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  • 1.
    Cone, David C
    et al.
    Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.
    Serra, John
    Department of Emergency Medicine, University of California San Diego, San Diego, California, USA.
    Kurland, Lisa
    Department of Clinical Research and Education, Karolinska Institutet, Stockholm, Sweden.
    Comparison of the SALT and Smart triage systems using a virtual reality simulator with paramedic students2011In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 18, no 6, 314-321 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Virtual reality systems may allow for organized study of mass casualty triage systems by allowing investigators to replicate the same mass casualty incident, with the same victims, for a large number of rescuers. The study objectives were to develop such a virtual reality system, and use it to assess the ability of trained paramedic students to triage simulated victims using two triage systems.

    METHODS: Investigators created 25 patient scenarios for a highway bus crash in a virtual reality simulation system. Paramedic students were trained to proficiency on the new 'Sort, Assess, Life saving interventions, Treat and Transport (SALT)' triage system, and 22 students ran the simulation, applying the SALT algorithm to each victim. After a 3-month washout period, the students were retrained on the 'Smart' triage system, and each student ran the same crash simulation using the Smart system. Data inputs were recorded by the simulation software and analyzed with the paired t-tests.

    RESULTS: The students had a mean triage accuracy of 70.0% with SALT versus 93.0% with Smart (P=0.0001). Mean overtriage was 6.8% with SALT versus 1.8% with Smart (P=0.0015), and mean undertriage was 23.2% with SALT versus 5.1% with Smart (P=0.0001). The average time for a student to triage the scene was 21 min 3 s for SALT versus 11 min 59 s for Smart (P=0.0001).

    CONCLUSION: The virtual reality platform seems to be a viable research tool for examining mass casualty triage. A small sample of trained paramedic students using the virtual reality system was able to triage simulated patients faster and with greater accuracy with 'Smart' triage than with 'SALT' triage.

  • 2.
    Djalali, Ahmadreza
    et al.
    Center for Research and Education in Emergency and Disaster Medicine, Università Del Piemonte Orientale, Novara, Italy; Department of Clinical Sciences and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Ardalan, Ali
    Department of Disaster and Emergency Health, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran; Harvard Humanitarian Initiative, Department of Global Health and Population, Harvard School of Public Health, Cambridge, MA, United States.
    Ohlen, Gunnar
    Intervention and Technology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Ingrassia, Pier Luigi
    Center for Research and Education in Emergency and Disaster Medicine, Università Del Piemonte Orientale, Novara, Italy.
    Corte, Francesco Della
    Center for Research and Education in Emergency and Disaster Medicine, Università Del Piemonte Orientale, Novara, Italy.
    Castren, Maaret
    Department of Clinical Sciences and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Sciences and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Nonstructural Safety of Hospitals for Disasters: A Comparison Between Two Capital Cities2014In: Disaster Medicine and Public Health Preparedness, ISSN 1935-7893, E-ISSN 1938-744X, Vol. 8, no 2, 179-184 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Hospitals are expected to function as a safe environment during disasters, but many become unusable because of nonstructural damage. This study compares the nonstructural safety of hospitals to disasters in Tehran and Stockholm.

    METHODS: Hospital safety in Tehran and Stockholm was assessed between September 24, 2012, and April 5, 2013, with use of the nonstructural module of the hospital safety index from the World Health Organization. Hospital safety was categorized as safe, at risk, or inadequate.

    RESULTS: All 4 hospitals in Stockholm were classified as safe, while 2 hospitals in Tehran were at risk and 3 were safe. The mean nonstructural safety index was 90% ± 2.4 SD for the hospitals in Stockholm and 64% ± 17.4 SD for those in Tehran (P = .014).

    CONCLUSIONS: The level of hospital safety, with respect to disasters, was not related to local vulnerability. Future studies on hospital safety should assess other factors such as legal and financial issues. (Disaster Med Public Health Preparedness. 2014;0:1-6).

