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Ambulance
Terms modified by Ambulance Selected AbstractsCan First Responders Be Sent to Selected 9-1-1 Emergency Medical Services Calls without an Ambulance?ACADEMIC EMERGENCY MEDICINE, Issue 4 2003Craig B. Key MD Objectives: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). Methods: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. Results: For ALERTs (n= 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n= 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. Conclusions: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents. [source] Modeling the Emergency Ambulance Pass-By of Small Rural Hospitals in Victoria, AustraliaTHE JOURNAL OF RURAL HEALTH, Issue 4 2005Patrick Gleeson MBA ABSTRACT: Context: Many small rural hospitals struggle to attract sufficient numbers of suitable patients. Inadequate patient throughput threatens the viability of these hospitals and, consequently, the financial, physical, and social well-being of the whole community. Anecdotal evidence suggests that many emergency ambulance patients are routinely taken past their local small rural hospital to the area's major receiving hospital. Purpose: To quantify the ambulance pass-by of local small rural hospitals and identify the factors that influence its occurrence. Methods: Data were collected from the ambulance and hospital records of 3 small rural centers in central Victoria, Australia. Results: Ambulances transport a significant number of patients past their local small rural hospitals to the area's major receiving hospital. This takes less time for paramedics than bringing a patient to the local hospital first if the patient is then redirected by that hospital to the larger hospital. There is an inverse relationship between the rate of cases in which the local hospital redirects ambulances to the regional hospital and the rate of ambulance crew decisions to use the local hospital. Conclusions: If some patients are being transported directly to the major receiving hospital because paramedics are considering their own time commitments when making patient transport decisions, this could have revenue implications for rural hospitals. Attracting appropriate local ambulance patients to the smaller hospitals may provide an income source that is currently lost to the crowded major receiving hospital's emergency department. [source] Costs of neonatal care for low-birthweight babies in English hospitalsACTA PAEDIATRICA, Issue 7 2009Hema Mistry Abstract Aim:, To estimate mean costs of neonatal care for babies with birthweights ,1800 g in a regional Level 3 unit and three Level 2 units providing short-term intensive care. Method:, Babies ,1800 g admitted to units in four hospitals in England over 15 months in 2001,2002 were audited until discharge. Unit costs (2005,2006 prices) were attributed to their resource items, including neonatal cot occupancy, pharmaceuticals, blood products and ambulance transfers. Bootstrapped mean costs were derived for the Level 3 unit and the Level 2 units combined. Results:, The mean gestation period for 199 Level 3 babies was 29.5 weeks compared with 30.4 weeks for 192 Level 2 babies (p = 0.003). Mean costs excluding ambulance journeys were £17 861 per Level 3 baby and £12 344 per Level 2 baby. Level 3 babies <1000 g averaged £26 815, whereas Level 2 babies <1000 g were generally less costly than babies 1000,1499 g. Ambulances transported 76 Level 3 babies and 62 Level 2 babies; their adjusted mean costs were £18 495 and £12 881, respectively. Conclusion:, By comprehensively costing resource components, the magnitude of total costs for low-birthweight babies has been revealed, thus demonstrating the importance of budgets for neonatal units being realistically determined by commissioners of neonatal services. [source] Clinical and Economic Factors Associated with Ambulance Use to the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 8 2006Jennifer Prah Ruger PhD Background: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. Objectives: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. Methods: This was a retrospective, cross-sectional study of all patients seen during 2001 (N= 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air-medical transport, walk-in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. Results: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0,10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight,8 AM (OR, 2.0; 95% CI = 1.8 to 2.1), and age ,65 years (OR, 1.3; 95% CI = 1.2 to 1.5). Conclusions: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means. [source] The Validity of Using Multiple Imputation for Missing Out-of-hospital Data in a State Trauma RegistryACADEMIC EMERGENCY MEDICINE, Issue 3 2006Craig D. Newgard MD Objectives: To assess 