To Örebro University

BACKGROUND: This study aimed to describe the characteristics of frequent users of ambulance services and their corresponding ambulance missions.

METHODS: A retrospective cohort study using register data from a Swedish region (approximately 308,000 inhabitants) was conducted. The dataset covered ambulance missions dispatched between 2019 and 2023; data from 2020-2022 were analyzed, with the extended timeframe (2019-2023) used to identify frequent users. Frequent users were defined as patients with four or more ambulance missions within a 365-day period, divided into moderate (patients with 4-11 missions within 365 days) and high-frequency users (≥ 12 missions within 365 days). Missions associated with these users were referred to as frequent, moderate-frequent, high-frequency, or non-frequent ambulance missions.

RESULTS: Between 2020 and 2022, 73,461 ambulance missions were utilized by 41,407 unique patients. Of these 41,407 patients, 8.4% were frequent users (7.9% moderate and 0.5% high-frequency users), but accounted for 29.0% of all ambulance missions. The remaining 91.6% were non-frequent users, accounting for 71.0% of the ambulance missions. Frequent users were older than non-frequent users (median age 75 vs 62, p < .001). Frequent ambulance missions were more often dispatched for dyspnoea (17.8% vs 11.6%, p < .001), convulsions (4.2% vs 2.1%, p < .001), and abdominal pain (10.5% vs 8.7%, p < .001) compared with non-frequent ambulance missions. Frequent ambulance missions were also more likely to be assigned to a higher triage level, and 77.7% resulted in transport to the emergency department. Compare to moderate-frequent ambulance missions, high-frequency missions were more often dispatched for psychiatric emergencies (6.2% vs 2.1%, p < .001) and intoxications (5.3% vs 2.0%, p < .001), and more frequently resulted in transport to psychiatric emergency care (3.6% vs 1.4%, p < .001), or not being conveyed (24.0% vs 16.1%, p < .001).

CONCLUSIONS: Frequent ambulance users account for a large proportion of all ambulance missions. The results indicate that frequent users are often in need of emergency care, and understanding this population's needs is essential to ensure appropriate care. However, the group is heterogeneous and can be divided into frequent and high-frequency users, which have different characteristics. We suggest that future research investigates system-level approaches to identify frequent ambulance users and implement care plans to address patients' needs and reduce ambulance utilisation.

OBJECTIVE: To describe postoperative analgesic regimens and patient-reported pain-related outcomes after tonsil surgery.

METHODS: Cohort study including perioperative data (n = 9274) and patient-reported outcome measures (n = 5080) registered in the Swedish Quality Register for Tonsil Surgery during 2023.

RESULTS: After tonsil surgery, 92.7% received at least paracetamol and a NSAID/COX inhibitor, while 6.8% received no NSAID/COX inhibitor. Opioids were prescribed after tonsillectomy to 62.9% of adults and less often to adolescents and children (13-17-year-olds: 48.2%, 6-12-year-olds: 8.8%, 0-5-year-olds: 4.0%). Clonidine was frequently prescribed to 0-5-year-olds after tonsillectomy (54.4%). Overall, 11.7% reported dissatisfaction with the pain treatment, with the highest dissatisfaction rate after tonsillectomy in adolescents (20.6%) and adults (20.0%), and the lowest after tonsillotomy in children (4.9-6.8%). The most common complaint among dissatisfied patients was analgesics not being sufficiently helpful. Adult patients who received addition of opioids were less dissatisfied with the pain treatment (15.9% vs. 25.9%, p < 0.001), but also reported more side effects (5.7% vs. 2.7%, p = 0.039), compared with patients who received only paracetamol and NSAID/COX inhibitors.

CONCLUSION: Tonsil surgery patients in Sweden receive various analgesic regimens. Although most are satisfied with pain treatment, there is room for improvement, particularly among adolescents and adults undergoing tonsillectomy. Paracetamol and a NSAID/COX inhibitor seem advisable as basic treatment. However, many patients need more effective treatment. The addition of opioids in adults results in greater satisfaction with pain treatment, but safety issues with opioid prescriptions must be taken into consideration.

