To Örebro University

Background: The ambulance service in Sweden has most often only crystalloids as resuscitation, even though restrictive use of clear fluids in bleeding patients is recommended. The aim of this study was to describe the treatment and outcome of bleeding patients treated by the ambulance service.

Methods: This was a prospective observational multi-center study. Ambulance organizations in six different regions were invited to participate, each of them for a period of six months. Adult bleeding patients where fluid resuscitation with crystalloids was initiated by the ambulance service was consecutively included. Prehospital data on type of bleeding, mechanism and severity of injury, vital signs, estimated bleeding volume, treatment and transport time was collected from the ambulance service. Results from laboratory tests and data of transfusion requirements and mortality were obtained from the medical records, after hospital admission.

Results: 181 patients were resuscitated with crystalloid fluids by the ambulance service and were included in the study. Gastrointestinal bleeding was the cause of fluid resuscitation in 48% of the patients and bleeding due to trauma in 23%. A high proportion of the patients (41%) had a coagulopathy upon admission at the hospital, defined as prothrombin time > 1,2, platelet count < 150 x 10(9)/L and/or activated prothrombin time > 32 s. Shock Index (SI) was 1.2 (mean) (SD 0.4). The mean volume of crystalloid fluids administered was 626 mL (SD 366), with one third of the patients receiving 1000 mL or more. Tranexamic acid was administered to 28% of the patients. Blood transfusions were given to 50% of the patients upon hospital admission. SI more than 1.3 predicted need of blood transfusions and bleeding > 500 mL predicted increased 24 h mortality. The overall 24-hour mortality was 7.2% and in patients with blood loss greater than 500 mL, the mortality rate was 12.1%.

Conclusion: In this study gastrointestinal bleeding and trauma were the leading causes of severe prehospital bleeding. Blood loss over 500 mL and Shock Index above 1.3 were key predictors of poor outcome, highlighting the potential benefit of earlier blood product administration.

Introduction: Advanced cancer surgery has been centralized according to the Sweden National Specialised Medical Care system. Knowledge about how patients experience having surgery far from home is lacking.

The aim was to describe the transition experience of elective cancer surgery within the National Specialised Medical Care, including the recovery at the local hospital and returning home.

Method: Individual interviews was conducted with 20 patients who had undergone cancer surgery between the years 2016 – 2023. The Meleis' Transition Theory was the theoretical framework and content analysis the metod used.

Result: Being fortunate: Being part of the centralized cancer surgery was perceived as an opportunity, which gave hope for a greater chance of survival.

Being alone: The patients found it difficult to be alone, and away from their family. Loneliness was perceived to have a negative impact on recovery.

Having to adapt to the system: Patients had no choice but to trust the system. The healthcare system was not always perceived to consider the patient's individual needs.

A need for personal engagement: Communication and coordination within and between the hospitals, was perceived as inadequate. Some patients felt that they needed to organise their own examinations, surgery, and return appointments.

Discussion: Established and well-functioning communication and coordination channels between patient and caregiver are important for a well-functioning system. Care needs to be organised in accordance with the needs and wishes of patients. Staff at all relevant units need to have knowledge of the complexity of the surgery to understand the transition experience and the patient's unique needs.

Background: Workplace violence is a widely recognised problem within the ambulance service context. The causes of workplace violence have often been attributed to patient- or situation-related risk factors. However, there is a lack of research on workplace violence from the offender's perspective.

Aim: To explore workplace violence directed toward ambulance services from the offender's perspective.

Methods: An explorative qualitative study was conducted using inductive thematic analysis of trial transcripts from cases tried in court between 2013 and 2023. Plaintiffs in these cases were ambulance personnel or the ambulance service itself. Offenders were those convicted of committing or attempting any of the following acts: threats, theft, assault, molestation or murder.

Results: Twenty-three trial transcripts were analysed, and four themes were found: (I) the offender was misunderstood, which included communication problems and other misunderstandings; (II) the offender was disrespected, which described perceived unprofessional behaviour and unpleasant or painful treatment by ambulance personnel; (III) the offender was vulnerable, which described the state of the offender (i.e., being under the influence of alcohol or drugs); and (IV) the offender had unmet expectations, which included perceived unreasonable waiting time and conflicting expectations of ambulance care.

Conclusion: The analysis of trial transcripts revealed four themes from the offender perspective: feelings of being misunderstood, disrespected, vulnerable, and having unmet expectations. It is important to view these results critically, as they are based on trial transcripts in which the offender was found guilty of a crime and may have been attempting to defend his or her actions during the trial. Despite this caveat, healthcare professionals need also to recognise that their behaviour may influence the risk of workplace violence. This knowledge can be harnessed to develop training programs for ambulance personnel.

BACKGROUND: An increasing number of patients receive ambulance care without being conveyed to a definitive care provider. This process has been described as complex, challenging, and lacking in guideline support by EMS clinicians. The use of quality- and outcome measures among non-conveyed patients is an understudied phenomenon.

AIM: To identify current quality- and outcome measures for the general population of non-conveyed patients in order to describe major trends and knowledge gaps.

METHODS: A scoping review of peer-reviewed original articles was conducted to identify quality- and outcome measures for non-conveyance within emergency medical services. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews statement (PRISMA-ScR) was followed. The PROSPERO and OSF database were checked for pending reviews or protocols. PubMed, CINAHL, Scopus, Web of Science and the Cochrane Library database were searched for relevant articles. Searches were performed in November 2023.

RESULTS: Thirty-six studies fulfilled the inclusion criteria and were included in the review. Mortality was the most used outcome measure, reported in 24 (67%) of the articles. Emergency department attendance and hospital admission were the following most used outcome measures. Follow-up durations varied substantially between both measures and studies. Mortality rates were found to have the longest follow-up times, with a median follow-up duration a little bit over one week.