1) the agreement of multiply imputed out-of-hospital values previously missing in a state trauma registry compared with known ambulance values and 2) the potential impact of using multiple imputation versus a commonly used method for handling missing data (i.e., complete case analysis) in a typical multivariable injury analysis. Methods: This was a retrospective cohort analysis. Multiply imputed out-of-hospital data from 1998 to 2003 for four variables (intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate) were compared with known values from probabilistically linked ambulance records using measures of agreement (,, weighted ,, and Bland,Altman plots). Ambulance values were assumed to represent the "true" values for all analyses. A hypothetical multivariable regression model was used to demonstrate the impact (i.e., bias and precision of model results) of handling missing out-of-hospital data with multiple imputation versus complete case analysis. Results: A total of 6,150 matched ambulance and trauma registry records were available for comparison. Multiply imputed values for the four out-of-hospital variables demonstrated fair to good agreement with known ambulance values. When included in typical multivariable analyses, multiple imputation increased precision and reduced bias compared with using complete case analysis for the same data set. Conclusions: Multiply imputed out-of-hospital values for intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate have fair to good agreement with known ambulance values. Multiple imputation also increased precision and reduced bias compared with complete case analysis in a typical multivariable injury model, and it should be considered for studies using out-of-hospital data from a trauma registry, particularly when substantial portions of data are missing. [source] Overdose deaths following previous non-fatal heroin overdose: Record linkage of ambulance attendance and death registry dataDRUG AND ALCOHOL REVIEW, Issue 4 2009MARK A. STOOVÉ Abstract Introduction and Aims. Experiencing previous non-fatal overdoses have been identified as a predictor of subsequent non-fatal overdoses; however, few studies have investigated the association between previous non-fatal overdose experiences and overdose mortality. We examined overdose mortality among injecting drug users who had previously been attended by an ambulance for a non-fatal heroin overdose. Design and Methods. Using a retrospective cohort design, we linked data on non-fatal heroin overdose cases obtained from ambulance attendance records in Melbourne, Australia over a 5-year period (2000,2005) with a national death register. Results. 4884 people who were attended by ambulance for a non-fatal heroin overdose were identified. One hundred and sixty-four overdose deaths occurred among this cohort, with an average overdose mortality rate of 1.20 per 100 person-years (95% CI, 1.03,1.40). Mortality rate decreased 10-fold after 2000 coinciding with widely reported declines in heroin availability. Being male, of older age (>35 years) and having been attended multiple times for previous non-fatal overdoses were associated with increased mortality risk. Discussion and Conclusions. As the first to show a direct association between non-fatal overdose and subsequent overdose mortality, this study has important implications for the prevention of overdose mortality. This study also shows the profound effect of macro-level heroin market dynamics on overdose mortality.[Stoové MA, Dietze PM, Jolley D. Overdose deaths following previous non-fatal heroin overdose: Record linkage of ambulance attendance and death registry data. Drug Alcohol Rev 2009;28:347,352] [source] Why are alcohol-related emergency department presentations under-detected?DRUG AND ALCOHOL REVIEW, Issue 6 2008An exploratory study using nursing triage text Abstract Introduction and Aims. This study examined two methods of detecting alcohol-related emergency department (ED) presentations, provisional medical diagnosis and nursing triage text, and compared patient and service delivery characteristics to determine which patients are being missed from formal diagnosis in order to explore why alcohol-related ED presentations are under-detected. Design and Methods. Data were reviewed for all ED presentations from 2004 to 2006 (n = 118 881) for a major teaching hospital in Sydney, Australia. Each record included two nursing triage free-text fields, which were searched for over 60 alcohol-related terms and coded for a range of issues. Adjusted odds ratios were used to compare diagnostically coded alcohol-related presentations to those detected using triage text. Results. Approximately 4.5% of ED presentations were identified as alcohol-related, with 24% of these identified through diagnostic codes and the remainder