  • 3.
    Djalali, Ahmadreza
    et al.
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
    Castren, Maaret
    Karolinska Institutet, Department of Clinical Sciences and Education and Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Hosseinijenab, Vahid
    Department of emergency management, Natural Disaster Research Institute, Tehran, Iran.
    Khatib, Mahmoud
    Tehran social security organization, Tehran, Iran.
    Ohlen, Gunnar
    Karolinska Institutet, Department of Clinical Science, Intervention and Technology, Stockholm, Sweden.
    Kurland, Lisa
    Karolinska Institutet, Department of Clinical Sciences and Education and Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Hospital Incident Command System (HICS) performance in Iran; decision making during disasters2012In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 20, 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, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; RIMEDIM - Center for Research and Education in Emergency and Disaster Medicine, Università del Piemonte Orientale, Novara, Italy.
    Castren, Maaret
    epartment of Clinical Sciences and Education and Section of Emergency Medicine, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Khankeh, Hamidreza
    epartment of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; ursing Department, University of Social Welfare and Rehabilitation, Tehran, Iran.
    Gryth, Dan
    epartment of Physiology and Pharmacology and Section of Anaesthesiology and Intensive care, Karolinska Institutet, Stockholm, Sweden.
    Radestad, Monica
    epartment of Clinical Sciences and Education and Section of Emergency Medicine, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Öhlen, Gunnar
    epartment of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    epartment of Clinical Sciences and Education and Section of Emergency Medicine, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Hospital disaster preparedness as measured by functional capacity: a comparison between Iran and Sweden2013In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 28, no 5, 454-461 p.Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Hospitals are expected to continue to provide medical care during disasters. However, they often fail to function under these circumstances. Vulnerability to disasters has been shown to be related to the socioeconomic level of a country. This study compares hospital preparedness, as measured by functional capacity, between Iran and Sweden.

    METHODS: Hospital affiliation and size, and type of hazards, were compared between Iran and Sweden. The functional capacity was evaluated and calculated using the Hospital Safety Index (HSI) from the World Health Organization. The level and value of each element was determined, in consensus, by a group of evaluators. The sum of the elements for each sub-module led to a total sum, in turn, categorizing the functional capacity into one of three categories: A) functional; B) at risk; or C) inadequate.

    RESULTS: The Swedish hospitals (n = 4) were all level A, while the Iranian hospitals (n = 5) were all categorized as level B, with respect to functional capacity. A lack of contingency plans and the availability of resources were weaknesses of hospital preparedness. There was no association between the level of hospital preparedness and hospital affiliation or size for either country.

    CONCLUSION: The results suggest that the level of hospital preparedness, as measured by functional capacity, is related to the socioeconomic level of the country. The challenge is therefore to enhance hospital preparedness in countries with a weaker economy, since all hospitals need to be prepared for a disaster. There is also room for improvement in more affluent countries.

  • 5.
    Djalali, Ahmadreza
    et al.
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset (KI SÖS), Stockholm, Sweden.
    Khankeh, Hamidreza
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset (KI SÖS), Stockholm, Sweden; Nursing Department, University of Social Welfare and Rehabilitation, Tehran, Iran.
    Öhlén, Gunnar
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset (KI SÖS), Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset (KI SÖS), Stockholm, Sweden.
    Facilitators and obstacles in pre-hospital medical response to earthquakes: a qualitative study2011In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 19, 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.

  • 6.
    Djärv, Therese
    et al.
    Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institute, Stockholm, Sweden.
    Mårtenson, Linda
    Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Section of Emergency Medicine, Karolinska Institute, Stockholm, Sweden.
    Decreased general condition in the emergency department: high in-hospital mortality and a broad range of discharge diagnoses2015In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 22, no 4, 241-246 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Decreased general condition (DGC) is a frequent presenting complaint within the Adaptive Triage Process. DGC describes a nonspecific decline in health and well-being, and it is common among elderly patients in the emergency department (ED).

