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  • 1.
    Andsberg, Gunnar
    et al.
    Department of Rehabilitation Medicine and Neurology, Lund University, Skåne University Hospital, Lund, Sweden.
    Esbjörnsson, Magnus
    Department of Medicine, Hässleholm, Sweden.
    Olofsson, Arne
    Region Skåne Prehospital Unit, Lund, Sweden.
    Lindgren, Arne
    Department of Rehabilitation Medicine and Neurology, Lund University, Skåne University Hospital, Lund, Sweden.
    Norrving, Bo
    Department of Rehabilitation Medicine and Neurology, Lund University, Skåne University Hospital, Lund, Sweden.
    von Euler, Mia
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden.
    PreHospital Ambulance Stroke Test: pilot study of a novel stroke test2017In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 25, no 1, article id 37Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is a need for a prehospital stroke test that in addition to high sensitivity for stroke, also is able to communicate stroke severity similar to the National Institute of Health Stroke Scale (NIHSS).

    METHODS: The PreHospital Ambulance Stroke Test (PreHAST), an eight item test based on NIHSS, which scores stroke severity from 0-19 points, was designed and adapted for the ambulance services. In the pilot study the ambulance nurses used PreHAST to assess patients with suspected stroke in the prehospital setting. Regardless of the results after PreHAST testing the patients were triaged with a provisional stroke diagnosis. The PreHAST scores were compared with the final diagnosis and the ability to differentiate stroke and transient ischemic attacks (TIA) with ongoing symptoms at evaluation from non-stroke patients was analysed.

    RESULTS: 69 patients were included in the study, 26 had stroke/TIA and 43 other diagnoses. All stroke/TIA patients were identified by PreHAST (sensitivity 100% (95% CI; 87-100%)). The specificity increased with higher PreHAST scores and the discriminative capacity for PreHAST for different cut off values showed an area under the curve of 0.77 (95%CI; 0.66-0.88) in the receiver operating characteristic (ROC) analysis.

    DISCUSSION: PreHAST is designed for high sensitivity, screening for a broad range of stroke symptoms including most key components of NIHSS. The promising sensitivity between 87 and 100% in our study has to be confirmed in a larger study also including multiple centres. Higher PreHAST scores implied more typical patterns of stroke and accordingly the proportion of stroke mimics decrease with higher scores. However, also stroke mimics with epilepsy/seizure and patients with deficit after prior stroke could show higher PreHAST scores. Other prehospital stroke tests that evaluate stroke severity have been designed with the main purpose to screen for large vessel occlusion. The advantage of PreHAST is the dual purpose not only to evaluate stroke severity but also to screen for stroke in general.

    CONCLUSIONS: PreHAST is a new screening test of stroke adapted for ambulance services that in addition to high sensitivity for stroke, provides a grading system with increasing specificity with higher scores.

  • 2.
    Bohm, K.
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Emergency Medicine, Örebro University Hospital, Örebro, Sweden.
    The accuracy of medical dispatch: a systematic review2018In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 26, no 1, article id 94Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: It is a challenge to dispatch Emergency medical Services (EMS) appropriately with limited resources and maintaining patient safety; this requires accurate dispatching systems. The objective of the current systematic review was to examine the evidence, according to GRADE, for medical dispatching systems to accurately dispatch EMS according to level of acuity and in recognition of specific conditions.

    A systematic search was performed trough PubMed, Web of Science, Embase (free text in all fields), Centre for Reviews and Dissemination (CRD), and Cochrane Central Register of Controlled Trials up to 16th of May, 2017. A combination of keywords and Medical Subject Heading (MeSH) terms relevant to "emergency medical dispatch criteria" were used, to search for articles published between 2012 and 2017. Publications were included according to the inclusion/exclusion criteria using the Systematic Reviews and Meta-Analyses (PRISMA) protocol. Level of evidence was evaluated in accordance with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Articles included were those that provided evidence for at least one of the measures of dispatch system accuracy; i.e. sensitivity, specificity, positive and negative predictive and/or over- and under-triage. The search identified 1445 articles. After the removal of duplicates, 382 titles were reviewed for relevance and an additional 359 articles were excluded based on manuscript title and abstract. An additional five articles were excluded after review of the full text versions of the remaining articles. The current review included 18 publications which all were based on primary research.

    CONCLUSIONS: The 18 articles addressed the identification of cardiac arrest, stroke, medical priority and major trauma using different dispatching systems. The results of the current review show that there is a very low to low overall level of evidence for the accuracy of medical dispatching systems. We suggest that it is necessary to create a consensus on common standards for reporting before consensus can be reached for the level of accuracy in medical dispatching systems.

  • 3.
    Djalali, Ahmadreza
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Castren, Maaret
    Department of Clinical Sciences and Education and Department of Emergency Medicine, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Hosseinijenab, Vahid
    Department of emergency management, Natural Disaster Research Institute, Tehran, Iran.
    Khatib, Mahmoud
    Tehran social security organization, Tehran, Iran.
    Ohlen, Gunnar
    Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Sciences and Education and Department of Emergency Medicine, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Hospital Incident Command System (HICS) performance in Iran; decision making during disasters2012In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 20, article id 14Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Hospitals are cornerstones for health care in a community and must continue to function in the face of a disaster. The Hospital Incident Command System (HICS) is a method by which the hospital operates when an emergency is declared. Hospitals are often ill equipped to evaluate the strengths and vulnerabilities of their own management systems before the occurrence of an actual disaster. The main objective of this study was to measure the decision making performance according to HICS job actions sheets using tabletop exercises.

    METHODS: This observational study was conducted between May 1st 2008 and August 31st 2009. Twenty three Iranian hospitals were included. A tabletop exercise was developed for each hospital which in turn was based on the highest probable risk. The job action sheets of the HICS were used as measurements of performance. Each indicator was considered as 1, 2 or 3 in accordance with the HICS. Fair performance was determined as < 40%; intermediate as 41-70%; high as 71-100% of the maximum score of 192. Descriptive statistics, T-test, and Univariate Analysis of Variance were used.