identified by triage text. Diagnostic coding was more likely if the patient arrived by ambulance [odds ratio (OR) = 2.35] or showed signs of aggression (OR = 1.86). Failure to code alcohol-related issues was more than three times (OR = 3.23) more likely for patients with injuries. Discussion and Conclusions. Alcohol-related presentations place a high demand on ED staff and less than one-quarter have an alcohol-related diagnosis recorded by their treating doctor. In order for routine ED data to be more effective for detecting alcohol-related ED presentations, it is recommended that additional resources such as an alcohol health worker be employed in Australian hospitals. These workers can educate and support ED staff to identify more clearly and record the clinical signs of alcohol and directly provide brief interventions. [source] The Use of Scripting at Triage and Its Impact on ElopementsACADEMIC EMERGENCY MEDICINE, Issue 5 2010Daniel A. Handel MD Abstract Objectives:, The objective of this study was to measure the effect of scripting language at triage on the likelihood of elopements, controlling for patient volume and other potential confounding variables. Methods:, This was a pre- and postintervention cohort study using the same 5-month period (November 2007,March 2008 and November 2008,March 2009, respectively) that included in the analysis all patients 21 years of age and older, who presented to the triage window in the emergency department (ED) waiting room (not by ambulance). As part of the scripting, triage nurses informed patients of the longest waiting time (at that point in time) for any patients still waiting to be brought back from the waiting room into the ED. Rates of elopement were compared between patients who did and did not receive the scripting, controlling for individual and daily ED variables. Results:, A total of 24,390 ED visits were included in this analysis. The elopement rate was 4.4% among ED patients in the prescripting period, compared to 2.3% in the postscripting period. In a multivariate logistic regression model, the use of scripting was significantly associated with decreased odds of elopement, compared to the nonscripting group (odds ratio [OR] = 0.61, 95% confidence interval [CI] = 0.46 to 0.80). Conclusions:, The use of triage scripting was found to significantly reduce elopement rates in patients placed in the ED waiting room, even after controlling for other confounding variables. Scripting is a simple and underutilized technique that can have a positive effect for patients and the ED. ACADEMIC EMERGENCY MEDICINE 2010; 17:495,500 © 2010 by the Society for Academic Emergency Medicine [source] Emergency management of the morbidly obeseEMERGENCY MEDICINE AUSTRALASIA, Issue 4 2004Peter Grant Abstract Objectives: To identify the difficulties encountered with the emergency management of morbidly obese patients and formulate recommendations to streamline care. Methods: An English language literature search was undertaken using Medline (1966,2003) with key words ,morbid obesity',anaesthesia',imaging',obesity',emergency',transportation',retrieval',critical illness' and ,monitoring'. Potential articles were selected for content applicable to emergency medicine based on title and abstract and reviewed in detail. Reference lists were manually searched for further relevant articles. In view of the very limited systematic study in this area, all information deemed by the authors' to be of assistance to the emergency physician was included regardless of evidence level. Additional information was sought from standard critical care textbooks and their bibliographies and through personal communication with local ambulance and retrieval services. The authors' unpublished personal experience in providing emergency care to the morbidly obese was included for aspects of management not documented in medical literature. Results: Obesity levels and associated health problems are rapidly rising in Australia. Few studies were identified dealing with critical illness in the morbidly obese and none specifically addressing ED management. Problems identified included size related logistical issues, and limitations of physical assessment, monitoring and routine investigations. Invasive procedures, intubation and ventilation can be particularly problematic, and modified techniques may be required. Limited data indicates a poorer outcome from critical illness most marked in the case of blunt traumatic injury. Conclusion: Very obese patients present a variety of logistical and medical challenges for EDs. A series of recommendations are made based on available data. Further studies in this area would be desirable to more specifically address ED issues. [source] Can First Responders Be Sent to Selected 9-1-1 Emergency Medical Services Calls