    AIM: The aim of this study was to compare the in-hospital mortality among patients presenting with DGC with that among patients in the corresponding triage category presenting with other complaints to an ED. The secondary aim was to describe the discharge diagnoses of patients presenting with DGC.

    METHODS: All patients admitted to Södersjukhuset from the ED in 2008 were included. The difference in the in-hospital mortality rate was stratified for triage category at the ED, between patients with DGC (n=1182) and those with all other presenting complaints (n=20 775), and assessed with sex-adjusted and age-adjusted logistic regression models. Discharge diagnoses were assessed as the primary discharge diagnosis according to International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10) in the medical discharge notes.

    RESULTS: A total of 1182 patients with DGC at the ED were admitted for in-hospital care, and they had a four-fold risk of suffering an in-hospital death [odds ratio 4.74 (95% confidence interval 3.88-5.78)] compared with patients presenting with other presenting complaints. The most common discharge diagnoses were diseases of the circulatory system (14%), respiratory system (14%), and genitourinary system (10%).

    INTERPRETATION: Patients presenting with DGC to an ED often receive low triage priority, frequently require admission for in-hospital care, and, because of the three-fold increased risk of in-hospital death compared with others, belong to a high-risk group.

  • 7.
    Dryver, Eric T
    et al.
    Emergency Department, Skane's University Hospital, Akutkliniken, Lund, Sweden; Practicum Clinical Skills Centre, Region Skåne, Sweden.
    Eriksson, Anders
    Anesthesiology Department, Ersta Hospital, Stockholm, Sweden.
    Söderberg, Patrik
    Stockholm's County Council, Södersjukhus Hospital, Stockholm, Sweden.
    Kurland, Lisa
    Karolinska Institution, Södersjukhus Hospital, Stockholm, Sweden.
    The Swedish specialist examination in emergency medicine: form and function2017In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 24, no 1, 19-24 p.Article in journal (Refereed)
    Abstract [en]

    AIM/BACKGROUND: The purpose of the Swedish specialist examination in Emergency Medicine is not only to determine whether residents have attained the level of competence of specialists, but also to guide and facilitate residency training.

    METHODS: The Swedish Society for Emergency Medicine has developed checklists that delineate criteria of consideration and action items for particular processes. These checklists are freely available and used to assess competence during the examination. They are also intended for use during teaching and clinical care, thus promoting alignment between clinical practice, teaching and assessment. The examination is carried out locally by residency program educators, thereby obviating travel expenses. It consists of a total of 24 stations and over 100 potential scenarios, thereby minimizing case specificity. Each station consists of a scenario based on a real case. The checklists allow for direct feedback to the examinee after each station.

    RESULTS AND CONCLUSION: This model may be of interest to other European countries.

  • 8.
    Ekelund, Ulf
    et al.
    Emergency Medicine, Department of Clinical Sciences at Lund, Lund University, Sweden.
    Kurland, Lisa
    Karolinska Institutet, Department of Clinical Sciences and Education and Section of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Eklund, Fredrik
    Karolinska Institutet, Medical Management Centre, Stockholm, Sweden.
    Torkki, Paulus
    HEMA-Institute, BIT Research Centre, Aalto University, Finland.
    Letterstål, Anna
    Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden.
    Lindmarker, Per
    Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden.
    Castrén, Maaret
    Karolinska Institutet, Department of Clinical Sciences and Education and Section of Emergency Medicine, Södersjukhuset, 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, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 19, 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.