    RESULTS: None of the participating hospitals had a hospital disaster management plan. The performance according to HICS was intermediate for 83% (n = 19) of the participating hospitals. No hospital had a high level of performance. The performance level for the individual sections was intermediate or fair, except for the logistic and finance sections which demonstrated a higher level of performance. The public hospitals had overall higher performances than university hospitals (P = 0.04).

    CONCLUSIONS: The decision making performance in the Iranian hospitals, as measured during table top exercises and using the indicators proposed by HICS was intermediate to poor. In addition, this study demonstrates that the HICS job action sheets can be used as a template for measuring the hospital response. Simulations can be used to assess preparedness, but the correlation with outcome remains to be studied.

  • 4.
    Djalali, Ahmadreza
    et al.
    Department of Clinical Science and Education, Södersjukhuset (KI SÖS), Karolinska Institute, Stockholm, Sweden.
    Khankeh, Hamidreza
    Department of Clinical Science and Education, Södersjukhuset (KI SÖS), Karolinska Institute, Stockholm, Sweden; Nursing Department, University of Social Welfare and Rehabilitation, Tehran, Iran.
    Öhlén, Gunnar
    Department of Clinical Science and Education, Södersjukhuset (KI SÖS), Karolinska Institute, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Södersjukhuset (KI SÖS), Karolinska Institute, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Södersjukhuset (KI SÖS), Karolinska Institute, Stockholm, Sweden.
    Facilitators and obstacles in pre-hospital medical response to earthquakes: a qualitative study2011In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 19, article id 30Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Earthquakes are renowned as being amongst the most dangerous and destructive types of natural disasters. Iran, a developing country in Asia, is prone to earthquakes and is ranked as one of the most vulnerable countries in the world in this respect. The medical response in disasters is accompanied by managerial, logistic, technical, and medical challenges being also the case in the Bam earthquake in Iran. Our objective was to explore the medical response to the Bam earthquake with specific emphasis on pre-hospital medical management during the first days.

    METHODS: The study was performed in 2008; an interview based qualitative study using content analysis. We conducted nineteen interviews with experts and managers responsible for responding to the Bam earthquake, including pre-hospital emergency medical services, the Red Crescent, and Universities of Medical Sciences. The selection of participants was determined by using a purposeful sampling method. Sample size was given by data saturation.

    RESULTS: The pre-hospital medical service was divided into three categories; triage, emergency medical care and transportation, each category in turn was identified into facilitators and obstacles. The obstacles identified were absence of a structured disaster plan, absence of standardized medical teams, and shortage of resources. The army and skilled medical volunteers were identified as facilitators.

    CONCLUSIONS: The most compelling, and at the same time amenable obstacle, was the lack of a disaster management plan. It was evident that implementing a comprehensive plan would not only save lives but decrease suffering and enable an effective praxis of the available resources at pre-hospital and hospital levels.

  • 5.
    Ekelund, Ulf
    et al.
    Emergency Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden.
    Kurland, Lisa
    Department of Clinical Sciences and Education and Section of Emergency Medicine, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Eklund, Fredrik
    Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
    Torkki, Paulus
    HEMA-Institute, BIT Research Centre, Aalto University, Espoo, Finland.
    Letterstål, Anna
    Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden.
    Lindmarker, Per
    Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Sciences and Education and Section of Emergency Medicine, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Patient throughput times and inflow patterns in Swedish emergency departments: A basis for ANSWER, A National SWedish Emergency Registry2011In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 19, article id 37Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Quality improvement initiatives in emergency medicine (EM) often suffer from a lack of benchmarking data on the quality of care. The objectives of this study were twofold: 1. To assess the feasibility of collecting benchmarking data from different Swedish emergency departments (EDs) and 2. To evaluate patient throughput times and inflow patterns.

    METHOD: We compared patient inflow patterns, total lengths of patient stay (LOS) and times to first physician at six Swedish university hospital EDs in 2009. Study data were retrieved from the hospitals' computerized information systems during single on-site visits to each participating hospital.

    RESULTS: All EDs provided throughput times and patient presentation data without significant problems. In all EDs, Monday was the busiest day and the fewest patients presented on Saturday. All EDs had a large increase in patient inflow before noon with a slow decline over the rest of the 24 h, and this peak and decline was especially pronounced in elderly patients. The average LOS was 4 h of which 2 h was spent waiting for the first physician. These throughput times showed a considerable diurnal variation in all EDs, with the longest times occurring 6-7 am and in the late afternoon.

    CONCLUSION: These results demonstrate the feasibility of collecting benchmarking data on quality of care targets within Swedish EM, and form the basis for ANSWER, A National SWedish Emergency Registry.

  • 6.
    Ekström, Andreas
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Eng-Larsson, Fredrik
    Stockholm Business School, Stockholm University, Stockholm, Sweden.
    Isaksson, Olov
    Stockholm Business School, Stockholm University, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Emergency Medicine, Örebro University Hospital, Örebro, Sweden.
    Nordberg, Martin
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    The effect of a terrorist attack on emergency department inflow: an observation study using difference-in-differences methodology2019In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 27, no 1, article id 57Article in journal (Refereed)
    Abstract [en]

    STUDY OBJECTIVE: The objective of this study was to investigate how the terrorist attack in Stockholm, Sweden affected patient inflow to the general emergency departments (EDs) in close proximity of the attack. The study analyzed if, and to what extent, the attack impacted ED inflow during the following days and weeks.

    METHODS: In a retrospective observational study, anonymized aggregated data on ED arrivals (inflow of patients) to all seven of the EDs in the Stockholm County was analyzed using the Difference-in-Differences (DiD) estimator. The control groups were the affected hospitals in the years prior to the terrorist attack. The number of ED visits was retrieved from the Stockholm County Council administrative database.

    RESULTS: The study shows a statistically significant reduction in overall ED inflow of 7-9% following the attack. The effect was strongest initially after the attack, and ED inflow regained normal levels within approximately three weeks' time, without any significant rebound effect. The effect on ED inflow also decreased with distance from ground zero, and was not significant further away than 10 km.

    CONCLUSION: The results showed that ED inflow was significantly decreased in the weeks immediately following the Stockholm terrorist attack. The reasons for this cannot be fully explained in this observational study. However, the results suggest that some patients actively choose when, where and if they should go to the ED.

