To Örebro University

Alert fatigue remains a major barrier to the effective deployment of predictive models in emergency care, particularly in the context of rare but critical outcomes such as in-hospital mortality (IHM), which often occurs in less than 5.0% of patients admitted from the emergency department (ED). Severe class imbalance leads to low positive predictive value (PPV), undermining the clinical utility of even high-performance predictive models. To address this issue, we propose AI-TEW (Artificial Intelligence-powered Tiered Early Warning), a novel two-stage early warning framework designed to reduce false alarms and improve clinical interpretability. In Stage 1, a robust machine learning model was developed and validated using data from 174,292 ED visits across three hospitals in China and the United States. The model demonstrated strong discriminative ability for IHM prediction, achieving AUROCs ranging from 0.84 (95% CI, 0.81-0.86) to 0.91 (95% CI, 0.90-0.91) in internal and external validation cohorts. In Stage 2, AI-TEW implements a tiered risk stratification strategy by optimizing decision thresholds to prioritize high-risk patients, thereby increasing PPV from baseline levels of 9.8-18.8% to 32.5-40.5% across sites, while maintaining a high negative predictive value (NPV) of over 98% for low-risk individuals. To further refine alert precision, a knowledge-based filtering layer is introduced, leveraging large language models (LLM) to interpret patient-specific risk factors derived from SHAP (Shapley Additive exPlanations) method. Integrating explainable AI with clinical reasoning enhances contextual understanding and reduces spurious alerts, leading to an 11.53% increase in PPV in external validation (p = 0.0092 for MedGemma). By integrating improved predictive efficiency with interpretable, knowledge-informed filtering, AI-TEW reduces alert burden while supporting timely clinical intervention, demonstrating a promising approach to mitigating the impact of class imbalance in emergency risk prediction.

Painful procedures requiring sedation and analgesia are commonly performed in pediatric emergency departments. However, there is little knowledge about the possible delayed effects of procedural sedation and analgesia on children's behavior. The aim of the current study was to examine children's behavioral changes 4 weeks after procedural sedation and analgesia with intranasal dexmedetomidine and nitrous oxide. Parents of the children who participated in a clinical trial comparing intranasal dexmedetomidine and nitrous oxide for procedural sedation and analgesia during painful procedures were interviewed 4 weeks after procedural sedation and analgesia. The Post Hospitalization Behavior Questionnaire was used for the parental interviews by phone to evaluate changes in children's behavior. Behavioral changes were reported in 13 of 128 (10.2%) children, of which eight experienced negative behavioral changes and five positive changes. Young age was associated with negative behavioral changes; median age was 5.7 years in children with negative behavioral changes and 9.4 years in children with no behavioral changes (p-value 0.0062). Children with negative behavioral changes were less likely to accept the same method for procedural sedation and analgesia in the future (p-value 0.049) as were their parents (p-value 0.012). Parents of children with negative behavioral changes were less satisfied with the general management of procedural sedation and analgesia than parents whose children did not experience negative changes (p-value 0.024). No association with higher pain scores during the procedure and negative behavioral changes was seen. Behavioral changes are uncommon 4 weeks after procedural sedation and analgesia with intranasal dexmedetomidine or nitrous oxide for painful procedures such as fracture reduction.

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.

The host immune response in sepsis involves both pro- and anti-inflammatory mechanisms, with monocytes playing a central role in the process. We have previously identified an in vitro response profile of endotoxin (LPS) tolerant primary human monocytes, consisting of eight cytokines/chemokines as well as a set of five transcription factors. In the current study, we evaluated differences in expression levels of these investigated molecular markers across different patient groups (patients with or without infection, and with or without sepsis), and their association with clinical outcomes (septic shock and in-hospital mortality), among 809 ambulance patients. The results showed that patients with sepsis displayed the lowest HLA-DRA expression levels together with the lowest TNF/IL-10 ratio, while most other cytokine/chemokines and gene expressions were elevated. Higher levels of HGF, CCL8, CCL2, TNF and IL-10, as well as upregulation of HIF1A and NFKBIA were seen in septic patients with septic shock. The data suggests that the investigated immunological markers linked to immunosuppressed monocyte responses are associated with patients with sepsis and septic shock.

