The use of a pre-hospital questionnaire expedited the acute management of patients with ischemic stroke in a comprehensive stroke center.

BACKGROUND: Delays in intravenous thrombolysis (IVT) treatment for acute ischemic stroke decrease the benefit of treatment. Difficulties determining a patient's clinical eligibility for IVT is a frequent cause of treatment delays. OBJECTIVE: We aimed to assess the effectiveness of the "PROVIDENCE" datasheet, a pre- hospital assessment of contraindications for IVT use applied by emergency medical services personnel. METHODS: We performed a single-center cohort study comparing IVT decision and treatment times between patients with PROVIDENCE datasheets and those without. Patients were eligible if they were over 18 years old and presented to our comprehensive stroke center from the field with stroke-like symptoms with onset within 4.5 hours. RESULTS: We identified 465 records and included 166 records in our final analysis (54 in the study group and 112 in the control group). A subgroup of 85 patients received IVT (30 in the study group patients and 55 in the control group). The PROVIDENCE datasheet was associated with a faster median time by five minutes from the patient's initial presentation at the emergency department to the final decision regarding IVT eligibility (p = 0.032) and a faster time between the first encounter with a neurology provider and the decision regarding IVT administration by six minutes (p = 0.002) for the entire sample. In the subgroup that received IVT, the PROVIDENCE datasheet decreased the median decision time by seven minutes (p = 0.044) There was no significant difference in door-to-needle times between groups. CONCLUSION: Using the PROVIDENCE datasheet, first responders can quickly identify potential contraindications for IVT treatment in patients with stroke-like symptoms. This tool expedited decision-making and led to faster IVT administration process at a comprehensive stroke center.

Effect of COVID-19 Pandemic Lockdown on Emergency Medical Service Utilisation, and Percutaneous Coronary Intervention Volume-An Australian Perspective.

BACKGROUND: Acute coronary syndrome (ACS) admissions and percutaneous coronary intervention (PCI) volume declined during periods of COVID-19 lockdown internationally in 2020. The effect of lockdown on emergency medical service (EMS) utilisation, and PCI volume during the initial phase of the pandemic in Australia has not been well described. METHOD: We analysed data from the Victorian Cardiac Outcomes Registry (VCOR), a state-wide PCI registry, linked with the Ambulance Victoria EMS registry. PCI volume, 30-day major adverse cardiovascular and cerebrovascular events (MACCE; composite of mortality, myocardial infarction, stent thrombosis, unplanned revascularisation, and stroke), and EMS utilisation were compared over four time periods: lockdown (26 Mar 2020-12 May 2020); pre-lockdown (26 Feb 2020-25 Mar 2020); post-lockdown (13 May 2020-10 Jul 2020); and the year prior (26 Mar 2019-12 May 2019). Interrupted time series analysis was performed to assess PCI trends within and between consecutive periods. RESULTS: The EMS utilisation for ACS during lockdown was higher compared with other periods: lockdown 39.4% vs pre-lockdown 29.7%; vs post-lockdown 33.6%; vs year prior 27.1%; all p<0.01. Median daily PCI cases were similar: 31 (IQR 10, 38) during lockdown; 39 (15, 49) pre-lockdown; 39.5 (11, 44) post-lockdown; and, 42 (10, 49) the year prior; all p>0.05. Median door-to-procedure time for ACS indication during lockdown was shorter at 3 hours (1.2, 20.6) vs pre-lockdown 3.9 (1.7, 21); vs post-lockdown 3.5 (1.5, 21.26); and, the year prior 3.5 (1.5, 23.7); all p<0.05. Lockdown period was associated with lower odds for 30-day MACCE compared to pre-lockdown (odds ratio [OR] 0.55 [0.33-0.93]; p=0.026); post-lockdown (OR 0.66; [0.40-1.06]; p=0.087); and the year prior (OR 0.55 [0.33-0.93]; p=0.026). CONCLUSIONS: Contrary to international trends, EMS utilisation for ACS increased during lockdown but PCI volumes remained similar throughout the initial stages of the pandemic in Victoria, with no observed adverse effect on 30-day MACCE during lockdown. These data suggest that the public health response in Victoria was not associated with poorer quality cardiovascular care in patients receiving PCI.

Utilization of Multi-Parameter Blood Gas Analysis in Prehospital Emergency Medicine-A Scoping Review.