  • 7.
    Engström, Joakim
    et al.
    Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Reinius, Henrik
    Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Ström, Jennie
    Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Bergström, Monica Frick
    Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Larsson, Ing-Marie
    Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Larsson, Anders
    Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Borg, Tomas
    Orthopedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Lung complications are common in intensive care treated patients with pelvis fractures: a retrospective cohort study2016In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 24, article id 52Article in journal (Refereed)
    Abstract [en]

    Background: The incidence of severe respiratory complications in patients with pelvis fractures needing intensive care have not previously been studied. Therefore, the aims of this registry study were to 1) determine the number of ICU patients with pelvis fractures who had severe respiratory complications 2) whether the surgical intervention in these patients is associated with the pulmonary condition and 3) whether there is an association between lung complications and mortality. We hypothesized that acute hypoxic failure (AHF) and acute respiratory distress syndrome (ARDS) 1) are common in ICU treated patients with pelvis fractures, 2) are not related to the reconstructive surgery, or to 3) to mortality.

    Methods: All patients in the database cohort (n = 112), scheduled for surgical stabilization of pelvis ring and/or acetabulum fractures, admitted to the general ICU at Uppsala University Hospital between 2007 and 2014 for intensive care were included.

    Results: The incidence of AHF/ARDS was 67 % (75/112 patients), i.e., the percentage of patients that at any period during the ICU stay fulfilled the AHF/ARDS criteria. The incidence of AHF was 44 % and incidence of ARDS was 23 %. The patients with AHF/ARDS had more lung contusions and pneumonia than the patients without AHF/ARDS. Overall, there were no significant changes in oxygenation variables associated with surgery. However, 23 patients with pre-operative normal lung status developed AHF/ARDS in relation to the surgical procedure, whereas 12 patients with AHF/ARDS normalized their lung condition. The patients who developed AHF/ARDS had a higher incidence of lung contusion (P = 0.04) and the surgical stabilization was performed earlier (5 versus 10 days) in these patients (P = 0.03).

    Conclusions: We found that the incidence of respiratory failure in ICU treated patients with pelvis fractures was high, that the procedure around surgical stabilization seems to be associated with a worsening in the respiratory function in patients with lung contusion, and that mortality was low and was probably not related to the respiratory condition.

    Download full text (pdf)
    Lung complications are common in intensive care treated patients with pelvis fractures - a retrospective cohort study
  • 8.
    Hugelius, Karin
    et al.
    Örebro University, School of Health Sciences.
    Rådestad, M.
    Department of Clinical Science and Education, Karolinska Institutet, SödersjukhusetStockholm, Sweden; Capio St. Görans Hospital, Stockholm, Sweden.
    Al-Dhahir, H.
    Department of Emergency Medicine, Örebro University Hospital, Örebro, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Medical Sciences.
    Decision-making by medical officer in charge during major incidents: a qualitative study2021In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 29, no 1, article id 120Article in journal (Refereed)
    Abstract [en]

    Background: An incident command structure is commonly used to manage responses to major incidents. In the hospital incident command structure, the medical officer in charge (MOC) is in a key position. The decision-making process is essential to effective management, but little is known about which factors influence the process. Therefore, the current study aimed to describe factors influencing decision-making of MOCs.

    Methods: A conventional content analysis was conducted based on 16 individual interviews with medical doctors who had been deployed as MOCs at Swedish hospitals during major incidents.

    Results: The results showed that the decision-making and re-evaluation process was a comprehensive analysis influenced by three categories of factors: event factors, including consequences from the type of event, levels of uncertainty and the circumstances; organizational factors, including the doctor's role, information management and the response to the event; and personal factors, such as competence, personality and mental preparedness.

    Conclusions: Reliable and timely information management structure enabling the gathering and analysis of essential information, a clear command structure and appropriate personal qualities were essential and contributed to successful MOCs decision making in major incidents.

  • 9.
    Höglund, Erik
    et al.
    Örebro University, School of Health Sciences.
    Schröder, Agneta
    Örebro University, School of Health Sciences. Örebro University Hospital. Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Gjøvik, Norway.
    Andersson-Hagiwara, Magnus
    Faculty of Caring Science, Centre for Prehospital Research, Work Life and Social Welfare, University of Borås, Borås, Sweden.
    Möller, Margareta
    Örebro University, School of Health Sciences.
    Ohlsson-Nevo, Emma
    Örebro University, School of Health Sciences. Örebro University Hospital. Department of Surgery.
    Outcomes in patients not conveyed by emergency medical services (EMS): a one-year prospective study2022In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 30, no 1, article id 40Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The decision to not convey patients has become common in emergency medical services worldwide. A substantial proportion (12-51%) of the patients seen by emergency medical services are not conveyed by those services. The practice of non-conveyance is a result of the increasing and changing demands on the acute care system. Research focusing on the outcomes of the decision by emergency medical services to not convey patients is needed.

    AIM: The aim was to describe outcomes (emergency department visits, admission to in-hospital intensive care units and mortality, all within seven days) and their association with the variables (sex, age, day of week, time of day, emergency signs and symptoms codes, triage level colour, and destination) for non-conveyed patients.

    METHODS: This was a prospective analytical study with consecutive inclusion of all patients not conveyed by emergency medical services. Patients were included between February 2016 and January 2017. The study was conducted in Region Örebro county, Sweden. The region consists of both rural and urban areas and has a population of approximately 295,000. The region had three ambulance departments that received approximately 30,000 assignments per year.

    RESULTS: The result showed that no patient received intensive care, and 18 (0.7%) patients died within seven days after the non-conveyance decision. Older age was associated with a higher risk of hospitalisation and death within seven days after a non-conveyance decision.

    CONCLUSIONS: Based on the results of this one-year follow-up study, few patients compared to previous studies were admitted to the hospital, received intensive care or died within seven days. This study contributes insights that can be used to improve non-conveyance guidelines and minimise the risk of patient harm.