  • 9.
    Ekström, Andreas
    et al.
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Farrokhnia, Nasim
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden.
    Nordberg, Martin
    Department of Clinical Science and Education, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Forecasting emergency department visits using internet data2015In: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 65, no 4, 436-442.e1 p.Article in journal (Refereed)
    Abstract [en]

    STUDY OBJECTIVE: Using Internet data to forecast emergency department (ED) visits might enable a model that reflects behavioral trends and thereby be a valid tool for health care providers with which to allocate resources and prevent crowding. The aim of this study is to investigate whether Web site visits to a regional medical Web site, the Stockholm Health Care Guide, a proxy for the general public's concern of their health, could be used to predict the ED attendance for the coming day.

    METHODS: In a retrospective, observational, cross-sectional study, a model for forecasting the daily number of ED visits was derived and validated. The model was derived through regression analysis, using visits to the Stockholm Health Care Guide Web site between 6 pm and midnight and day of the week as independent variables. Web site visits were measured with Google Analytics. The number of visits to the ED within the region was retrieved from the Stockholm County Council administrative database. All types of ED visits (including adult, pediatric, and gynecologic) were included. The period of August 13, 2011, to August 12, 2012, was used as a training set for the model. The hourly variation of visits was analyzed for both Web site and the ED visits to determine the interval of hours to be used for the prediction. The model was validated with mean absolute percentage error for August 13, 2012, to October 31, 2012.

    RESULTS: The correlation between the number of Web site visits between 6 pm and midnight and ED visits the coming day was significant (r=0.77; P<.001). The best forecasting results for ED visits were achieved for the entire county, with a mean absolute percentage error of 4.8%. The result for the individual hospitals ranged between mean absolute percentage error 5.2% and 13.1%.

    CONCLUSION: Web site visits may be used in this fashion to predict attendance to the ED. The model works both for the entire region and for individual hospitals. The possibility of using Internet data to predict ED visits is promising.

  • 10.
    Khankeh, Hamidreza
    et al.
    University of Social Welfare & Rehabilitation Sciences, Tehran, Iran; Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden.
    Nakhaei, Maryam
    University of Social Welfare & Rehabilitation Sciences, Tehran, Iran.
    Masoumi, Gholamreza
    Iran University of Medical Sciences, Teheran, Iran.
    Hosseini, Mohammadali
    University of Social Welfare & Rehabilitation Sciences, Tehran, Iran.
    Parsa-Yekta, Zohreh
    Tehran University of Medical Sciences, Teheran, Iran.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden.
    Castren, Maaret
    Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden.
    Life recovery after disasters: a qualitative study in the Iranian context2013In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 28, no 6, 573-9 p.Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Planned and organized long-term rehabilitation services should be provided to victims of a disaster for social integration, economic self-sufficiency, and psychological health. There are few studies on recovery and rehabilitation issues in disaster situations. This study explores the disaster-related rehabilitation process.

    METHOD: This study was based on qualitative analysis. Participants included 18 individuals (eight male and ten female) with experience providing or receiving disaster health care or services. Participants were selected using purposeful sampling. Data were collected through in-depth and semi-structured interviews. All interviews were transcribed and content analysis was performed based on qualitative content analysis.

    RESULTS: The study explored three main concepts of recovery and rehabilitation after a disaster: 1) needs for health recovery; 2) intent to delegate responsibility; and 3) desire for a wide scope of social support. The participants of this study indicated that to provide comprehensive recovery services, important basic needs should be considered, including the need for physical rehabilitation, social rehabilitation, and livelihood health; the need for continuity of mental health care; and the need for family re-unification services. Providing social activation can help reintegrate affected people into the community.

    CONCLUSION: Effective rehabilitation care for disaster victims requires a clear definition of the rehabilitation process at different levels of the community. Involving a wide set of those most likely to be affected by the process provides a comprehensive, continuous, culturally sensitive, and family-centered plan.