without an Ambulance?ACADEMIC EMERGENCY MEDICINE, Issue 4 2003Craig B. Key MD Objectives: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). Methods: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. Results: For ALERTs (n= 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n= 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. Conclusions: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents. [source] A Comparison of Data Sources for Motor Vehicle Crash Characteristic AccuracyACADEMIC EMERGENCY MEDICINE, Issue 8 2000Robert J. Grant MD Abstract. Objective: To determine the accuracy of police reports (PRs), ambulance reports (ARs), and emergency department records (EDRs) in describing motor vehicle crash (MVC) characteristics when compared with an investigation performed by an experienced crash investigator trained in impact biomechanics. Methods: This was a cross-sectional, observational study. Ninety-one patients transported by ambulance to a university emergency department (ED) directly from the scene of an MVC from August 1997 to April 1998 were enrolled. Potential patients were identified from the ED log and consent was obtained to investigate the crash vehicle. Data describing MVC characteristics were abstracted from the PR, AR, and medical record. Variables of interest included restraint use (RU), air bag deployment (AD), and type of impact (TI). Agreements between the variables and the independent crash investigation were compared using kappa. Interrater reliability was determined using kappa by comparing a random sample of 20 abstracted reports for each data source with the originally abstracted data. Results: Agreement using kappa between the crash investigation and each data source was 0.588 (95% CI = 0.508 to 0.667) for the PR, 0.330 (95% CI = 0.252 to 0.407) for the AR, and 0.492 (95% CI = 0.413 to 0.572) for the EDR. Variable agreement was 0.239 (95% CI = 0.164 to 0.314) for RU, 0.350 (95% CI = 0.268 to 0.432) for AD, and 0.631 (95%= 0.563 to 0.698) for TI. Interrater reliability was excellent (kappa > 0.8) for all data sources. Conclusions: The strength of the agreement between the independent crash investigation and the data sources that were measured by kappa was fair to moderate, indicating inaccuracies. This presents ramifications for researchers and necessitates consideration of the validity and accuracy of crash characteristics contained in these data sources. [source] Hospital care of people living in residential care facilities: Profile, utilization patterns and factors impacting on quality and safety of careGERIATRICS & GERONTOLOGY INTERNATIONAL, Issue 3 2007Sanjay Jayasinghe Background: Residents in residential care facilities (RCF) are frequent users of acute hospital services. However, the interface between the two sectors remains relatively unexplored. Our objective was to determine the patterns of utilization, characteristics and experiences of RCF residents accessing a tertiary referral center (TRC). Methods: An observational study of RCF residents presenting to the TRC emergency department (ED). The experiences of acute care services were explored for more than one-quarter of this group 2,3 days postdischarge. The carer within the RCF acted as the proxy respondent. Results: During the study period, RCF residents accounted for 2.3% of all ED presentations. These presentations involved 526 residents. The dimension "continuity of care" for the Picker Patient Experience questionnaire had the highest proportion (53.1%) reporting a problem. The likelihood of reporting a problem for "continuity of care" (odds ratio [OR], 3.58; confidence interval [CI], 1.72,7.45) and "information and education" (OR, 2.62; CI, 1.14,3.01) were higher if the resident was admitted to a ward compared to ED only. If the resident had a low level care status the likelihood of reporting a problem for "continuity of care" (OR, 2.8; CI, 1.02,7.72) also increased. The odds of RCF staff reporting a problem for "ambulance service" were significantly higher if the resident's presentation was related to a fall. (OR, 3.35; CI, 1.28,8.8). Conclusion: The utilization rates for acute hospital care in our study were similar to the two previous Australian studies. Factors at the patient and organizational level impacted significantly on problems relating to the quality and safety of care being reported. [source] Fusion of dispatching centres into one entity: effects on performanceACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 6 2010T. MÄÄTTÄ Background: Dispatching centres were fused into one of the 112 entity, which caused concerns regarding whether the medical calls could be processed effectively also in the new centre. We evaluated the effects of the reform on key performance criteria in medical calls. Methods: This observational study in