BACKGROUND: Prehospital blood gas analysis (BGA) is an evolving field that offers the potential for early identification and management of critically ill patients. However, the utility and accuracy of prehospital BGA are subjects of ongoing debate. OBJECTIVES: We aimed to provide a comprehensive summary of the current literature on prehospital BGA, including its indications, methods, and feasibility. METHODS: We performed a scoping review of prehospital BGA. A thorough search of the PubMed, Embase, and Web of Science databases was conducted to identify relevant studies focusing on prehospital BGA in adult patients. RESULTS: Fifteen studies met the inclusion criteria. Prehospital BGA was most frequently performed in patients in out-of-hospital cardiac arrest, followed by traumatic and nontraumatic cases. The parameters most commonly analyzed were pH, pCO2, pO2, and lactate. Various sampling methods, including arterial, venous, and intraosseous, were reported for prehospital BGA. While prehospital BGA shows promise in facilitating early identification of critical patients and guiding resuscitation efforts, logistical challenges are to be considered. The handling of preclinical BGA is described as feasible and useful in most of the included studies. CONCLUSION: Prehospital BGA holds significant potential for enhancing patient care in the prehospital setting, though technical challenges need to be considered. However, further research is required to establish optimal indications and demonstrate the benefits for prehospital BGA in specific clinical contexts.

A study of prehospital EMS response time and influencing factors in the main urban area of Chongqing, China.

Shortening the prehospital emergency medical service (EMS) response time is crucial for saving lives and lowering mortality and disability rates in patients with sudden illnesses. Descriptive analyses of prehospital EMS response time and each component were conducted separately using ambulance trip data from the 120 Dispatch Command Centre in the main urban area of Chongqing in 2021, and then, logistic regression analyses were used to explore the influencing factors. The median prehospital EMS response time in the main urban area of Chongqing was 14.52 min and the mean was 16.14 min. A 44.89% of prehospital EMS response time exceeded 15 min. Response time was more likely to surpass this threshold during peak hours and in high population density areas. Conversely, lower probabilities exceeding 15 min were observed during the night shift, summer, and autumn seasons, and areas with a high density of emergency station. 33.28% of preparation time was >3 min, with the night shift and high population density areas more likely to be >3 min, while for the summer and autumn seasons, high Gross National Product (GDP) per capita areas had a lower likelihood of having preparation time >3 min. 45.52% of travel time was >11 min, with peak hours, summer and autumn, and high GDP per capita areas more likely to have had a travel time >11 min, while night shift and high emergency station density areas had a lower likelihood of travel time >11 min. The primary factors influencing prehospital EMS response time were shifts, traffic scenarios, seasons, GDP per capita, emergency station density, and population density. Relevant departments can devise effective interventions to reduce response time through resource allocation and department coordination, staff training and work arrangement optimisation, as well as public participation and education, thereby enhancing the efficiency of prehospital emergency medical services.

The application of health information technology for the elderly care in the emergency department: a conceptual model.

INTRODUCTION: In the emergency departments (EDs), usually the longest waiting time for treatment and discharge belongs to the elderly patients. Moreover, the number of the ED admissions for the elderly increases every year. It seems that the use of health information technology in geriatric emergency departments can help to reduce the burden of the healthcare services for this group of patients. This research aimed to develop a conceptual model for using health information technology in the geriatric emergency department. METHODS: This study was conducted in 2021. The initial conceptual model was designed based on the findings derived from the previous research phases (literature review and interview with the experts). Then, the model was examined by an expert panel (n = 7). Finally, using the Delphi technique (two rounds), the components of the conceptual model were reviewed and finalized. To collect data, a questionnaire was used, and data were analyzed using descriptive statistics. RESULTS: The common information technologies appropriate for the elderly care in the emergency departments included emergency department information system, clinical decision support system, electronic health records, telemedicine, personal health records, electronic questionnaires for screening, and other technologies such as picture archiving and communication systems (PACS), electronic vital sign monitoring systems, etc. The participants approved all of the proposed systems and their applications in the geriatric emergency departments. CONCLUSION: The proposed model can help to design and implement the most useful information systems in the geriatric emergency departments. As the application of technology accelerates care processes, investing in this field would help to support the care plans for the elderly and improve quality of care services. Further research is recommended to investigate the efficiency and effectiveness of using these technologies in the EDs.

Shift in emergency department utilization by frequent attendees with sickle cell disease during the COVID-19 pandemic: A multicentre cohort study.