  • 10.
    Ivic, Robert
    et al.
    Karolinska Institute, Department of Clinical Science and Education,Södersjukhuset, Stockholm, Sweden; Academic Emergency Medical Service, Region Stockholm, Stockholm,Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Karolinska Institute, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
    Vicente, Veronica
    Karolinska Institute, Department of Clinical Science and Education,Södersjukhuset, Stockholm, Sweden; Academic Emergency Medical Service, Region Stockholm, Stockholm,Sweden.
    Castrén, Maaret
    Karolinska Institute, Department of Clinical Science and Education,Södersjukhuset, Stockholm, Sweden; Emergency Medicine, Helsinki University and Department of EmergencyMedicine and Services, Helsinki University Hospital, Helsinki, Finland.
    Bohm, Katarina
    Karolinska Institute, Department of Clinical Science and Education,Södersjukhuset, Stockholm, Sweden; Academic Emergency Medical Service, Region Stockholm, Stockholm,Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Serious conditions among patients with non-specific chief complaints in the pre-hospital setting: a retrospective cohort study2020In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 28, no 1, article id 74Article in journal (Refereed)
    Abstract [en]

    Background: Emergency Medical Services (EMS) are faced daily with patients presenting with a non-specific chief complaints (NSC); i.e. decreased general condition, general malaise, sense of illness, or just being unable to cope with usual daily activities. Patients presenting with NSCs often have normal vital signs. It has previously been established that however, NSCs may have a serious underlying condition that has yet to be identified. The primary outcome of this study was to determine the prevalence of serious conditions in patients presenting with NSCs to the EMS.

    Method: A retrospective cohort study of patients >= 18 years of age who were reported as presenting with chief complaints compatible with NSCs to the EMS in Stockholm Region and transported to an emergency department between January 1st, 2013 and December 31st, 2013. Patients were identified via the EMS electronic health care record and followed via records from the National Patient Registry and Causes of Death Registry at Sweden's National Board for Health and Welfare. The definition of serious condition was defined by expert consensus. Descriptive statistics as well as regression analyses were used.

    Results: A total of 3780 patients were included, with a median age of 77 years. A serious condition was present in 35.3% of the patients. The in-hospital mortality rate for the group with serious conditions was 10.1% (OR 6.8, CI 95%, 4.1-11.3), and the 30-day mortality rate was 20.2% (OR 3.1, CI 95%, 2.3-4.0). In the group with no serious conditions the rates were 1.0 and 4.2%, respectively. The total hospitalization rate was 67.6%. The presence of serious conditions as well as increased mortality rates were associated with Rapid Emergency Triage and Treatment system (RETTS) as well as National Early Warning Score (NEWS) irrespective of triage score.

    Conclusion: More than one-third of the patients presenting with NSCs to EMS had a serious underlying condition which was associated with increased mortality and hospitalization rates.

  • 11.
    Ivic, Robert
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Academic Emergency Medical Service, Region Stockholm, Stockholm, Sweden.
    Nurmi, Jouni
    Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Vicente, Veronica
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Lindström, Veronica
    Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, division of nursing, Stockholm, Sweden; Samariten Ambulance Stockholm, Stockholm, Sweden.
    Djärv, Therese
    Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
    Kaartinen, Johanna
    Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
    Castrén, Maaret
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
    Bohm, Katarina
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Soluble urokinase plasminogen activator receptor and lactate as prognostic biomarkers in patients presenting with non-specific chief complaints in the pre-hospital setting - the PRIUS-study2021In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 29, no 1, article id 116Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Emergency Medical Services (EMS) are faced daily with patients presenting with non-specific chief complaints (NSC). Patients presenting with NSCs often have normal vital signs. It has previously been established that NSCs may have a serious underlying condition that has yet to be identified. The aim of the current study was to determine if soluble urokinase plasminogen activator receptor (suPAR) and lactate could be used to identify serious conditions among patients presenting with NSCs to the EMS. The secondary aim was to describe the prognostic value for mortality in the group.

    METHOD: A blinded prospective observational cohort study was conducted of patients brought to the ED by ambulance after calling the national emergency number 112 and who were assessed as having NSC by the EMS. Biomarkers were measured during index EMS assessment before transportation to the ED. Patients were followed via EMS and hospital electronic health records. Descriptive and logistic regression analyses were used.

    RESULTS: A total of 414 patients were included, with a median age of 82 years. A serious condition was present in 15.2% of the patients. Elevated suPAR above 3 ng/ml had a positive likelihood ratio (LR+) of 1.17 and a positive predictive value (PPV) of 17.3% as being predictive of a prevalent serious condition. Elevated suPAR above 9 ng/ml had LR+ 4.67 and a PPV of 16.7% as being predictive of 30-day mortality. Lactate was not significantly predictive.

    CONCLUSION: Pre-hospital suPAR and lactate cannot differentiate serious conditions in need of urgent treatment and assessment in the ED among patients presenting with non-specific chief complaints. suPAR has shown to be predictive of 30-day mortality, which could add some value to the clinical assessment.

    TRIAL REGISTRATION: NCT03089359. Registered 20 March 2017, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03089359 .

  • 12.
    Ljunggren, Malin
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki University, Helsinki, Finland.
    Nordberg, Martin
    Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden.
    The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population2016In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 24, article id 21Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Vital signs are widely used in emergency departments. Previous studies on the association between vital signs and mortality in emergency departments have been restricted to selected patient populations. We aimed to study the association of vital signs and age with 1-day mortality in patients visiting the emergency department.

    METHODS: This retrospective cohort included patients visiting the emergency department for adults at Södersjukhuset, Sweden from 4/1/2012 to 4/30/2013. Exclusion criteria were: age < 18 years, deceased upon arrival, chief complaint circulatory or respiratory arrest, key data missing and patients who were directed to a certain fast track for conditions demanding little resources. Vital sign data was collected through the Rapid Emergency Triage and Treatment System - Adult (RETTS-A). Descriptive analyses and logistic regression models were used. The main outcome measure was 1-day mortality.