  • 11.
    Kurland, Lisa
    et al.
    Swedish Society for Emergency Medicine, Stockholm, Sweden; Department of Clinical Research and Education, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Graham, Colin A
    Department of Emergency Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong.
    Emergency medicine development in the Nordic countries2014In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 21, no 3, 163-163 p.Article in journal (Refereed)
  • 12.
    Kurland, Lisa
    et al.
    Department of Medical Sciences, Uppsala University Hospital, Sweden; Department of Medicine, University Hospital, Uppsala, Sweden.
    Melhus, H
    Department of Medical Sciences, Uppsala University Hospital, Sweden.
    Sarabi, M
    Department of Medical Sciences, Uppsala University Hospital, Sweden.
    Millgård, J
    Department of Medical Sciences, Uppsala University Hospital, Sweden.
    Ljunghall, S
    Department of Medical Sciences, Uppsala University Hospital, Sweden.
    Lind, L
    Department of Medical Sciences, Uppsala University Hospital, Sweden.
    Polymorphisms in the renin-angiotensin system and endothelium-dependent vasodilation in normotensive subjects2001In: Clinical Physiology, ISSN 0144-5979, E-ISSN 1365-2281, Vol. 21, no 3, 343-349 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Our aim was to test the hypothesis that genes encoding components in the renin-angiotensin system influence endothelial vasodilatory function.

    METHODS: In 59 apparently healthy, normotensive individuals, endothelium-dependent vasodilation (EDV) and endothelial-independent vasodilation (EIDV) was evaluated by infusing metacholine and sodium nitroprusside into the brachial artery. Forearm blood flow was measured by venous occlusion plethysmography. The ACE insertion (I)/deletion (D) polymorphism, the T174M and M235T angiotensinogen restriction fragments length polymorphisms, the angiotensin II receptor type 1 (AT1R) A1166C, and the aldosterone synthase gene (CYP11B2) C-344T polymorphisms were analysed.

    RESULTS: When analysing the ACE, the two angiotensinogen and the aldosterone synthase CYP11B2 genotypes independently, no significant association with endothelial vasodilatory function was found. However, a significant reduction in endothelium-dependent vasodilation was observed in the subjects (n=9) with the ACE D allele and the angiotensinogen T174M genotype (P<0.05). Subjects with the AT1R genotype AC showed a reduction in both EDV (P=0.05) and EIDV (P=0.04) when compared with those with the AA genotype.

    CONCLUSIONS: The subjects with the ACE D allele in combination with the angiotensinogen T174M genotype are associated with a reduced EDV. This together with the observation that the AC AT1R genotype is associated with a reduction in both EDV and EIDV, supports the hypothesis that endothelial vasodilatory function is influenced by genes in the renin-angiotensinogen system.

  • 13.
    Ljunggren, Malin
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden.
    Castrén, Maaret
    Department of Clinical Science and Education, Södersjukhuset, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finland.
    Nordberg, Martin
    Department of Clinical Science and Education, Södersjukhuset, Section of Emergency Medicine, Karolinska Institutet, Stockholm, Sweden.
    Kurland, Lisa
    Department of Clinical Science and Education, Södersjukhuset, 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, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 24, 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.