While the coronavirus disease-2019 (COVID-19) might have increased acute episodes in people living with sickle cell disease (SCD), it may also have changed their reliance on emergency department (ED) services. We assessed the impact of the COVID-19 pandemic and lockdowns on ED visits in adult SCD people followed in five French reference centres, with a special focus on 'high users' (≥10 visits in 2019). We analysed the rate of ED visits from 1 January 2015 to 31 December 2021, using a self-controlled case series. Among 1530 people (17 829 ED visits), we observed a significant reduction in ED visits during and after lockdowns, but the effect vanished over time. Compared to pre-pandemic, incidence rate ratios for ED visits were 0.59 [95% CI 0.52-0.67] for the first lockdown, 0.66 [95% CI 0.58-0.75] for the second and 0.85 [95% CI 0.73-0.99] for the third. High users (4% of people but 33.7% of visits) mainly drove the reductions after the first lockdown. COVID-19 lockdowns were associated with reduced ED visits. While most people returned to their baseline utilization by April 2021, high users had a lasting decrease in ED visits. Understanding the factors driving the drop in ED utilization among high users might inform clinical practice and health policy.

Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study.

BACKGROUND: Substance misuse poses a significant public health challenge, characterized by premature morbidity and mortality, and heightened healthcare utilization. While studies have demonstrated that previous hospitalizations and emergency department visits are associated with increased mortality in patients with substance misuse, it is unknown whether prior utilization of emergency medical service (EMS) is similarly associated with poor outcomes among this population. The objective of this study is to determine the association between EMS utilization in the 30 days before a hospitalization or emergency department visit and in-hospital outcomes among patients with substance misuse. METHODS: We conducted a retrospective analysis of adult emergency department visits and hospitalizations (referred to as a hospital encounter) between 2017 and 2021 within the Substance Misuse Data Commons, which maintains electronic health records from substance misuse patients seen at two University of Wisconsin hospitals, linked with state agency, claims, and socioeconomic datasets. Using regression models, we examined the association between EMS use and the outcomes of in-hospital death, hospital length of stay, intensive care unit (ICU) admission, and critical illness events, defined by invasive mechanical ventilation or vasoactive drug administration. Models were adjusted for age, comorbidities, initial severity of illness, substance misuse type, and socioeconomic status. RESULTS: Among 19,402 encounters, individuals with substance misuse who had at least one EMS incident within 30 days of a hospital encounter experienced a higher likelihood of in-hospital mortality (OR 1.52, 95% CI [1.05 - 2.14]) compared to those without prior EMS use, after adjusting for confounders. Using EMS in the 30 days prior to an encounter was associated with a small increase in hospital length of stay but was not associated with ICU admission or critical illness events. CONCLUSIONS: Individuals with substance misuse who have used EMS in the month preceding a hospital encounter are at an increased risk of in-hospital mortality. Enhanced monitoring of EMS users in this population could improve overall patient outcomes.

Ambulance professionals' experiences of teamwork in the context of a team training programme - a qualitative study.

BACKGROUND: Teamwork in the context of ambulance services exhibits unique characteristics, as this environment involves a small core team that must adapt to a dynamic team structure that involves health care professionals and emergency services. It is essential to acquire a deeper understanding of how ambulance teams operate. Therefore, this study aimed to explore the experiences of ambulance professionals with teamwork and how they were influenced by the implementation of a team training programme. METHODS: A qualitative descriptive study was conducted involving ambulance professionals who took part in focus group interviews carried out both before and after the implementation of a team training program across seven ambulance stations within a Norwegian hospital trust. The data were analysed using reflexive thematic analysis based on a deductive-inductive approach. RESULTS: Our analysis revealed 15 subthemes that characterised ambulance professionals' experiences with teamwork and a team training programme, which were organised according to the five main themes of team structure, communication, leadership, situation monitoring, and mutual support. Ambulance professionals' experiences ranged from the significance of team composition and interpersonal and professional relationships to their preferences regarding different communication styles and the necessity of team leaders within the ambulance service. The team training programme raised awareness of teamwork, while the adoption of teamwork tools was influenced by both individual and contextual factors. The Introduction/Identity, Situation, Background, Assessment and Recommendation (ISBAR) communication tool was identified as the most beneficial aspect of the programme due to its ease of use, which led to improvements in the structure and quality of consultations and information handover. CONCLUSIONS: This study documented the diverse characteristics and preferences associated with teamwork among ambulance professionals, emphasising the particular importance of proficient partnerships in this context. Participation in a team training programme was perceived as a valuable reminder of the significance of teamwork, thus providing a foundation for the enhancement of communication skills. TRIAL REGISTRATION: ClinicalTrials.gov-ID: NCT05244928.