    RESULTS: The 1-day mortality rate was 0.3%. 96,512 patients met the study criteria. After adjustments of differences in the other vital signs, comorbidities, gender and age the following vital signs were independently associated with 1-day mortality: oxygen saturation, systolic blood pressure, temperature, level of consciousness, respiratory rate, pulse rate and age. The highest odds ratios was observed when comparing unresponsive to alert patients (OR 31.0, CI 16.9 to 56.8), patients ≥ 80 years to <50 years (OR 35.9, CI 10.7 to 120.2) and patients with respiratory rates <8/min to 8-25/min (OR 18.1, CI 2.1 to 155.5).

    DISCUSSION: Most of the vital signs used in the ED are significantly associated with one-day mortality. The more the vital signs deviate from the normal range, the larger are the odds of mortality. We did not find a suitable way to adjust for the inherent influence the triage system and medical treatment has had on mortality.

    CONCLUSIONS: Most deviations of vital signs are associated with 1-day mortality. The same triage level is not associated with the same odds for death with respect to the individual vital sign. Patients that were unresponsive or had low respiratory rates or old age had the highest odds of 1-day mortality.

  • 13.
    Madsen, Michael Moesmann
    et al.
    Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
    Eiset, Andreas Halgreen
    Research Center for Emergency Medicine, University of Aarhus, Aarhus, Denmark.
    Mackenhauer, Julie
    Research Center for Emergency Medicine, University of Aarhus, Aarhus, Denmark.
    Odby, Annette
    The Danish Clinical Registers, Aarhus, Denmark.
    Christiansen, Christian Fynbo
    Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
    Kurland, Lisa
    Department of Clinical Research and Education, Karolinska Institutet, Stockholm, Sweden; Department of EM, Södersjukhuset, Stockholm, Sweden.
    Kirkegaard, Hans
    Research Center for Emergency Medicine, University of Aarhus, Aarhus, Denmark.
    Selection of quality indicators for hospital-based emergency care in Denmark, informed by a modified-Delphi process2016In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 24, article id 11Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In 2013, Danish policy-makers on a nationwide level decided to set up a national quality of care database for hospital-based emergency care in Denmark including the selection of quality indicators. The aim of the study was to describe the Delphi process that contributed to the selection of quality indicators for a new national database of hospital-based emergency care in Denmark.

    METHODS: The process comprised a literature review followed by a modified-Delphi survey process, involving a panel of 54 experts (senior clinicians, researchers and administrators from the emergency area and collaborating specialties). Based on the literature review, we identified 43 potential indicators, of which eight were time-critical conditions. We then consulted the Expert panel in two consecutive rounds. The Expert panel was asked to what extent each indicator would be a good measure of hospital-based emergency care in Denmark. In each round, the Expert panel participants scored each indicator on a Likert scale ranging from one (=disagree completely) through to six (=agree completely). Consensus for a quality indicator was reached if the median was greater than or equal to five (=agree). The Delphi process was followed by final selection by the steering group for the new database.

    RESULTS: Following round two of the Expert panel, consensus was reached on 32 quality indicators, including three time-critical conditions. Subsequently, the database steering group chose a set of nine quality indicators for the initial version of the national database for hospital-based emergency care.

    CONCLUSIONS: The two-round modified Delphi process contributed to the selection of an initial set of nine quality indicators for a new a national database for hospital-based emergency care in Denmark. Final selection was made by the database steering group informed by the Delphi process.

  • 14.
    Murphy, Jason P.
    et al.
    Department of Clinical Science and Education, Karolinska Insititutet, Stockholm, Sweden; Sophiahemmet University, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Clinical Science and Education, Karolinska Insititutet, Stockholm, Sweden; Department of Neurobiology and Society, Karolinska Institutet, Stockholm, Sweden.
    Radestad, Monica
    Department of Clinical Science and Education, Karolinska Insititutet, Stockholm, Sweden.
    Rüter, Anders
    Department of Clinical Science and Education, Karolinska Insititutet, Stockholm, Sweden; Sophiahemmet University, Stockholm, Sweden.
    Hospital incident command groups' performance during major incident simulations: a prospective observational study2020In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 28, no 1, article id 73Article in journal (Refereed)
    Abstract [en]

    Background: Hospital incident command groups' (HICG) performance may have a profound impact on hospital response to major incidents. Previous research has assessed hospital incident command group capacity as opposed to performance and factors associated to performance. The objective was to assess associations between decision-making and staff procedure skills of the hospital incident command group.

    Methods: This was a prospective observational study using performance indicators to assess hospital incident command groups' decision-making and performance. A total of six hospitals in Stockholm, Sweden, with their respective HICGs participated. Associations between decision-making skills and staff procedure skills during major incident simulations were assessed using measurable performance indicators.

    Results: Decision-making skills are correlated to staff procedure skills and overall HICG performance. Proactive decision-making skills had significantly lower means than reactive decision-making skills and are significantly correlated to staff procedure skills.

    Conclusion: There is a significant correlation between decision-making skills and staff procedural skills. Hospital incident command groups' proactive decision-making abilities tended to be less developed than reactive decision-making abilities. These proactive decision-making skills may be a predictive factor for overall hospital incident command group performance. A lack of proactive decision-making ability may hamper efforts to mitigate the effects of a major incident.

  • 15.
    Sadi, Lin
    et al.
    Department of Surgery, Capio St Görans Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Beta-blockade is not associated with improved outcomes in isolated severe extracranial injury: an observational cohort study2021In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 29, no 1, article id 132Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is evidence supporting the use of beta-blockade in patients with traumatic brain injury. The reduction in sympathetic drive is thought to underlie the relationship between beta-blockade and increased survival. There is little evidence for similar effects in extracranial injuries. This study aimed to assess the association between beta-blockade and survival in patients suffering isolated severe extracranial injuries.

    METHODS: Patients treated at an academic urban trauma centre during a 5-year period were retrospectively identified. Adults suffering isolated severe extracranial injury [Injury Severity Score (ISS) ≥ 16 with Abbreviated Injury Score of ≤ 2 for any intracranial injury] were included. Patient characteristics and outcomes were collected from the trauma registry and hospital medical records. Patients were subdivided into beta-blocker exposed and unexposed groups. Patients were matched using propensity score matching. Differences were assessed using McNemar's or paired Student's t test. The primary outcome of interest was 90-day mortality and secondary outcome was in-hospital complications.