  • 14.
    Lo, Ronson S L
    et al.
    Department of Emergency Medicine, Chinese University of Hong Kong, Hong Kong.
    Brabrand, Mikkel
    Department of Emergency Medicine, Odense University Hospital, Hospital of South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
    Graham, Colin A
    Department of Emergency Medicine, Chinese University of Hong Kong, Hong Kong.
    Sepsis - where are the emergency physicians?2016In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 23, no 3, 159-159 p.Article in journal (Refereed)
  • 15.
    Madsen, Michael
    et al.
    Silkeborg Hospital and University of Copenhagen, Denmark.
    Kiuru, Sampsa
    Ashburton Hospital, Canterbury DHB, New Zealand; University of Turku, Finland.
    Castrèn, Maaret
    Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Finland.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institutet; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    The level of evidence for emergency department performance indicators: systematic review2015In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 22, no 5, 298-305 p.Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to perform a comprehensive systematic review of emergency department performance indicators in relation to evidence. A systematic search was performed through PUBMED, EMBASE, CINAHL and COCHRANE databases with (and including synonyms of) the search words: [emergency medicine OR emergency department] AND [quality indicator(s) OR performance indicator(s) OR performance measure(s)]. Articles were included according to the inclusion/exclusion criteria using the PRISMA protocol. The level of evidence was rated according to the evidence levels by the Oxford Centre for Evidence-Based Medicine. Performance indicators were extracted and organized into five categories; outcome, process, satisfaction, equity and structural/organizational measures. Six thousand four hundred and forty articles were initially identified; 127 provided evidence for/against a minimum of one performance indicator: these were included for further study. Of the 127 articles included, 113 (92%) were primary research studies and only nine (8%) were systematic reviews. Within the 127 articles, we found evidence for 202 individual indicators. Approximately half (n=104) of all this evidence (n=202) studied process-type indicators. Only seven articles (6%) qualified for high quality (level 1b). Sixty-six articles (51%) were good retrospective quality (level 2b or better), whereas the remaining articles were either intermediate quality (25% level 3a or 3b) or poor quality (17% level 4 or 5). We found limited evidence for most emergency department performance indicators, with the majority presenting a low level of evidence. Thus, a core group of evidence-based performance indicators cannot currently be recommended on the basis of this broad review of the literature.

  • 16.
    Mäkinen, M.
    et al.
    Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Finland; Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden.
    Niemi-Murola, L.
    Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Finland; Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden.
    Ponzer, S.
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden.
    Kurola, J.
    Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland.
    Aune, S.
    Division of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Kurland, Lisa
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden.
    Castrén, M.
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden; Helsinki University Hospital, Helsinki, Finland.
    Healthcare professionals hesitate to perform CPR for fear of harming the patient2014In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 85, no 11, e181-e182 p.Article in journal (Refereed)
  • 17.
    Nakhaei, Maryam
    et al.
    Birjand Health Qualitative Research Center, Birjand University of Medical Sciences, Birjand, Iran.
    Khankeh, Hamid Reza
    University of Social Welfare and Rehabilitation Sciences, Tehran, Iran; Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden.
    Masoumi, Gholam Reza
    Iran University of Medical Sciences, Tehran, Iran.
    Hosseini, Mohammad Ali
    University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
    Parsa-Yekta, Zohreh
    Tehran University of Medical Sciences, Tehran, Iran.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden.
    Castren, Maaret
    Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden.
    Impact of disaster on women in Iran and implication for emergency nurses volunteering to provide urgent humanitarian aid relief: A qualitative study2015In: Australasian emergency nursing journal : AENJ, ISSN 1574-6267, Vol. 18, no 3, 165-172 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Men and women are equally affected by disasters, but they experience disaster in different ways. To provide new knowledge and promote women's involvement in all phases of the disaster management, we decided to capture the perspectives and experiences of the women themselves; and to explore the conditions affecting Iranian women after recent earthquake disasters.

    METHODS: The study was designed as a qualitative content analysis. Twenty individuals were selected by purposeful sampling and data collected by in-depth, semi-structured interviews analysed qualitatively.

    RESULTS: Three main themes were evident reflecting women's status after disaster: individual impacts of disaster, women and family, and women in the community. Participants experienced the emotional impact of loss, disorganisation of livelihood and challenges due to physical injuries. Women experienced changes in family function due to separation and conflicts which created challenges and needed to be managed after the disaster. Their most urgent request was to be settled in their own permanent home. This motivated the women to help reconstruction efforts.

    CONCLUSIONS: Clarification of women's need after a disaster can help to mainstream gender-sensitive approaches in planning response and recovery efforts.