[Prehospital Care Times and Interventions for Victims of Major Trauma in the Central Region of Portugal: A Retrospective Study]. / Tempos de Resposta e Intervenções Extra-Hospitalar à Vítima de Trauma Major na Região Centro de Portugal: Um Estudo Retrospetivo.

INTRODUCTION: The quality and promptness of prehospital care for major trauma patients are vital in order to lower their high mortality rate. However, the effectiveness of this response in Portugal is unknown. The objective of this study was to analyze response times and interventions for major trauma patients in the central region of Portugal. METHODS: This was a retrospective, descriptive study, using the 2022 clinical records of the National Institute of Medical Emergency's differentiated resources. Cases of death prior to arrival at the hospital and other non-transport situations were excluded. Five-time intervals were determined, among which are the response time (T1, between activation and arrival at the scene), on-scene time (T2), and transportation time (T5; between the decision to transport and arrival at the emergency service). For each ambulance type, averages and dispersion times were calculated, as well as the proportion of cases in which the nationally and internationally recommended times were met. The frequency of recording six key interventions was also assessed. RESULTS: Of the 3366 records, 602 were eliminated (384 due to death), resulting in 2764 cases: nurse-technician ambulance (SIV) = 36.0%, physician- nurse ambulance (VMER) = 62.2% and physician-nurse helicopter = 1.8%. In a very large number of records, it was not possible to determine prehospital care times: for example, transport time (T5) could be determined in only 29%, 13% and 8% of cases, respectively for SIV, VMER and helicopter. The recommended time for stabilization (T2 ≤ 20 min) was met in 19.8% (SIV), 36.5% (VMER) and 18.2% (helicopter). Time to hospital (T5 ≤ 45 min) was achieved in 80.0% (SIV), 93.1% (VMER) and 75.0% (helicopter) of the records. The administration of analgesia (42% in SIV) and measures to prevent hypothermia (23.5% in SIV) were the most recorded interventions. CONCLUSION: There was substantial missing data on statuses and a lack of information in the records, especially in the VMER and helicopter. According to the records, the time taken to stabilize the victim on-scene often exceeded the recommendations, while the time taken to transport them to the hospital tended to be within the recommendations.

Introdução: A qualidade e rapidez do socorro pré-hospitalar à pessoa vítima de trauma major é vital para diminuir a sua elevada mortalidade. Contudo, desconhece-se a efetividade desta resposta em Portugal. O objetivo deste estudo foi analisar os tempos de resposta e as intervenções realizadas às vítimas de trauma major na região centro de Portugal. Métodos: Estudo retrospetivo, descritivo, utilizando os registos clínicos de 2022 dos meios diferenciados do Instituto Nacional de Emergência Médica. Casos de óbito pré-chegada ao hospital e outras situações de não transporte foram excluídos. Determinaram-se cinco tempos, entre os quais o tempo de resposta (T1, decorrente entre acionamento e chegada ao local), o tempo no local (T2) e o tempo de transporte (T5, intervalo entre a decisão de transporte e a chegada ao serviço de urgência). Foram calculadas médias e medidas de dispersão para cada meio, bem como a proporção de casos em que foram cumpridos os tempos recomendados nacional e internacionalmente. Avaliou-se também a frequência de registo de seis intervenções chave. Resultados: Dos 3366 registos, eliminaram-se 602 (384 por óbito), resultando em 2764 casos [suporte imediato de vida (SIV) = 36,0%, viaturas médicas de emergência e reanimação (VMER) = 62,2%, helicóptero de emergência médica (HEM) = 1,8%]. Num elevado número de registos não foi possível determinar tempos de socorro: por exemplo, o tempo de transporte (T5) foi determinável em apenas 29%, 13%, e 8% dos casos, respetivamente para SIV, VMER e HEM. O tempo recomendado para a estabilização (T2 ≤ 20 min), foi cumprido em 19,8% (SIV), 36,5% (VMER), e 18,2% (HEM) dos regis- tos. Já o tempo de transporte (T5 ≤ 45 min) foi cumprido em 80,0% (SIV), 93,1% (VMER) e 75,0% (HEM) dos registos (avaliáveis). A administração de analgesia (42% na SIV) e as medidas de prevenção de hipotermia (23,5% na SIV) foram as intervenções mais registadas. Conclusão: Observaram-se muitos status omissos e falta de informação nos registos, sobretudo na VMER e HEM. De acordo com os registos, o tempo no local superou frequentemente as recomendações, enquanto o tempo de transporte tende a estar dentro das normas.

