive set of strategies. Some of the strategies seemed to be used deliberately, while others seemed tacit and applied in a routinised way. These strategies could potentially be useful for RNs working with telephone triage in different contexts.

The perspectives of Swedish registered nurses about managing difficult calls to emergency medical dispatch centres: a qualitative descriptive study.

BACKGROUND: Telephone triage at emergency medical dispatch centres is often challenging for registered nurses due to lack of visual cues, lack of knowledge about the patient, and time pressure - and making the right decision can be a matter of life and death. Some calls may be more difficult to handle, and more knowledge is needed about these calls to develop education and coping strategies. Therefore, the aim of this study was to describe the perspectives of registered nurses' views about managing difficult calls to emergency medical dispatch centres. METHODS: A descriptive design with a qualitative inductive approach was used. Three dispatch centers in mid-Sweden were investigated, covering about 950,000 inhabitants and handling around 114,000 calls per year. Individual interviews were carried out with a purposeful sample of 24 registered nurses. Systematic text condensation was conducted. RESULTS: Seven themes were generated: calls with communication barriers, calls from agitated or rude callers, calls about psychiatric illness, calls from third parties, calls about rare or unclear situations, calls with unknown addresses and calls regarding immediate life-threatening conditions. There was a strong consensus among the registered nurses about which calls were experienced as difficult, with the exception of calls about immediate life-threatening conditions. Some registered nurses thought calls about immediate life-threatening conditions were easy to handle as they simply adhered to protocol, while others described these calls as difficult and were emotionally affected. CONCLUSION: The registered nurses' descriptions of difficult calls focused on the callers, while their own role, the organisational framework, and leadership were not mentioned. Many types of calls included difficulties, which could be related to the caller, their symptoms, or different circumstances. The registered nurses pointed to language barriers and rude, agitated callers as increasing problems. An investigation of actual emergency calls is warranted to examine the extent and nature of such calls.

Registered nurses' understandings of emergency medical dispatch center work: A qualitative phenomenographic interview study.

Non-urgent and urgent telephone nursing services are increasing globally, and phenomenographic research has shown that how work is understood may influence work performance. This descriptive study makes a qualitative inductive investigation of understandings of emergency medical dispatch center work among registered nurses. Twenty-four registered nurses at three mid Swedish emergency medical dispatch centers were interviewed. Analysis based on phenomenographic principles identified five categories in the interviews: (i) Assess, prioritize, direct, or refer; (ii) Facilitate ambulance nursing work; (iii) Perform nursing care; (iv) Always be available for the public; and (v) Have the person behind the patient in mind. The first constitutes the basis of the work. The second emphasizes cooperation with and support for the ambulance staff. The third entails remotely providing nursing care, whilst the fourth stresses serving the entire population. The fifth and most comprehensive way of understanding work involves having a holistic view of the person in need, including person-centered care. Provision of high-quality emergency medical dispatch center work involves all categories. Combined, they constitute a "work map," valuable for reflection, competence development, and introduction of new staff.

Prehospital identification of Covid-19: an observational study.

BACKGROUND: The novel coronavirus disease 2019 (Covid-19) pandemic has affected prehospital care systems across the world, but the prehospital presentation of affected patients and the extent to which prehospital care providers are able to identify them is not well characterized. In this study, we describe the presentation of Covid-19 patients in a Swedish prehospital care system, and asses the predictive value of Covid-19 suspicion as documented by dispatch and ambulance nurses. METHODS: Data for all patients with dispatch, ambulance, and hospital records between January 1-August 31, 2020 were extracted. A descriptive statistical analysis of patients with and without hospital-confirmed Covid-19 was performed. In a subset of records beginning from April 14, we assessed the sensitivity and specificity of documented Covid-19 suspicion in dispatch and ambulance patient care records. RESULTS: A total of 11,894 prehospital records were included, of which 481 had a primary hospital diagnosis code related to-, or positive test results for Covid-19. Covid-19-positive patients had considerably worse outcomes than patients with negative test results, with 30-day mortality rates of 24% vs 11%, but lower levels of prehospital acuity (e.g. emergent transport rates of 14% vs 22%). About half (46%) of Covid-19-positive patients presented to dispatchers with primary complaints typically associated with Covid-19. Six thousand seven hundred seventy-six records were included in the assessment of predictive value. Sensitivity was 76% (95% CI 71-80) and 82% (78-86) for dispatch and ambulance suspicion respectively, while specificities were 86% (85-87) and 78% (77-79). CONCLUSIONS: While prehospital suspicion was strongly indicative of hospital-confirmed Covid-19, based on the sensitivity identified in this study, prehospital suspicion should not be relied upon as a single factor to rule out the need for isolation precautions. The data provided may be used to develop improved guidelines for identifying Covid-19 patients in the prehospital setting.