    RESULTS: 698 patients were included of whom 10.5% were on a beta-blocker. Most patients suffered blunt force trauma (88.5%) with a mean [standard deviation] ISS of 24.6 [10.6]. Unadjusted mortality was higher in patients receiving beta-blockers (34.2% vs. 9.1%, p < 0.001) as were cardiac complications (8.2% vs. 1.4%, p = 0.002). Patients on beta-blockers were significantly older (69.5 [14.1] vs. 43.2 [18.0] years) and of higher comorbidity. After matching, no statistically significant differences were seen in 90-day mortality (34.2% vs. 30.1%, p = 0.690) or in-hospital complications.

    CONCLUSIONS: Beta-blocker therapy does not appear to be associated with improved survival in patients with isolated severe extracranial injuries.

  • 16.
    Sewalt, Charlie Aletta
    et al.
    Department of Public Health, Erasmus MC Medical Center, Rotterdam, The Netherlands.
    Gravesteijn, Benjamin Yaël
    Department of Public Health, Erasmus MC Medical Center, Rotterdam, The Netherlands; Department of Anesthesiology, Erasmus MC Medical Center, Rotterdam, The Netherlands.
    Menon, David
    Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
    Lingsma, Hester Floor
    Department of Public Health, Erasmus MC Medical Center, Rotterdam, The Netherlands.
    Maas, Andrew I. R.
    Department of Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium.
    Stocchetti, Nino
    Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
    Venema, Esmee
    Department of Public Health, Erasmus MC Medical Center, Rotterdam, The Netherlands; Department of Neurology, Erasmus MC Medical Center, Rotterdam, The Netherlands.
    Lecky, Fiona E.
    Center for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
    Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study2021In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 29, no 1, article id 113Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients.

    METHODS: Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively.

    RESULTS: A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78-1.69), nor with survival at discharge (1.05, 0.58-1.90).

    CONCLUSIONS: Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation.

  • 17.
    Sund, Björn
    Örebro University, Örebro University School of Business. Swedish Civil Contingencies Agency (MSB), Karlstad, Sweden; Dept Economy & Statistics, Karlstad Business School, Karlstad University, Karlstad, Sweden.
    Developing an analytical tool for evaluating EMS system design changes and their impact on cardiac arrest outcomes: combining geographic information systems with register data on survival rates2013In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 21, no 8Article in journal (Refereed)
    Abstract [en]

    Background: Out-of-hospital cardiac arrest (OHCA) is a frequent and acute medical condition that requires immediate care. We estimate survival rates from OHCA in the area of Stockholm, through developing an analytical tool for evaluating Emergency Medical Services (EMS) system design changes. The study also is an attempt to validate the proposed model used to generate the outcome measures for the study.

    Methods and results: This was done by combining a geographic information systems (GIS) simulation of driving times with register data on survival rates. The emergency resources comprised ambulance alone and ambulance plus fire services. The simulation model predicted a baseline survival rate of 3.9 per cent, and reducing the ambulance response time by one minute increased survival to 4.6 per cent. Adding the fire services as first responders (dual dispatch) increased survival to 6.2 per cent from the baseline level. The model predictions were validated using empirical data.

    Conclusion: We have presented an analytical tool that easily can be generalized to other regions or countries. The model can be used to predict outcomes of cardiac arrest prior to investment in EMS design changes that affect the alarm process, e.g. (1) static changes such as trimming the emergency call handling time or (2) dynamic changes such as location of emergency resources or which resources should carry a defibrillator

  • 18.
    Torlén, Klara
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finland.
    Olanders, Knut
    Department of Anaesthesiology and ICU, Lund University Hospital, Lund, Sweden.
    Bohm, Katarina
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    A comparison of two emergency medical dispatch protocols with respect to accuracy2017In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 25, no 1, article id 122Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Emergency medical dispatching should be as accurate as possible in order to ensure patient safety and optimize the use of ambulance resources. This study aimed to compare the accuracy, measured as priority level, between two Swedish dispatch protocols - the three-graded priority protocol Medical Index and a newly developed prototype, the four-graded priority protocol, RETTS-A.

    METHODS: A simulation study was carried out at the Emergency Medical Communication Centre (EMCC) in Stockholm, Sweden, between October and March 2016. Fifty-three voluntary telecommunicators working at SOS Alarm were recruited nationally. Each telecommunicator handled 26 emergency medical calls, simulated by experienced standard patients. Manuscripts for the scenarios were based on recorded real-life calls, representing the six most common complaints. A cross-over design with 13 + 13 calls was used. Priority level and medical condition for each scenario was set through expert consensus and used as gold standard in the study.

    RESULTS: A total of 1293 calls were included in the analysis. For priority level, n = 349 (54.0%) of the calls were assessed correctly with Medical Index and n = 309 (48.0%) with RETTS-A (p = 0.012). Sensitivity for the highest priority level was 82.6% (95% confidence interval: 76.6-87.3%) in the Medical Index and 54.0% (44.3-63.4%) in RETTS-A. Overtriage was 37.9% (34.2-41.7%) in the Medical Index and 28.6% (25.2-32.2%) in RETTS-A. The corresponding proportion of undertriage was 6.3% (4.7-8.5%) and 23.4% (20.3-26.9%) respectively.

    CONCLUSION: In this simulation study we demonstrate that Medical Index had a higher accuracy for priority level and less undertriage than the new prototype RETTS-A. The overall accuracy of both protocols is to be considered as low. Overtriage challenges resource utilization while undertriage threatens patient safety. The results suggest that in order to improve patient safety both protocols need revisions in order to guarantee safe emergency medical dispatching.

  • 19.
    Torlén Wennlund, Klara
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Medical Sciences and Department of Emergency Medicine, Örebro University, Örebro, Sweden.
    Olanders, Knut
    Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Helsinki University, Helsinki, Finland; Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
    Bohm, Katarina
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Emergency Department, Södersjukhuset, Stockholm, Sweden .
    A registry-based observational study comparing emergency calls assessed by emergency medical dispatchers with and without support by registered nurses2022In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 30, no 1, article id 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The requirement concerning formal education for emergency medical dispatcher (EMD) is debated and varies, both nationally and internationally. There are few studies on the outcomes of emergency medical dispatching in relation to professional background. This study aimed to compare calls handled by an EMD with and without support by a registered nurse (RN), with respect to priority level, accuracy, and medical condition.