Diagnostic accuracy of a prehospital electrocardiogram rule-based algorithm for ST-elevation myocardial infarction: results from a population-wide project.

INTRODUCTION: This study reviewed the diagnostic accuracy of the prehospital electrocardiogram (PHECG) rule-based algorithm for ST-elevation myocardial infarction (STEMI) universally utilised in Hong Kong. METHODS: This prospective observational study was linked to a population-wide project. We analysed 2210 PHECGs performed on patients who presented to the emergency medical service (EMS) with chest pain from 1 October to 31 December 2021. The diagnostic accuracy of the adopted rulebased algorithm, the Hannover Electrocardiogram System, was evaluated using the adjudicated blinded rating by two investigators as the primary reference standard. Diagnostic accuracy was also evaluated using the attending emergency physician's diagnosis and the diagnosis on hospital discharge as secondary reference standards. RESULTS: The prevalence of STEMI was 5.1% (95% confidence interval [CI]=4.2%-6.1%). Using the adjudicated blinded rating by investigators as the reference standard, the rule-based PHECG algorithm had a sensitivity of 94.6% (95% CI=88.2%-97.8%), specificity of 87.9% (95% CI=86.4%-89.2%), positive predictive value of 29.4% (95% CI=24.8%-34.4%), and negative predictive value of 99.7% (95% CI=99.3%-99.9%) [all P<0.05]. CONCLUSION: The rule-based PHECG algorithm that is widely used in Hong Kong demonstrated high sensitivity and fair specificity for the diagnosis of STEMI.

Providing Performance Feedback and Patient Outcome Follow-Up to Emergency Medical Services (EMS) is Associated with Subsequent Improved Clinical Performance.

Objective: Emergency Medical Services (EMS) clinicians desire performance feedback (PF) and patient outcome follow-up (POF). Within our agency, both a peer-review and feedback/outcome (PF/POF) process exist. Our objective was to determine whether receiving feedback and outcome data improved future clinical care amongst EMS, based upon peer-review scores.Methods: This retrospective cohort study took place between 1/1/2020 and 6/7/2023 within an EMS agency site with 22,000 average annual 9-1-1 calls. Requests for PF/POF were submitted on an individual basis beginning June 2020 and completed by a dedicated EMS nurse, EMS physician, or emergency medicine (EM) resident. Peer review of select high-acuity cases were scored by two Quality Assurance (QA) specialists within the categories of assessment, treatment, disposition/outcome and process/administrative guidelines. Association between overall peer-review score and number of PF/POF requests at time of assessment was evaluated by linear regression.Results: A total of 378 PF/POF requests were received, with the most common patient complaints being cardiac (n= 105; 27.8%, including 49 (13.0%) out of hospital cardiac arrests), altered mental status/neurologic (n= 103; 27.2%), trauma (n= 61; 16.1%, including 2 (0.5%) traumatic arrests); and respiratory distress (n = 47; 12.4%). A total of 378 runs meeting QA criteria were peer-reviewed post-PF/POF process implementation, including 337 (89.2%) cardiac/respiratory arrests, 27 (7.1%) with difficult airway management, and 14 (3.7%) major trauma/traumatic arrests. The number of prior PF/POF requests made by the team leader was associated with higher overall peer-review scores. Team leaders with >5 prior PF/POF requests had a peer-review score 0.39 points greater (95% CI: 0.16 - 0.62, p= 0.001) than those with <5 prior requests. The number of prior PF/POF requests amongst the entire crew was also associated with higher peer-review scores. Crews that collectively had >5 prior PF/POF requests had an increase in peer-review score 0.32 points greater (95% CI: 0.14 - 0.50, p < 0.001) than those with <5 prior requests.Conclusion: Providing performance feedback and patient outcome follow-up to EMS is associated with improved peer-review scores of clinical performance. Future studies should assess if those that are submitting cases for feedback/outcome are higher performers at baseline or if the process of receiving feedback/outcome improves their performance.

Design and construct of an assessment tool for the handover of critical patient the in urgent care and emergency setting.