LEVELS OF EVIDENCE: Level 4 Laryngoscope, 2024.

BACKGROUND: Postoperative bleeding after tonsillectomy is a potentially serious complication. Cold techniques reduce bleeding risks, but hot techniques remain widely used, reflecting national variations in clinical practice.

AIMS/OBJECTIVES: This study aimed to investigate postoperative bleeding rates after tonsillectomy and their correlation with demographic factors and surgical and haemostatic techniques, using data from national tonsil surgery registries in Norway and Sweden.

MATERIALS AND METHODS: A prospective cohort study included 28,254 tonsillectomies (2017-2022), with patients completing a 30-day postoperative questionnaire. Data on indication for surgery, surgical and haemostatic technique and postoperative bleeding were analyzed using multivariate logistic regression.

RESULTS: Postoperative bleeding was reported in 7.2% of the patients, with higher rates in Norway (8.1%) compared to Sweden (6.3%). A hot + hot technique significantly increased the bleeding risk (OR 3.64), while the cold + cold technique had the lowest rate. Patients aged 19-24 years and males had higher bleeding risks.

CONCLUSIONS AND SIGNIFICANCE: The cold + cold technique significantly reduces postoperative bleeding, but the cold + hot technique remains the most utilized approach. Norway performed more surgeries in high-risk age groups and had less frequent use of the cold + cold technique compared to Sweden. Increased adoption of the cold + cold technique may improve outcome in tonsil surgery.

Background: Many patients who receive palliative home care wish to die at home, even when the symptom of the disease deteriorates. Despite this, large number of patients die in hospital. 

Aim: To map the occurrence of patients receiving specialized palliative home care being transported to hospital near death in Sweden. 

Methods: A national retrospective cross-sectional study based on data from the Swedish Register of Palliative Care. Patients ≥18 years of age enrolled in specialized palliative home care with dates of death 2015 11 01 – 2022-10-31 were included (n= 39,698). Descriptive statistics were used to compare patients who were transported to hospital and died there within seven days of arrival, and patients who were not transported or transported earlier than seven days before death.

Results: Of the total study population, 7,383 patients were identified as dying in hospital/other care unit within 7 days of transport from specialized palliative home care. The majority (74%) were admitted to a specialized palliative care unit, 23% to a non-specialized palliative care unit and 3% to additional care units. Most patients died 1-2 days after arriving at the hospital. No clinical relevance differences were noted regarding sex, age, or diagnosis when comparing transported patients with non-transported patients, whereas the transported patients had more frequent dyspnea (31% vs. 23%, p <0.001) and anxiety (60% vs. 57%, p<0.001). Presence of several simultaneous symptoms was significantly more common in the transported group (27% vs. 25%).

Conclusion: Many patients enrolled in specialized palliative home care were transported and died in hospital. Most died 1-2 days after arrival. They had complex symptoms and not all patients were admitted to a specialist palliative care unit. Some common denominators, such as symptoms and symptom burden, can be noted in the patients who are transported, but more studies are needed to identify the causal relationship of these transports.

OBJECTIVE: The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS).

MATERIALS & METHODS: A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries).

RESULTS: Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy.

CONCLUSION: The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.

Patients near death being transported to emergency care despite receiving specialized palliative home care - A registry study

Background: A significant proportion of patients who receive palliative home care express a preference for dying at home, even when the symptoms of their disease deteriorate. Despite this, a large number of patients die in hospital, suggesting that patients are transported from home to emergency care. These transports can mean that dying patients end up in the emergency department, a place that is less suited to end-of-life care. The emergency department environment poses great challenges for emergency nurses trying to care for patients near death. Lack of space, time and staff are cited as the main barriers.   

The aim of this study was to map data on patients near death who had received specialized palliative home care and were transported to hospitals in Sweden.