Registered Nurses' experiences of using a clinical decision support system for triage of emergency calls: A qualitative interview study.

OBJECTIVES: To describe how Registered Nurses make use of a Clinical Decision Support System to triage calls to emergency medical dispatch centres, from the perspective of professional autonomy. DESIGN: The study had a descriptive design with a qualitative inductive approach. METHODS: Interviews were done with 24 Registered Nurses during 2018-2019. Thematic analysis was conducted. RESULTS: Five themes and 16 subthemes were established: (a) Using the CDSS as a general support to professional competence in emergency calls, including subthemes: Support for professional competence, an aid to reflection, a compulsory support; (b) A specific support useful in difficult situations and calls, with subthemes: RN being tired or stressed out; vague and unclear symptoms, rare situations, aggressive and agitated callers; (c) Using the CDSS but changing triage recommendations/priority, including subthemes: Recommending a higher priority than the CDSS and recommending a lower priority than the CDSS; (d) Development areas for better use of the CDSS in collaboration with other services, with subthemes: Request for common documentation system with ambulances and closer collaboration with the national telephone nursing helpline; and (e) Possible technical development areas in the CDSS for optimal use, including subthemes: image transfer, medical records, development of certain areas in the CDSS, update of maps, a need for more knowledge. CONCLUSION: The CDSS was not perceived as a restriction on professional autonomy. It was particularly useful in rare situations. Technical improvements as well as education and training should be done in close collaboration with registered nurses. IMPACT: The study contributes with knowledge about how registered nurses triaging emergency calls use a decision support system. The system was a support for professional competence and did not seem to restrict them. The findings could be useful for clinicians and researchers in development of telephone triage and decision support systems.

Using trigger tools to identify triage errors by ambulance dispatch nurses in Sweden: an observational study.

OBJECTIVES: This study aimed to assess whether trigger tools were useful identifying triage errors among patients referred to non-emergency care by emergency medical dispatch nurses, and to describe the characteristics of these patients. DESIGN: An observational study of patients referred by dispatch nurses to non-emergency care. SETTING: Dispatch centres in two Swedish regions. PARTICIPANTS: A total of 1089 adult patients directed to non-emergency care by dispatch nurses between October 2016 and February 2017. 53% were female and the median age was 61 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was a visit to an emergency department within 7 days of contact with the dispatch centre. Secondary outcomes were (1) visits related to the primary contact with the dispatch centre, (2) provision of care above the primary level (ie, interventions not available at a typical local primary care centre) and (3) admission to hospital in-patient care. RESULTS: Of 1089 included patients, 260 (24%) visited an emergency department within 7 days. Of these, 209 (80%) were related to the dispatch centre contact, 143 (55%) received interventions above the primary care level and 99 (38%) were admitted to in-patient care. Elderly (65+) patients (OR 1.45, 95% CI 1.05 to 1.98) and patients referred onwards to other healthcare providers (OR 1.58, 95% CI 1.15 to 2.19) had higher likelihoods of visiting an emergency department. Six avoidable patient harms were identified, none of which were captured by existing incident reporting systems, and all of which would have received an ambulance if the decision support system had been strictly adhered to. CONCLUSION: The use of these patient outcomes in the framework of a Global Trigger Tool-based review can identify patient harms missed by incident reporting systems in the context of emergency medical dispatching. Increased compliance with the decision support system has the potential to improve patient safety.

A validation of machine learning-based risk scores in the prehospital setting.