OBJECTIVES: To design and construct an assessment tool for the handover of critical patients in the urgent care and emergency setting. RESEARCH METHODOLOGY: This metric and descriptive study comprised two phases in accordance with the Clinical practice guidelines for A Reporting Tool for Adapted Guidelines in Health Care: The RIGHT-Ad@pt Checklist. In the first phase, the identification and selection of items related to the handover of critical patients were performed by consensus of a group of experts. The second phase consisted of two stages. In the first stage, the items were selected by applying the e-Delphi technique across two assessment rounds and in the second stage, the items were subjected a pilot test in a real critical patient handover scenario. Professionals from different disciplines and work areas (hospital and prehospital) caring for critically ill patients in the urgency and emergency setting participated in each of the phases. RESULTS: A total of 58 critical patient care, and urgent and emergency care professionals participated in the design and construction of the assessment tool. The initial list consisted of 14 categories and 57 items, which were reduced to 28 items grouped into five categories after the intervention of the participants. The content validity index (CVI) of the instrument was 0.966. CONCLUSIONS: This study describes an assessment tool developed in Spanish-language designed to assess the handover of critical patients in the urgent care and emergency setting. This tool has a high CVI, and is the only currently available tool that consider all of the dimensions and characteristics of the handover process. IMPLICATIONS FOR CLINICAL PRACTICE: The assessment tool developed in this study could enable critical care professionals in their clinical practice to work in a systematic way, universalizing the handover of critically ill patients in the urgent care and emergency setting through scientifically proven guidelines.

Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Received Naloxone in an Emergency Medical Services System With a High Prevalence Of Opioid Overdose.

BACKGROUND: Opioid-associated out-of-hospital cardiac arrest (OA-OHCA) is a subset of cardiac arrests that could benefit from measures outside of standard Advanced Cardiac Life Support (ACLS), such as naloxone. STUDY OBJECTIVES: In this study, we sought to examine whether OHCA patients chosen for naloxone therapy by emergency medical services (EMS) clinicians in a system with high rates of opioid overdose would have increased rates of return of spontaneous circulation (ROSC) and survival to hospital discharge. METHODS: The study took place in an urban EMS system with a high prevalence of opioid overdose. Paramedics could administer naloxone in cardiac arrest in addition to ACLS. It was often administered based on clinical gestalt for suspected OA-OHCA. The outcomes of OHCA patients who received naloxone were compared against those who received usual care in both an adjusted and unadjusted fashion. Lastly, we created a logistic regression model to test for an independent association of naloxone administration on ROSC and survival to hospital discharge. RESULTS: A consecutive sample of 769 OHCA patients was obtained, of which 175 (23%) received naloxone. On average, patients who received naloxone had significantly fewer comorbidities and were younger. There was no difference in ROSC, survival to hospital discharge, or modified Rankin Scores. Using logistic regression modeling, there was no statistically significant effect of naloxone administration on these outcomes. CONCLUSION: OHCA patients who received naloxone, despite being younger and having fewer comorbidities, had similar outcomes compared to those who received usual care. The difference in baseline characteristics suggests that paramedic gestalt reasonably selected for OA-OHCA.

Utilization of emergency medical services by Culturally and Linguistically Diverse patients: a population-based retrospective study.

Objectives: To compare emergency medical services (EMS) utilization between culturally and linguistically diverse (CALD) and non-CALD patients in Victoria, Australia.Methods: A retrospective study of EMS attendances and transports in Victoria from January 2015 to June 2019, utilising linked EMS, hospital emergency and admissions data. The CALD and non-CALD patients who received EMS care and transport to a Victorian public emergency department were included. The incidence of EMS use for CALD and non-CALD patients based on the 2016 Census population and expressed per 100,000 person-years.Results: In 1,261,167 included patients, there were 272,100 (21.6%) CALD and 989,067 (78.4%) non-CALD patients. Before adjustment for age and sex, EMS utilization for CALD patients was 13% lower than non-CALD patients (incidence rate ratio [IRR] 0.87, 95% CI: 0.87-0.87). When stratified by age groups, CALD patients aged under 70 years had significantly lower rates of EMS utilization than non-CALD patients, while CALD patients aged 75 years or older were more likely than non-CALD patients to use EMS (IRR 1.08, 95% CI: 1.07-1.09). The CALD patients were less likely to utilize EMS for trauma/external injury (IRR = 0.67, 95% CI: 0.66-0.68) and mental health/alcohol/drug problems (IRR = 0.39, 95% CI: 0.38-0.40). After adjustment for differences in the age and sex distribution of CALD and non-CALD populations, CALD patients were 51% less likely to utilise EMS than non-CALD patients (IRR 0.49, 95% CI: 0.42-0.56).Conclusions: The CALD patients used EMS less frequently than non-CALD patients with significant variation observed across age groups, countries of birth, and clinical presentation. Further research is needed to understand the factors that may be contributing to these disparities.