Method: A national retrospective cross-sectional study was conducted using data from the Swedish Register of Palliative Care. The study included patients aged 18 years or above who were enrolled in specialized palliative home care and who died between 1 November 2015 and 31 October 2022 (n=39,698). Descriptive statistics were utilized to contrast patients who were transported to hospital and subsequently died within seven days of arrival, with patients who were not transported or transported earlier than seven days before death.

Results: A total of 7,383 patients were identified as having died within seven days of being transported from specialized palliative home care to a hospital or other care unit. The majority (74%) were admitted to a specialized palliative inpatient care unit, 23% to a non-specialized palliative inpatient care unit, and 3% to additional care units. The majority of these patients died within one to two days of arrival at the hospital. No clinical relevance was observed in the comparison of transported patients with non-transported patients with regard to sex, age, or diagnosis. However, transported patients exhibited a higher prevalence of dyspnoea (31% vs. 23%, p <0.001) and anxiety (60% vs. 57%, p <0.001). The simultaneous occurrence of multiple symptoms (e.g., confusion/anxiety, pain/severe pain, dyspnoea/respiratory secretion) was significantly more prevalent in the transported group (27% vs. 25%).

Discussion & Conclusions: A significant proportion of patients enrolled in specialized palliative home care were transported to hospital and subsequently died there. The majority of patients died within one or two days of admission. Complex symptoms were present, and not all patients were admitted to a specialized palliative inpatient care unit. Some commonalities, such as symptoms and symptom burden, can be observed in the patients who were transported. However, further studies are required to identify the causal relationship between these transports. Our study visibilises a phenomenon that can be experienced by the involved patients, relatives, and healthcare personnel as a major event in a vulnerable situation. We see a necessity to gain a deeper understanding of the underlying reasons for this type of transport and whether they are compatible with good palliative care and a dignified death.

Background: The majority of palliative care patients express a preference for remaining at home for as long as possible. Despite progression of disease there is a strong desire to die at home. Nonetheless, there are transfers between care settings, demonstrating a discrepancy between desired and actual place of death.

Aim: To map the prevalence of patients near death undergoing specialized palliative home care and being transferred to inpatient care in Sweden.

Methods: A national retrospective cross-sectional study based on data from the Swedish Register of Palliative Care. Patients >= 18 years of age enrolled in specialized palliative home care with dates of death between 1 November 2015 and 31 October 2022 were included (n = 39,698). Descriptive statistics were used.

Results: Seven thousand three hundred eighty-three patients (18.6%), approximately 1,000 per year, were transferred to inpatient care and died within seven days of arrival. A considerable proportion of these patients died within two days after admission. The majority (73.6%) were admitted to specialized palliative inpatient care units, 22.9% to non-specialized palliative inpatient care units and 3.5% to additional care units. Transferred patients had more frequent dyspnoea (30.9% vs. 23.2%, p < 0.001), anxiety (60.2% vs. 56.5%, p < 0.001) and presence of several simultaneous symptoms was significantly more common (27.0% vs. 24.8%, p 0.001).

Conclusion: The results show that patients admitted to specialized palliative home care in Sweden are being transferred to inpatient care near death. A notable proportion of these patients dies within two days of admission. Common features, such as symptoms and symptom burden, can be observed in the patients transferred. The study highlights a phenomenon that may be experienced by patients, relatives and healthcare personnel as a significant event in a vulnerable situation. A deeper understanding of the underlying causes of these transfers is required to ascertain whether they are compatible with good palliative care and a dignified death.

Objectives: The primary aim of this study was to describe pain treatment in relation to surgery of the tonsils in Sweden. The secondary aim was to determine the impact of the provider’s regimens of analgesic treatment on the patient reported pain-related outcome measures (pain-PROMs) from National Tonsil surgery Register in Sweden (NTSRS).

Methods: A descriptive cross-sectional study based on a web-questionary enrolled one respondent from 47 out of 48 invited ENT-clinics in Sweden. Pain-PROMs from the NTSRS were included.