CONCLUSIONS: This scoping review shows that studies report a wide range of quality and outcome measures in the ambulance setting to measure non-conveyance. Reported quality and outcome measures were also heterogeneous with regard to their follow-up timeframe. The variety of approaches to evaluate non-conveyance poses challenges for future research and quality improvement. A more uniform approach to reporting and measuring non-conveyance is needed to enable comparisons between contexts and formal meta-analysis.

OBJECTIVE: To measure the 1 year cumulative incidence of and analyse the risk factors associated with workplace violence directed towards the ambulance service in a Swedish region. DESIGN: Prospective cohort study.

SETTING: The ambulance services in Örebro County Council (Sweden) contain approximately 300 000 inhabitants.

PARTICIPANTS: All ambulance missions during the period of 12 months (n=28 640) were assessed.

PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was workplace violence together with the associated risk factors.

RESULTS: The 1 year cumulative incidence of workplace violence within the ambulance service was 0.7%. Non-physical violence was most common. There was an increased odds for violence when the patient was under the influence of alcohol or drugs or suffering from mental illness. There was an association between the dispatch categories intoxication, unconsciousness or mental health problems and workplace violence against ambulance personnel. The offenders were mostly men aged 18-29 and workplace violence was more likely to occur in public places.

CONCLUSIONS: The 1 year cumulative incidence of workplace violence within the regional ambulance service was low in comparison to that of previous research. The overall regression model had low explanatory power, indicating that the phenomenon is complex and that additional variables need to be taken into account when trying to predict when workplace violence will occur. Additional research is needed to fully understand why workplace violence within the ambulance service occurs and how to mitigate such situations.

Objectives Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response times in future medical emergencies. This study aimed to scope the current research on dynamic ambulance relocation.

Design A scoping review was conducted using a structured search in PubMed, Scopus and Web of Science. In total, 21 papers were included.

Results Most papers described research with experimental designs involving the use of mathematical models to calculate the optimal use and temporary relocations of ambulances. The models relied on several variables, including distances, locations of hospitals, demographic-geological data, estimation of new emergencies, emergency medical services (EMSs) working hours and other data. Some studies used historic ambulance dispatching data to develop models. Only one study reported a prospective, real-time evaluation of the models and the development of technical systems. No study reported on either positive or negative patient outcomes or real-life chain effects from the dynamic relocation of ambulances.

Conclusions Current knowledge on dynamic relocation of ambulances is dominated by mathematical and technical support data that have calculated optimal locations of ambulance services based on response times and not patient outcomes. Conversely, knowledge of how patient outcomes and the working environment are affected by dynamic ambulance dispatching is lacking. This review has highlighted several gaps in the scientific coverage of the topic. The primary concern is the lack of studies reporting on patient outcomes, and the limited knowledge regarding several key factors, including the optimal use of ambulances in rural areas, turnaround times, domino effects and aspects of working environment for EMS personnel. Therefore, addressing these knowledge gaps is important in future studies.

Background

There is an increasing demand for ambulance services and more patients than before are requesting ambulance assistance for low acuity conditions. Ambulance services non-convey patients because they lack acute care needs. Non-conveying patients can be a person-centred, resource- and cost-efficient measure and can allow the ambulance to become available sooner for patients with more acute illnesses or injuries. However, validated non-conveyance guidelines are lacking and non-conveying patients raises patient safety issues.

Aim

The overarching aim of the research project was to describe the patients that were non-conveyed, to explore if there were any potential patient safety issues with the regional non-conveyance guidelines, and to describe how patients and nurses experience non-conveyance.

Methods

All non-conveyance assignments during one year in a region in Sweden (n=2691) were consecutively and prospectively included. The quantitative data was described, compared, and analysed (Studies I and II). Two interview studies were carried out. Phenomenography and conventional content analysis were used to analyse the qualitative data. In total 14 patients were interviewed in Study III and 20 nurses were interviewed in Study IV.

Conclusions

Patients of all ages with varying characteristics and complaints were non-conveyed. No patient received intensive care, and few were admitted to in-hospital care or died within seven days after being non-conveyed. Older age increases the risk of hospitalisation and death. Patients could feel ashamed for being non-conveyed, and the ambulance nurse could feel frustration when believing that the ambulance resource was misused

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.

Introduction: Over time, ambulance assignments have increased in number both nationally and internationally, and a substantial proportion of patients encountered by emergency medical services are assessed as not being in need of services. Non-conveying patients has become a way for emergency medical services clinicians to meet this increasing workload. It has been shown that ambulances can be made available sooner if patients are non-conveyed, but there is no previous research describing the factors that influence the non-conveyance time.

Study objective: To describe ambulance time consumption and the factors that influence time consumption when patients are non-conveyed.

Methods: A prospective observational review of 2615 non-conveyed patients' ambulance and hospital medical records was conducted using a consecutive sample. Data were analysed with the Kruskal-Wallis test, Mann-Whitney U test and Spearman's rank correlation (rho) for linear correlations.

Results: The mean NC time for all ambulance assignments during the study period was 26 minutes, with a median of 25 minutes. The shortest NC time was 4 minutes, and the longest NC time was 73 minutes. NC times were significantly faster during the day than at night.

Conclusions: This study provides new knowledge about time consumption when patients are non-conveyed. Although there are time differences when patients are non-conveyed, the differences observed in this study are small and not of clinical value. Ambulances will most often become available sooner if patients are non-conveyed. Although patients might be eligible for non-conveyance, policy-makers might have to decide when it is appropriate to non-convey patients from time, resource, patient safety and patient-centred care perspectives.

Background: There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data.

Methods: A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients' medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test.

Results: Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women.

Conclusions: Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.