Enhancing telehealth services development in Pakistani healthcare sectors through examining various medical service quality characteristics.

Introduction: The telehealth service increased attention both during and after the Covid-19 outbreak. Nevertheless, there is a dearth of research in developing countries, including Pakistan. Hence, the objective of this study was to examine telehealth service quality dimensions to promote the telehealth behavior intention and sustainable growth of telehealth in Pakistan. Methods: This study employed a cross-sectional descriptive design. Data were collected from doctors who were delivering telehealth services through a well-designed questionnaire. To examine the hypothesis of the study, we employed the Smart PLS structural equation modeling program, namely version 0.4. Results: The study findings indicate that medical service quality, affordability, information quality, waiting time, and safety have a positive impact on the intention to engage in telehealth behavior. Furthermore, the adoption of telehealth behavior has a significant favorable effect on the actual utilization of telehealth services, which in turn has a highly good impact on sustainable development. Conclusion: The study determined that telehealth services effectively decrease the amount of time and money spent on travel, while still offering convenient access to healthcare. Furthermore, telehealth has the potential to revolutionize payment methods, infrastructure, and staffing in the healthcare industry. Implementing a well-structured telehealth service model can yield beneficial results for a nation and its regulatory efforts in the modern age of technology.

Rural-urban differences in emergency medical services bypass routing of stroke in North Carolina.

PURPOSE: Acute stroke is a serious, time-sensitive condition requiring immediate medical attention. Emergency medical services (EMS) routing and direct transport of acute stroke patients to stroke centers improves timely access to care. This study aimed to describe EMS stroke routing and transports by rurality in North Carolina (NC). METHODS: We conducted a retrospective study using existing data on EMS transports of suspected stroke patients in NC in 2019. The primary study outcome was EMS bypass of the nearest hospital for transport to a nonnearest hospital, determined by geographic information systems (GIS) analysis. Incident addresses were geocoded to census tracts and classified as urban, suburban, or rural by Rural-Urban Commuting Area codes. We compared the frequency of bypass and estimated additional transport times by urban, suburban, and rural incident locations. FINDINGS: Of 3666 patients, 1884 (51%) EMS transports bypassed the nearest hospital. Bypass occurred less often for rural EMS incidents (39%) compared to those in urban (57%) and suburban (63%) tracts. The estimated additional transport time for rural bypasses of nonendovascular-capable stroke centers for endovascular-capable stroke centers was a median of 25 min (interquartile range 13-33). CONCLUSIONS: Using GIS analysis, we found nearly half of EMS transports of suspected stroke patients in NC bypassed the nearest hospital, including noncertified hospitals and stroke centers. Bypasses occurred less often in rural areas, though incurred significantly longer transport times, compared to urban areas. These findings are important for regional stroke system planning, especially for improving rural access to acute stroke care.

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.

Assessment of the Severity of COVID-19 on the Basis of Examination and Laboratory Diagnostics in Relation to Computed Tomography Imagery of Patients Hospitalised Due to COVID-19-Single-Centre Study.

From the moment the SARS-CoV-2 virus was identified in December 2019, the COVID-19 disease spread around the world, causing an increase in hospitalisations and deaths. From the beginning of the pandemic, scientists tried to determine the major cause that led to patient deaths. In this paper, the background to creating a research model was diagnostic problems related to early assessment of the degree of damage to the lungs in patients with COVID-19. The study group comprised patients hospitalised in one of the temporary COVID hospitals. Patients admitted to the hospital had confirmed infection with SARS-CoV-2. At the moment of admittance, arterial blood was taken and the relevant parameters noted. The results of physical examinations, the use of oxygen therapy and later test results were compared with the condition of the patients in later computed tomography images and descriptions. The point of reference for determining the severity of the patient's condition in the computer imagery was set for a mild condition as consisting of a percentage of total lung parenchyma surface area affected no greater than 30%, an average condition of between 30% and 70%, and a severe condition as greater than 70% of the lung parenchyma surface area affected. Patients in a mild clinical condition most frequently had mild lung damage on the CT image, similarly to patients in an average clinical condition. Patients in a serious clinical condition most often had average levels of damage on the CT image. On the basis of the collected data, it can be said that at the moment of admittance, BNP, PE and HCO3- levels, selected due to the form of lung damage, on computed tomography differed from one another in a statistically significant manner (p < 0.05). Patients can qualify for an appropriate group according to the severity of COVID-19 on the basis of a physical examination and applied oxygen therapy. Patients can qualify for an appropriate group according to the severity of COVID-19 on the basis of BNP, HCO3 and BE parameters obtained from arterial blood.