Objectives: Disposition decisions in emergency departments involve multiple, often conflicting objectives. This study aimed to develop avalue assessment framework, expressed as a hierarchy of objectives, based on emergency physicians' values.

Methods: We used value-focused thinking to analyze the disposition decision through semi-structured interviews with thirteen emergency physicians in Sweden. A hierarchy of objectives was developed through content analysis and refined through iterative group interviews with the participants.

Results: Three fundamental objectives were identified: maximizing patient health, maximizing alignment with patient preferences, and maximizing healthcare equity. Maximizing patient healthencompassed minimizing morbidity and mortality risk while maximizing wellbeing. Maximizing healthcare equity required balancing individual patient needs against those of other patients in the ED, hospital, and broader healthcare system.

Conclusions: This study conceptualizes the disposition decision as a value-based decision about subsequent care after an ED visit. The hierarchy of objectives provides a transparent framework for analyzing value conflicts, supporting stakeholder communication, and facilitating the development and evaluation of disposition alternatives.

BACKGROUND: Inability to walk (IATW) has predicted mortality in emergency units in low-income settings, but its value among inpatients in high-income countries is unknown. AIM: To evaluate the predictive accuracy of IATW for 30-day in-hospital mortality among inpatients in a high-income country, compare its performance with NEWS CRITICAL (the threshold for urgent review), and assess whether IATW provides complementary risk stratification when combined with NEWS.

METHODS: All adult inpatients in four Swedish hospitals were prospectively examined in a multicenter point-prevalence assessment. IATW was defined as inability to walk five steps without physical assistance or walking aids. NEWS was calculated from contemporaneous vital signs. The primary outcome was 30-day in-hospital mortality. We computed sensitivity, specificity, predictive values, and likelihood ratios. Multivariable logistic regression assessed the association between IATW and mortality, adjusted for NEWS, age, and sex.

RESULTS: Of 1842 patients, 59.9% were IATW-positive and 22.3% met NEWS CRITICAL (≥5 or any single-parameter score of 3). Mortality was 4.6%. IATW had higher sensitivity (86.9% vs 66.7%) but lower specificity (41.4% vs 79.8%) than NEWS CRITICAL; NPV was high for both (98.5% vs 98.0%). IATW was independently associated with mortality after adjustment for NEWS (OR 2.43, 95% CI 1.24-4.76; p = 0.009). Those both IATW-negative and with NEWS <5 (35.2% of the cohort) had 1.1% mortality.

CONCLUSIONS: Inability to walk (IATW) is a bedside assessment that when negative identifies patients with low 30-day in-hospital mortality and provides complementary information to NEWS. Its low complexity, high sensitivity and low negative likelihood ratios support its use in clinical risk assessments.

Introduction: The ageing of the population is expected to increase the costs and consumption of health care. Care should be patient-centred. Patient-centred care (PCC) has been shown to increase the quality of life for older patients living with frailty, as well as reduce health care costs. As one of the core principles of PCC, it is important to investigate and consider patients' wishes regarding their care.

Aim: The aim of this study was to investigate and identify factors and information that older patients find important when planning for their care.

Methods: Sixteen patients at the geriatric ward at & Ouml;rebro University Hospital in Sweden were interviewed using focus group discussions. The patients were >= 65 years of age, spoke Swedish, and were cognitively and physically able to participate in a focus group discussion. The interviews were recorded, transcribed, and analysed using content analysis.

Results: Three main categories were formed to summarize what mattered most to the patients when planning their care were that they maintained autonomy, that no harm was done and that the care had a holistic approach. These were further divided into the subcategories: the right to be well informed, taking part in planning of their care, having accessible care and a feeling of safety and security, considering emotional wellbeing, including relatives and close friends and maintaining their wellbeing.