  • 18.
    Rüter, Andres
    et al.
    Sophiahemmet University, Stockholm, Sweden; Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
    Kurland, Lisa
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
    Gryth, Dan
    Karolinska Institutet, Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Stockholm, Sweden.
    Murphy, Jason
    Sophiahemmet University, Stockholm, Sweden; Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
    Rådestad, Monica
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
    Djalali, Ahmadreza
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Center for Research and Education in Emergency and Disaster Medicine, Novara, Italy.
    Evaluation of Disaster Preparedness Based on Simulation Exercises: A Comparison of Two Models2016In: Disaster Medicine and Public Health Preparedness, ISSN 1935-7893, E-ISSN 1938-744X, Vol. 10, no 4, 544-548 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The objective of this study was to highlight 2 models, the Hospital Incident Command System (HICS) and the Disaster Management Indicator model (DiMI), for evaluating the in-hospital management of a disaster situation through simulation exercises.

    METHODS: Two disaster exercises, A and B, with similar scenarios were performed. Both exercises were evaluated with regard to actions, processes, and structures. After the exercises, the results were calculated and compared.

    RESULTS: In exercise A the HICS model indicated that 32% of the required positions for the immediate phase were taken under consideration with an average performance of 70%. For exercise B, the corresponding scores were 42% and 68%, respectively. According to the DiMI model, the results for exercise A were a score of 68% for management processes and 63% for management structure (staff skills). In B the results were 77% and 86%, respectively.

    CONCLUSIONS: Both models demonstrated acceptable results in relation to previous studies. More research in this area is needed to validate which of these methods best evaluates disaster preparedness based on simulation exercises or whether the methods are complementary and should therefore be used together. (Disaster Med Public Health Preparedness. 2016;10:544-548).

  • 19.
    Sjölin, Helena
    et al.
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, Stockholm, Sweden; Södersjukhuset, Section of Emergency Medicine, Stockholm, Sweden.
    Lindström, Veronica
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, Stockholm, Sweden; Academic EMS in Stockholm, Sweden.
    Hult, Håkan
    Department of Behavioural Science and Learning, Linköpings University, Linköping, Sweden.
    Ringsted, Charlotte
    Department of Anesthesia and The Wilson Centre, University of Toronto and University Health Network, Toronto, Canada.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, Stockholm, Sweden; Södersjukhuset, Section of Emergency Medicine, Stockholm, Sweden.
    What an ambulance nurse needs to know: a content analysis of curricula in the specialist nursing programme in prehospital emergency care2015In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013X, Vol. 23, no 2, 127-132 p.Article in journal (Refereed)
    Abstract [en]

    In Sweden, ambulances must be staffed by at least one registered nurse. Twelve universities offer education in ambulance nursing. There is no national curriculum for detailed course content and there is a lack of knowledge about the educational content that deals with the ambulance nurse practical professional work. The aim of this study was to describe the content in course curricula for ambulance nurses. A descriptive qualitative research design with summative content analysis was used. Data were generated from 49 courses in nursing and medical science. The result shows that the course content can be described as medical, nursing and contextual knowledge with a certain imbalance with largest focus on medical knowledge. There is least focus on nursing, the registered nurses' main profession. This study clarifies how the content in the education for ambulance nurses in Sweden looks today but there are reasons to discuss the content distribution.

  • 20.
    Wallgren, Ulrika M
    et al.
    Department of Clinical Research and Education, Karolinska Institutet, Södersjukhuset, Sweden; Fisksätra Vårdcentral, Saltsjöbaden, Sweden.
    Castrén, Maaret
    Department of Clinical Research and Education, Karolinska Institutet, Södersjukhuset, Sweden; Section of Emergency Medicine, Södersjukhuset, Sweden.
    Svensson, Alexandra E V
    Department of Clinical Research and Education, Karolinska Institutet, Södersjukhuset, Sweden.
    Kurland, Lisa
    Department of Clinical Research and Education, Karolinska Institutet, Södersjukhuset, Sweden; Section of Emergency Medicine, Södersjukhuset, Sweden.
    Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment2014In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 21, no 4, 260-265 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Timely identification and treatment of sepsis is crucial for patient outcome. The aim of this study was to compare two previously unvalidated prehospital sepsis screening tools with clinical judgment by emergency medical services (EMS) personnel with respect to identification of septic patients.