BACKGROUND: The triage of patients in prehospital care is a difficult task, and improved risk assessment tools are needed both at the dispatch center and on the ambulance to differentiate between low- and high-risk patients. This study validates a machine learning-based approach to generating risk scores based on hospital outcomes using routinely collected prehospital data. METHODS: Dispatch, ambulance, and hospital data were collected in one Swedish region from 2016-2017. Dispatch center and ambulance records were used to develop gradient boosting models predicting hospital admission, critical care (defined as admission to an intensive care unit or in-hospital mortality), and two-day mortality. Composite risk scores were generated based on the models and compared to National Early Warning Scores (NEWS) and actual dispatched priorities in a prospectively gathered dataset from 2018. RESULTS: A total of 38203 patients were included from 2016-2018. Concordance indexes (or areas under the receiver operating characteristics curve) for dispatched priorities ranged from 0.51-0.66, while those for NEWS ranged from 0.66-0.85. Concordance ranged from 0.70-0.79 for risk scores based only on dispatch data, and 0.79-0.89 for risk scores including ambulance data. Dispatch data-based risk scores consistently outperformed dispatched priorities in predicting hospital outcomes, while models including ambulance data also consistently outperformed NEWS. Model performance in the prospective test dataset was similar to that found using cross-validation, and calibration was comparable to that of NEWS. CONCLUSIONS: Machine learning-based risk scores outperformed a widely-used rule-based triage algorithm and human prioritization decisions in predicting hospital outcomes. Performance was robust in a prospectively gathered dataset, and scores demonstrated adequate calibration. Future research should explore the robustness of these methods when applied to other settings, establish appropriate outcome measures for use in determining the need for prehospital care, and investigate the clinical impact of interventions based on these methods.

Small is beautiful? Explaining resident satisfaction in Swedish nursing home care.

BACKGROUND: Resident satisfaction is an important aspect of nursing home quality. Despite this, few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction. In Sweden, a large number of processual and structural measures are collected to describe the quality of nursing home care, though the impact of these measures on outcomes including resident satisfaction is poorly understood. METHODS: A cross-sectional analysis of data collected in two nationally representative surveys of Swedish eldercare quality using multi-level models to account for geographic differences. RESULTS: Of the factors examined, nursing home size was found to be the most important predictor of resident satisfaction, followed by the amount of exercise and activities offered by the nursing home. Measures of individualized care processes, ownership status, staffing ratios, and staff education levels were also weakly associated with resident satisfaction. Contrary to previous research, we found no clear differences between processual and structural variables in terms of their association with resident satisfaction. CONCLUSIONS: The results suggest that of the investigated aspects of nursing home care, the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction. Investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research.

Tests of the single-hit DNA damage model.

The algebra of target theory for damage by radiation was laid out by Atwood and Norman in 1949. Their equations provide a widely embraced framework for distinguishing single-hit and multi-hit mechanisms of damage. The present work asks whether in vitro damage to DNA duplexes by different agents affects amplification by the polymerase chain reaction (PCR) in a single-hit manner. Real-time monitoring of fluorescent PCR product (qPCR) was used to measure the fraction of DNA (S) surviving doses (D) of three damaging agents: gamma irradiation, DNase I, and UV radiation. The log fraction surviving was compared to the best-fit straight line predicted for a random single-hit model (lnS=kD). Human DNA targets for analysis were segments of multiple (nested) DNA lengths from the nuclear and the mitochondrial genomes within 10% of 150, 250, 350, 450, 650, 1000 and 2000 bases. For gamma irradiation, the results were consistent with a single-hit model for all segment sizes. In the case of DNase I, the shortest segment (150 bp), for both genomic and mitochondrial DNA, experienced more damage at low concentrations of DNase than the random single-hit model predicted. Conversely, in the case of UV, all segments of the nuclear target gene were less damaged at low doses and more damaged at high doses than predicted by the one hit model. These deviations from the predictions of a random single-hit model were interpreted as evidence for concerted activity in the case of DNase and of a multi-hit, sequence-dependent mechanism in the case of UV, perhaps due to the accumulation of lesions that slowed but did not entirely block Taq polymerase elongation.