Design and Interrater Reliability of the Pediatric Version of the Race Scale: PedRACE.

BACKGROUND: Acute ischemic stroke is a leading cause of pediatric death and disability. A clinical scale adapted for children can ensure early detection of candidates for urgent acute ischemic stroke treatment. The Rapid Arterial Occlusion Evaluation (RACE) scale for adults, which scores 5 items (facial palsy 0-2; arm motor function 0-2; leg motor function 0-2; head/gaze deviation 0-1; and aphasia or agnosia 0-2), has good sensitivity and specificity in detecting large vessel occlusion. METHODS: We adapted the previously validated RACE scale for use in children as the Pediatric RACE scale. This adapted scale was tested by prehospital/emergency room staff attending to patients covered by the Catalan Pediatric Stroke Code and child neurologists for its correlation with the Pediatric National Institutes of Health Stroke Scale and for interrater reliability. RESULTS: The study included 50 children, 18 with confirmed strokes (7 acute ischemic strokes and 11 hemorrhagic strokes). Prehospital/emergency staff and child neurologists agreed fully regarding 82% of patients and 100% regarding head/gaze deviation and agnosia. The Pediatric RACE scale correlated strongly with the Pediatric National Institutes of Health Stroke Scale in evaluations by child neurologists (Spearman ρ, 0.852; P<0.001) and prehospital/emergency staff (Spearman ρ, 0.781; P<0.001). The median Pediatric RACE score was significantly higher in patients with large vessel occlusion (6.5; interquartile range, 6-7) than with other etiologies. CONCLUSIONS: Pediatric RACE, showing good interrater reliability and correlation with the Pediatric National Institutes of Health Stroke Scale, is a simple scale to detect candidates for pediatric acute stroke treatment, designed for both prehospital and in-hospital use by non-neurologist medical staff.

Evaluation of the Use of Ketamine in Prehospital Seizure Management: A Retrospective Review of the ESO Database.

Objectives: Benzodiazepines are the primary antiseizure medication used by Emergency Medical Services (EMS) for seizures. Available literature in the United States and internationally shows 30% to 40% of seizures do not terminate with benzodiazepines called benzodiazepine refractory status epilepticus (BRSE). Ketamine is a potential treatment for BRSE due to its unique pharmacology. However, its application in the prehospital setting is mostly documented in case reports. Little is known about its use by EMS professionals for seizure management, whether as initial treatment or for BRSE, creating an opportunity to describe its current use and inform future research.Methods: We performed a retrospective review of 9-1-1 EMS encounters with a primary or secondary impression of seizure using the ESO Data Collaborative from 2018-2021. We isolated encounters during which ketamine was administered. We excluded medication administrations prior to EMS arrival and encounters without medication administration. Subgroup analysis was performed to control for airway procedure as an indication for ketamine administration. We also evaluated for co-administration with other antiseizure medications, dose and route of administration, and response to treatment.Results: We identified 99,576 encounters that met inclusion. There were 2,531/99,576 (2.54%) encounters with ketamine administration and 50.7% (1,283/2,531) received ketamine without an airway procedure. There were 616 cases (48%, 616/1,283) where ketamine was given without another antiseizure medication (ASM) and without any airway procedure. The remaining 667 (52%) cases received ketamine with at least one other ASM, most commonly midazolam (89%, 593/667). Adjusted for the growth in the ESO dataset, ketamine use by EMS professionals during encounters for seizures without an airway procedure increased from 0.90% (139/15,375) to 1.45% (416/28,651) an increase of 62% over the study period.Conclusions: In this retrospective review of the ESO Data Collaborative, ketamine administration for seizure encounters without an airway procedure increased over the study period, both as a single agent and with another ASM. Most ketamine administrations were for adult patients in the south and in urban areas. The frequency of BRSE, the need for effective treatment, and the growth in ketamine use warrant prospective prehospital research to evaluate the value of ketamine in prehospital seizure management.