Conclusions: What mattered most to the patients was closely related to the World Health Organization's recommendations for ethical and good quality health care. Generally, the patients agreed on what mattered most. Further studies are needed to enrich the understanding of what is important to older patients.

BACKGROUND: Despite increasing interest in the occurrence of workplace violence in ambulance services, few studies have explored the phenomenon from the perspective of the ambulance personnel. While previous studies have identified its incidence and risk factors, this study aimed to explore ambulance personnel's understanding of why workplace violence occurs.

METHODS: An inductive, qualitative study was conducted using digital focus group interviews. The inclusion criteria were as follows - having worked in ambulance services for a minimum of two years and having personally experienced workplace violence. Reflexive thematic analysis was employed in this study.

RESULTS: Three focus group interviews with 10 Swedish ambulance personnel were included in the study. Three themes were identified: (I) ambulance personnel's lack of competence and willingness to adapt can lead to workplace violence; (II) ambulance personnel's inability to cope with their emotional response to provocation can lead to workplace violence; and (III) experiencing limited control in unpredictable situations. Workplace violence occurred when the ambulance personnel lacked empathy and compassion for the patient, acted disrespectfully, or when the power imbalance between ambulance personnel and the patient became apparent. If ambulance personnel felt provoked by the patient's behaviour, it triggered workplace violence. Furthermore, if they could not read the situation and lost control of it or if the patient's behaviour was unpredictable (e.g. if the patient was under the influence of drugs or alcohol), workplace violence ensued.

CONCLUSIONS: Ambulance personnel need to acknowledge their own contributions to the risk of workplace violence and identify situations and actions that could both increase and decrease the risk of exposure. Future studies should focus on implementing interventions to identify potential high-risk situations and train ambulance personnel to deescalate risky situations.

INTRODUCTION: As people age, frailty becomes increasingly prevalent and is associated with adverse outcomes, including higher risks of hospitalisation, institutionalisation and mortality. Early identification of frailty in ambulance and emergency department (ED) settings may support clinical decision-making and help predict outcomes for older patients. However, there is currently no consensus on how frailty should be assessed in these settings, and the clinical usefulness of available tools remains uncertain. This protocol outlines the methods for a planned scoping review that aims to identify frailty screening tools used for older adults (age ≥65 years) in the ambulance and ED settings and to evaluate existing evidence on their clinical usefulness.

METHODS AND ANALYSIS: This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Protocols, and the final review will follow the Joanna Briggs Institute methodology and is reported in accordance with the PRISMA extension for Scoping Reviews guidelines. Studies will be included if they examine the use of frailty screening or assessment tools in individuals aged 65 years or older in ambulance and/or ED settings and report on aspects of clinical usefulness, such as feasibility, predictive validity or influence on clinical decisions. A comprehensive literature search will be conducted in PubMed, Embase, CINAHL, Scopus and Web of Science for studies published in English between January 2014 and December 2025. To refine the search strategy, an initial systematic pre-search was performed in PubMed using Medical Subject Headings terms, followed by a pilot study. A sample pilot screening of 101 references identified in the pre-search was conducted as a support for finalising the search. Ten of the papers in the pre-screening were furthermore used as a support for testing and validating the data extraction variables and quality assessment procedures. In the full scoping review, study selection and data extraction will be independently conducted by two reviewers using the Covidence software (Veritas Health Innovation, Melbourne, Australia), with any discrepancies resolved by a third reviewer. Extracted data will be summarised in tabular format and analysed through narrative synthesis. The methodological quality of included studies will be evaluated using the quality assessment tool of the National Heart, Lung, and Blood Institute for cohort studies.

ETHICS AND DISSEMINATION: Ethical approval is not required as no primary data will be collected. Findings will be disseminated through publication in a peer-reviewed journal, conference presentations and summaries shared with relevant clinical and research-related stakeholders.