the Helsinki Dispatching Centre consisted of two periods: Period I 2 years before the reform and Period II 2 years after. The main outcome measures were answering and call processing times, accuracy of risk assessment and appropriate use of ambulances. Results: In Period I (n=574,276), 92.2% of all incoming phone calls were answered within 10 s and in Period II (n=758,022) 82.8% (P<0.0001). Time to dispatch a first responding fire unit increased from 98 to 113 s (P<0.0001) and an advanced life support unit in category A calls increased from 73 to 84 s (P<0.0001). In Period I 47.7%, 34.8% and 17.5% of phone calls were completed in <3, 3,5 and >5 min and in Period II 29.8%, 36.1% and 34.1% (P<0.0001). The number of three studied non-transportation call types and unnecessary lights-and-siren responses increased significantly (P<0.0001 and 0.0001, respectively). Neither the accuracy of risk assessment in the three studied call types nor the rate of telephone-guided cardiopulmonary resuscitation changed. Conclusions: The reform increased the total number of ambulance dispatches, prolonged answering and call processing times and had a negative effect on the appropriate use of ambulances. The accuracy of risk assessment was not affected. Evidence-based data should be the basis for the future as dispatching centre processes are shown to be vulnerable during organisational reforms. [source] Moving the ambulance to the top of the cliff: reducing the burden of depressive symptoms after strokeINTERNATIONAL JOURNAL OF STROKE, Issue 3 2009M. L. Hackett No abstract is available for this article. [source] A case of fatal caffeine poisoningACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2010T. RUDOLPH Caffeine is a natural alkaloid methylxanthine that is found in various plants such as coffee or tea. Symptoms of a severe overdose may present with hypokalemia, hyponatremia, ventricular arrhythmias, hypertension followed by hypotension, respiratory failure, seizures, rhabdomyolysis, ventricular fibrillation and finally circulatory collapse. A 21-year-old woman called for the ambulance herself soon after the ingestion of about 10,000 mg of caffeine. At the arrival of the ambulance, the patient went into cardiac arrest almost immediately. After a total resuscitation period of 34 min including seven counter-shocks and 2 mg epinephrine, the patient was stable enough to be transferred to the hospital. The patient soon went into VF again and received two more counter-shocks and 1 mg epinephrine and finally an intravenous bolus dose of 300 mg amiodarone. The initial arterial blood gas showed pH at 6.47, lactate at 33 mmol/l and potassium level at 2.3 mmol/l. Unfortunately, no blood samples for caffeine analysis were taken. Three days after hospital admission, the patient developed myoclonus, which did not respond to medical treatment. Excessive intake of caffeine may produce arrhythmias and pronounced hypokalemia and ensuing ventricular fibrillation. In case of counter-shock-resistant VF, it can be necessary to give an early loading dose of amiodarone. Furthermore, it may be beneficial to replace the potassium as early as possible. Epinephrine and buffer solutions used during resuscitation may further decrease blood potassium levels and should be administrated cautiously. Epinephrine can be replaced by other vasopressor drugs, such as vasopressin without effects on ,-receptors. [source] The GlideScope Ranger® video laryngoscope can be useful in airway management of entrapped patientsACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 10 2009A. R. NAKSTAD Background: Airway management of entrapped patients is challenging and alternatives to endotracheal intubation with a Macintosh laryngoscope must be considered. In this study, the GlideScope Ranger® video laryngoscope has been evaluated as an alternative to standard laryngoscopy. Methods: Eight anaesthesiologists from a Helicopter Emergency Medical Service intubated the trachea of a Laerdal SimMan® manikin using the studied laryngoscopes in two scenarios: (A) unrestricted access to the manikin in an ambulance and (B) no access from the head end, simulating an entrapped patient. The time used to secure the airway and the scored level of difficulty were the main variables. Results: In scenario A, all anaesthesiologists managed to secure the airway using both techniques within the 60-s time limit. In scenario B, all secured the airway when using the video laryngoscope, while 50% succeeded with endotracheal intubation using the Macintosh laryngoscope. The difference in the success rate was statististically significant (P=0.025). There were no significant differences in the time spent on endotracheal intubation in the two scenarios or between the devices. All stated that the availability of a video laryngsoscope would