    PATIENTS AND METHODS: We carried out a retrospective cross-sectional study of 353 adult patients, transported by the EMS, with a hospital discharge International Classification of Diseases code consistent with sepsis. We analyzed EMS records for the identification of sepsis according to two screening tools and clinical judgment by EMS providers. The Robson screening tool includes temperature, heart rate, respiratory rate, altered mental status, plasma glucose, and a history suggestive of a new infection. BAS 90-30-90 refers to the vital signs: oxygen saturation, respiratory rate, and systolic blood pressure. McNemar's two related samples test was used to compare the sensitivity of the two screening tools with the sensitivity of clinical judgment.

    RESULTS: The Robson screening tool had a sensitivity of 75% (18 out of 24 patients for whom all parameters were documented, P<0.001, as compared with clinical judgment). BAS 90-30-90 had a sensitivity of 43% (76 out of 175 patients, P<0.001). EMS personnel documented suspected sepsis in 42 out of 353 (12%) patients with sepsis.

    CONCLUSION: The Robson screening tool had a sensitivity superior to both BAS 90-30-90 and clinical judgment. This supports our hypothesis that the implementation of a screening tool could lead to increased prehospital identification of sepsis, which may enable a more timely treatment of these patients.

  • 21.
    Wallgren, Ulrika Margareta
    et al.
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden; Fisksätra Vårdcentral (Primary Health Care Center), Saltsjöbaden, Sweden.
    Bohm, Katarina Eva Margareta
    Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Örebro University Hospital. Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, 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, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 25, no 1, 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.

  • 22.
    Yanagizawa-Drott, Lisa
    et al.
    Department of Emergency Medicine, Brigham and Women's Hospital, Neville House, Boston MA, United States; Department of Medicine, Harvard Medical School, Boston MA, United States.
    Kurland, Lisa
    Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden.
    Schuur, Jeremiah D
    Department of Emergency Medicine, Brigham and Women's Hospital, Neville House, Boston MA, United States; Department of Medicine, Harvard Medical School, Boston MA, United States.
    Infection prevention practices in Swedish emergency departments: results from a cross-sectional survey2015In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 22, no 5, 338-42 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Healthcare-associated infections (HAIs) are a leading cause of preventable morbidity and mortality. Emergency departments (EDs) are a potential source of HAIs as they are the site for large volumes of patients in tight quarters and often focus on immediate life threats over prevention. We aimed to estimate the extent to which Swedish EDs have adopted evidence-based measures to prevent HAIs. The second aim was to identify predictors of high hand hygiene compliance.

    MATERIALS AND METHODS: We developed a survey on the basis of an instrument used in a US survey in 2011. We modified the survey to reflect Swedish ED practice, and emailed it to ED directors between February and April 2012. We calculated proportions, odds ratios, and 95% confidence intervals, and used logistic regression to adjust for independent variables.

    RESULTS: We received responses from 59 of Sweden's 72 EDs (82%). Thirty-nine percent of EDs participate in a project to improve hand hygiene compliance. Staff hand hygiene compliance rates were audited at least monthly in 45% of EDs. Forty-three percent reported a compliance rate of 80% or more. The only independent predictor of greater than 80% hand hygiene compliance was auditing compliance frequently - at least monthly (odds ratio 6.3, 95% confidence interval 1.7-24, P=0.01). A majority of Swedish EDs (58%) have a written policy for the appropriate use of urinary catheters. Twenty-one percent participate in a project to reduce catheter-associated urinary tract infections.

    CONCLUSION: A minority of Swedish EDs are participating in projects to address hand hygiene and catheter-associated urinary tract infection. Frequent auditing of hand hygiene compliance may improve compliance rates.

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