Results: Pre-emptive analgesia pre- and intraoperatively was paracetamol (100%), normally administered iv, and cox-inhibitors iv (74%). To prevent pain and nausea, betamethasone iv (92%/n=43) was administered. Paracetamol combined with cox-inhibitors (Ibuprofen) were recommended by all clinic as a basic analgesic regime postoperatively. The clinics usually prescribed (66%) higher dose of paracetamol day 1-3, followed by a reduced dose days 4-8. Additional rescue analgesics were prescribed after tonsillectomy to older children (62%/n=29), and to young children by 43%/n=20. The most common rescue analgesic was clonidine (55%), followed by oxicodon (34%), morphine (4%), and ketobemidone (2%). Pain-PROMs (NTSRS) showed the frequency of contacts with healthcare due to pain in children (15%). There was no significant difference in percentage of contacts due to pain regarding if clinics routinely prescribed rescue analgesics after tonsillectomy or not.

Conclusions: The national analgesic regime after tonsil surgery is overall good. Despite this, there is a need for rise in awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the complexity of pain management after tonsil surgery. 

Kartläggning av transporter till sjukhus av patienter nära livets slut som får specialiserad palliativ hemsjukvård - en nationell registerstudie

Camilla Wall 1,2, Karin Blomberg 2, Elisabeth Bergdahl 2, Helena Sjölin 2 & Fredrik Alm 2

1 Onkologiska kliniken, Universitetssjukhuset Örebro, Region Örebro Län

2 Institutionen för Hälsovetenskaper, Fakulteten för Medicin och Hälsa, Örebro universitet

Bakgrund: Tidigare forskning visar att majoriteten av patienter som erhåller palliativ vård i hemmet har en önskan om att få dö där. Viljan att få dö i hemmet kvarstår i de flesta fall även när symtomen av sjukdomen intensifieras. Samtidigt har det visat sig att det sker transporter till sjukhus av patienter nära livets slut som erhåller specialiserad palliativ hemsjukvård.

Frågeställning: Att kartlägga förekomsten av transporter till sjukhus av patienter nära livets slut som vårdas med specialiserad palliativ hemsjukvård i Sverige.

Metod: En nationell retrospektiv tvärsnittsstudie baserad på data från Svenska Palliativregistret. Patienter inskrivna i specialiserad palliativ hemsjukvård med dödsdatum 2015 10 31 – 2022-10-31 inkluderades.

Resultat: Totalt 7 383 patienter identifierades dö på sjukhus/annan vårdenhet inom 7 dagar från transport från specialiserad palliativ hemsjukvård. Vanligast var att de transporterade avled på sjukhuset dygn 1-2 efter ankomst. Av dessa patienter blev majoriteten (74%) inlagda på en specialiserad palliativ vårdavdelning, medan 23% blev inskrivna på icke-specialiserade palliativa vårdavdelningar och 3% till övriga vårdenheter. Vid jämförelse med patienter som inte transporterades eller transporterades tidigare än 7 dagar från dödstillfället (n= 32 315), noterades inga signifikanta skillnader av klinisk relevans beträffande kön, ålder eller diagnos. Båda grupperna hade en komplex symtombild, men signifikant fler patienter i den transporterade gruppen uppvisade symtom som andnöd (31% vs. 23%, p <0.001) och ångest (60% vs. 57%, p <0.001). Förekomst av flera samtidiga symtom (förvirring/ångest, smärta/svår smärta, andnöd/rosslighet) var vanligare i den transporterade gruppen (27% vs. 25%).   

Konklusion: Stort antal patienter inskrivna i specialiserad palliativ hemsjukvård transporteras och dör på sjukhus. Patientgruppen har komplex symtombild och alla patienter blir inte inskrivna på en specialiserad palliativ vårdavdelning när de anländer till sjukhus. Vissa karaktäristiska kan noteras hos dem som transporteras, men fler studier är nödvändiga för att kunna identifiera orsakssambandet till att dessa transporter sker.