make drug-facilitated intubation a realistic alternative when access to patients is limited. The lack of visual control when using the Macintosh laryngoscope excludes this technique in real-life settings. Conclusion: This study suggests that the Glidescope Ranger® may be merited in situations requiring endotracheal intubation by an experienced intubator in patient entrapment. Further studies are required to clarify whether performance in patients mimics that in a manikin. [source] Evaluation of Emergency Air Evacuation of Critically Ill Patients from Cruise ShipsJOURNAL OF TRAVEL MEDICINE, Issue 6 2001Laurence D. Prina Background: The study objectives were to assess the ship physician's diagnostic accuracy in making the decision to air evacuate critically ill patients from cruise ships, to determine the outcome of these patients, and the overall benefit of air evacuation. Methods: From October 1999 to May 2000, we performed a prospective study of critically ill patients coming from cruise ships in the Caribbean and transported to our institution by air ambulance. Demographics, initial diagnosis, and treatment on board were collected by the triage officer at the time of the cruise physician's first call. In route complications and flight team composition were obtained from the air ambulance monitoring log. Patients were followed-up in the hospital for complications, outcome, and final diagnosis. Results: A consecutive series of 104 patients were considered for analysis. There were 65 men and 39 women (mean age: 68.7 years). Cruise physician's diagnosis was correct in more than 90% of the cases. Internal medicine and surgical conditions represented 80.8% and 19.2% of the cases respectively, falling mainly into three categories: cardiac (34.6%), neurological (20.2%), and digestive (14%). Two cardiac arrests and 1 ventricular fibrillation were successfully resuscitated and 5 of 15 myocardial infarctions received thrombolytic therapy on board. Air transfers were warranted in 96.1% of the cases and physician presence in the flight was considered appropriate in 97.6%. In route complications and mortality rate were 5.8% and 2.9% respectively, related to serious cardiac events. Among the 98 hospitalized patients, 10 patients developed new complications and 5 died. The overall mortality rate was 7.7%. Conclusion: The cruise industry appears off to a good start in the medical treatment of passengers needing air evacuation to a land based medical facility. There is room for improvement and adoption of American College of Emergency Physicians (ACEP) and International Council of Cruise Lines (ICCL) Health Care Guidelines are meaningful first steps. Analysis of Caribbean medical facilities and implementation of active telemedicine conferencing represent alternatives to air evacuation that need to be studied. [source] Environmental temperature stress on drugs in prehospital emergency medical serviceACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2003M. Helm Background: Drugs used in prehospital emergency medical service (EMS) in principle are subject to the same storage restrictions as hospital-based medications. The prehospital emergency environment however, often exceeds these storage recommendations. Main stress factors are sunlight, vibration and extreme temperature, which may lead to alteration in chemical and physical stability of stored pharmaceuticals, as well as microbiological contamination and concentration enhancement of pharmacological inserts. Methods: The purpose of this study was to determine the environmental temperature stress upon drugs used in the prehospital EMS under real mission conditions within different types of rescue vehicles (rescue helicopter [HEMS], ambulance [AMB] and emergency physician transport vehicle [EPTV]) during a ,summer' and ,winter' monitoring period (2 months duration each/location: southern Germany). Results: Recorded temperatures varied from ,13.2°C to +50.6°C. The recommended maximum storage temperature (+25°C) was exceeded in all rescue vehicles (33,45% of total exposure time), whereas the recommended minimum storage temperature (0°C) only fell short in the EPTV (19% of total exposure time). The daily maximum temperature variations ranged from 19.0°C (winter) to 32.9°C (summer). Conclusions: These results show that even in a moderate climatic zone, drugs used in prehospital EMS are significantly influenced by temperature stress; furthermore, these results recommend the usage of temperature-controlled drug boxes. [source] Transcutaneous Electrical Nerve Stimulation as Prehospital Emergency Interventional Care: Treating Acute Pelvic Pain in Young WomenNEUROMODULATION, Issue 2 2006Renate Barker MD Abstract Objectives., In Europe, patients with acute pelvic pain are transported to the hospital in an ambulance without