    METHODS: A retrospective observational study, performed on registry data from specific regions during 2015. The ambulance personnel's first assessment of the priority level and medical condition was used as the reference standard. Outcomes were: the proportion of calls dispatched with a priority in concordance with the ambulance personnel's assessment; over- and undertriage; the proportion of most adverse over- and undertriage; sensitivity, specificity and predictive values for each of the ambulance priorities; proportion of calls dispatched with a medical condition in concordance with the ambulance personnel's assessment. Proportions were reported with 95% confidence intervals. χ2-test was used for comparisons. P-levels < 0.05 were regarded as significant.

    RESULTS: A total of 25,025 calls were included (EMD n = 23,723, EMD + RN n = 1302). Analyses relating to priority and medical condition were performed on 23,503 and 21,881 calls, respectively. A dispatched priority in concordance with the ambulance personnel's assessment were: EMD n = 11,319 (50.7%) and EMD + RN n = 481 (41.5%) (p < 0.01). The proportion of overtriage was equal for both groups: EMD n = 5904, EMD + RN n = 306, (26.4%) p = 0.25). The proportion of undertriage for each group was: EMD n = 5122 (22.9%) and EMD + RN n = 371 (32.0%) (p < 0.01). Sensitivity for the most urgent priority was 54.6% for EMD, compared to 29.6% for EMD + RN (p < 0.01), and specificity was 67.3% and 84.8% (p < 0.01) respectively. A dispatched medical condition in concordance with the ambulance personnel's assessment were: EMD n = 13,785 (66.4%) and EMD + RN n = 697 (62.2%) (p = 0.01).

    CONCLUSIONS: A higher precision of emergency medical dispatching was not observed when the EMD was supported by an RN. How patient safety is affected by the observed divergence in dispatched priorities is an area for future research.

  • 20.
    Wallgren, Ulrika M.
    et al.
    Örebro University, School of Medical Sciences. Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Fisksätra Vårdcentral (Primary Health Care Center), Saltsjöbaden, Sweden.
    Sjölin, Jan
    Department of Medical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden.
    Järnbert-Pettersson, Hans
    Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Performance of NEWS2, RETTS, clinical judgment and the Predict Sepsis screening tools with respect to identification of sepsis among ambulance patients with suspected infection: a prospective cohort study2021In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 29, no 1, article id 144Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is little evidence of which sepsis screening tool to use in the ambulance setting. The primary aim of the current study was to compare the performance of NEWS2 (National Early Warning score 2) and RETTS (Rapid Emergency Triage and Treatment System) with respect to identification of sepsis among ambulance patients with clinically suspected infection. The secondary aim was to compare the performance of the novel Predict Sepsis screening tools with that of NEWS2, RETTS and clinical judgment.

    METHODS: Prospective cohort study of 323 adult ambulance patients with clinically suspected infection, transported to hospitals in Stockholm, during 2017/2018. The sensitivity, specificity, and AUC (Area Under the receiver operating Curve) were calculated and compared by using McNemar´s test and DeLong's test.

    RESULTS: The prevalence of sepsis in the current study population was 44.6% (144 of 323 patients). No significant difference in AUC was demonstrated between NEWS2 ≥ 5 and RETTS ≥ orange. NEWS2 ≥ 7 demonstrated a significantly greater AUC than RETTS red. The Predict Sepsis screening tools ≥ 2 demonstrated the highest sensitivity (range 0.87-0.91), along with RETTS ≥ orange (0.83), but the lowest specificity (range 0.39-0.49). The AUC of NEWS2 (0.73) and the Predict Sepsis screening tools (range 0.75-0.77) was similar.

    CONCLUSIONS: The results indicate that NEWS2 could be the better alternative for sepsis identification in the ambulance, as compared to RETTS. The Predict Sepsis screening tools demonstrated a high sensitivity and AUCs similar to that of NEWS2. However, these results need to be interpreted with caution as the Predict Sepsis screening tools require external validation.

    TRIAL REGISTRATION: ClinicalTrials.gov, NCT03249597. Registered 15 August 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03249597 .

  • 21.
    Wallgren, Ulrika Margareta
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Fisksätra Vårdcentral (Primary Health Care Center), Nacka, Sweden.
    Antonsson, Viktor Erik
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Castrén, Maaret Kaarina
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki University, Helsinki, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Section of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Longer time to antibiotics and higher mortality among septic patients with non-specific presentations: a cross sectional study of Emergency Department patients indicating that a screening tool may improve identification2016In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 24, article id 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The presentation of sepsis is varied and our hypotheses were that septic patients with non-specific presentations such as decreased general condition (DGC) have a less favourable outcome, and that a screening tool could increase identification of these patients. We aimed to: 1) assess time to antibiotics and in-hospital mortality among septic patients with ED chief complaint DGC, as compared with septic patients with other ED chief complaints, and 2) determine whether a screening tool could improve identification of septic patients with non-specific presentations such as DGC.

    METHODS: Cross sectional study comparing time to antibiotics (Mann Whitney and Kaplan-Meier tests), and in-hospital mortality (logistic regression), between 61 septic patients with ED chief complaint DGC and 516 septic patients with other ED chief complaints. The sensitivity and specificity of the modified Robson screening tool was compared with that of ED doctor clinical judgment (McNemar's two related samples test) among 122 patients presenting to the ED with chief complaint DGC, of which 61 were discharged with ICD code sepsis.

    RESULTS: Septic patients presenting to the ED with the chief complaint DGC had a longer median time to antibiotics (05:26 h:minutes; IQR 4:00-10:40, vs. 03:56 h:minutes; IQR 2:21-7:32) and an increased in-hospital mortality (crude OR = 4.01; 95% CI, 2.19-7.32), compared to septic patients with other ED chief complaints. This association remained significant when adjusting for sex, age, priority, comorbidity and fulfilment of the Robson score (OR 4.31; 95% CI, 2.12-8.77). The modified Robson screening tool had a higher sensitivity (63.0 vs. 24.6%, p < 0.001), but a lower specificity (68.3 vs. 100.0%, p < 0.001), as compared to clinical judgment.

    DISCUSSION: This is, to the best of our knowledge, the first study comparing outcome of septic patients according to ED chief complaint. Septic patients presenting with a non-specific ED presentation, here exemplified as the chief complaint DGC, have a less favourable outcome. Our results indicate that implementation of a screening tool may increase the identification of septic patients.

    CONCLUSIONS: The results indicate that septic patients presenting with ED chief complaint DGC constitute a vulnerable patient group with delayed time to antibiotics and high in-hospital mortality. Furthermore, the results support that implementation of a screening tool may be beneficial to improve identification of these patients.

  • 22.
    Wallgren, Ulrika Margareta
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Fisksätra Vårdcentral (Primary Health Care Center), Saltsjöbaden, Sweden.
    Bohm, Katarina Eva Margareta
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis2017In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 25, no 1, article id 23Article in journal (Refereed)
    Abstract [en]

    Background: Current sepsis screening tools rely on vital parameters which are, however, normal in one third of patients with serious infections. Therefore, there is a need to include other variables than vital parameters to identify septic patients. Our primary aim was to identify and quantify keywords related to the septic patients' symptom presentation in the prehospital setting. The secondary aims were to compare keywords in relation to in-hospital mortality and the distribution of keywords in relation to age categories, survivors/ deceased and severe/ non-severe sepsis.

    Methods: A mixed methods analysis using a sequential exploratory design was performed, starting with a content analysis of presentations of septic patients as documented in Emergency Medical Services (EMS) records (n = 80) from 2012, to identify keywords related to sepsis presentation. Thereafter, the identified keywords were quantified among 359 septic patients from 2013. All patients were adults, admitted to Södersjukhuset and discharged with an ICD-10-code (International Classification of Diseases, Tenth Revision) compatible with sepsis.

    Results: The most common keywords related to septic patients' symptom presentation were: abnormal/ suspected abnormal temperature (64.1.%), pain (38.4%), acute altered mental status (38.2%), weakness of the legs (35.1%), breathing difficulties (30.4%), loss of energy (26.2%) and gastrointestinal symptoms (24.0%). There was an association between keywords and in-hospital mortality. Symptoms varied between age categories, survivors/ deceased and severe/ non-severe sepsis.

    Discussion: This is, to the best of our knowledge, the first study exploring the symptom presentation as documented by EMS, of septic patients in the prehospital setting. Keywords related to patients´ symptom presentation recurred in the EMS records of septic patients, so that a pattern was discernible. In addition, certain symptom presentations were associated with increased in-hospital mortality CONCLUSIONS: Information relating to symptom presentation is not included in current sepsis screening tools. We suggest that keywords related to patients´ symptom presentation could be integrated into screening tools and may thus increase the identification of sepsis, and potentially also identify high-risk patients. However, as a first step, the specificity of these keywords, with respect to sepsis, needs to be examined.

  • 23.
    Wallgren, Ulrika Margareta
    et al.
    Karolinska Institutet, Department of Clinical Science and Education, Söderssjukhuset, Stockholm, Sweden; FisksätraVårdcentral (Primary Health Care Center), Saltsjöbaden, Sweden.
    Sjölin, Jan
    Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden.
    Järnbert-Pettersson, Hans
    Karolinska Institutet, Department of Clinical Science and Education, Söderssjukhuset, Stockholm, Sweden .
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Karolinska Institutet, Department of Clinical Science and Education, Söderssjukhuset, Stockholm, Sweden .
    The predictive value of variables measurable in the ambulance and the development of the Predict Sepsis screening tools: a prospective cohort study2020In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 28, no 1, article id 59Article in journal (Refereed)
    Abstract [en]

    Background: Despite sepsis being a time critical condition with a high mortality, it is often not identified in a timely fashion. The aim of the current study was to create a screening tool based on bedside measurable variables predictive of sepsis among ambulance patients with infection according to clinical judgment by ambulance personnel.

    Methods: Prospective cohort study of 551 adult patients presenting with suspected infection, performed in the ambulance setting of Stockholm during 2017-2018. 18 variables were measured in the ambulance (8 keywords related to medical history, 6 vital signs, 4 point-of-care blood tests, in addition to age, gender, and comorbidity. Logistic regression, area under the curve (AUC) and classification trees were used to study the association with sepsis. The AUC, sensitivity, specificity, predictive values and likelihood ratios were used to evaluate the predictive ability of sepsis screening models.

    Results: The six variables with the strongest association with sepsis were: systolic blood pressure <= 100 mmHg, temperature > 38.5 degrees C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status. These were combined into thePredict Sepsis screening tool 1, with a sensitivity of 0.90, specificity 0.41, AUC 0.77; 95% confidence interval [CI] 0.73-0.81, PPV 0.52, and NPV 0.86. Combining a history of acute altered mental status with GCS < 15 and excluding lactate in thePredict Sepsis screening tool 2did not noticeably affect the AUC. In addition, the AUCs of these models did not differ noticeably when compared to a model including vital signs alone, with novel calculated cut-offs; thePredict Sepsis screening tool 3.

    Conclusions: Systolic blood pressure <= 100 mmHg, temperature > 38.5 degrees C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status demonstrated the strongest association with sepsis. We present three screening tools to predict sepsis with similar sensitivity. The results indicated no noticeable increase of predictive ability by including symptom-variables and blood tests to a sepsis screening tool in the current study population.

  • 24.
    Wickbom, Fredrik
    et al.
    Department of Operation and Intensive Care, Halland; Lund University, Lund, Sweden Hospital, Halmstad, Sweden.
    Persson, Linda
    Department of Orthopaedics, Halland Hospital, Halmstad, Sweden.
    Olivecrona, Zandra
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Neurosurgery; Department for Medical Sciences.
    Undén, Johan
    Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden; Lund University, Lund, Sweden.
    Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey.2022In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 30, no 1, article id 35Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals.

    METHODS: This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0-17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020-March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable.

    RESULTS: 71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006.

    CONCLUSIONS: TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation.

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