an emergency physician. We hypothesized that transcutaneous electrical nerve stimulation (TENS) would be an effective noninvasive procedure for pain treatment. Methods., We conducted a prospective, randomized, blinded study where 100 women were randomly assigned into a real- or a sham-TENS group. TENS began before the transport to the ambulance and was left in place until the arrival at the hospital. Each patient rated her pain on paper using a visual analog scale. Results., Compared to sham TENS, patients with active TENS felt that their pain was reduced by half after treatment (p < 0.01), anxiety scores significantly decreased (p < 0.01), heart rate and arteriolar vasoconstriction decreased significantly (p < 0.01), and nausea (p < 0.01) was lessened. Overall satisfaction with the received care was significantly higher (p < 0.01). Conclusion., TENS is a safe, rapid, and effective analgesic treatment for acute pelvic pain. [source] Modeling the Emergency Ambulance Pass-By of Small Rural Hospitals in Victoria, AustraliaTHE JOURNAL OF RURAL HEALTH, Issue 4 2005Patrick Gleeson MBA ABSTRACT: Context: Many small rural hospitals struggle to attract sufficient numbers of suitable patients. Inadequate patient throughput threatens the viability of these hospitals and, consequently, the financial, physical, and social well-being of the whole community. Anecdotal evidence suggests that many emergency ambulance patients are routinely taken past their local small rural hospital to the area's major receiving hospital. Purpose: To quantify the ambulance pass-by of local small rural hospitals and identify the factors that influence its occurrence. Methods: Data were collected from the ambulance and hospital records of 3 small rural centers in central Victoria, Australia. Results: Ambulances transport a significant number of patients past their local small rural hospitals to the area's major receiving hospital. This takes less time for paramedics than bringing a patient to the local hospital first if the patient is then redirected by that hospital to the larger hospital. There is an inverse relationship between the rate of cases in which the local hospital redirects ambulances to the regional hospital and the rate of ambulance crew decisions to use the local hospital. Conclusions: If some patients are being transported directly to the major receiving hospital because paramedics are considering their own time commitments when making patient transport decisions, this could have revenue implications for rural hospitals. Attracting appropriate local ambulance patients to the smaller hospitals may provide an income source that is currently lost to the crowded major receiving hospital's emergency department. [source] A Method for Improving Arrival-to-electrocardiogram Time in Emergency Department Chest Pain Patients and the Effect on Door-to-balloon Time for ST-segment Elevation Myocardial InfarctionACADEMIC EMERGENCY MEDICINE, Issue 10 2009Kevin M. Takakuwa MD Abstract Objectives:, The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients. Methods:, This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders. Results:, A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (±standard deviation [SD]) age was 50 (±16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. Conclusions:, The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site. [source] Characterizing Waiting Room Time, Treatment Time, and Boarding Time in the Emergency Department Using Quantile RegressionACADEMIC EMERGENCY MEDICINE, Issue 8 2010Ru Ding MS ACADEMIC EMERGENCY MEDICINE 2010; 17:813,823 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, The objective was to characterize service completion times by patient, clinical, temporal, and crowding factors for different phases of emergency care using quantile regression (QR). Methods:, A retrospective cohort study was conducted on 1-year visit data from four academic emergency departments (EDs; N = 48,896,58,316). From each ED's clinical information system, the authors extracted electronic service information (date and time of registration; bed placement, initial contact with physician, disposition decision, ED discharge, and disposition status; inpatient medicine bed occupancy rate); patient demographics (age, sex, insurance status, and mode of arrival); and clinical characteristics (acuity level and chief complaint) and then used the service information to calculate patients' waiting room time, treatment time, and boarding time, as well as the ED occupancy rate. The 10th, 50th, and 90th percentiles of each phase of care were estimated as a function of patient, clinical, temporal, and crowding factors using multivariate QR. Accuracy of models was assessed by comparing observed and predicted service completion times and the proportion of observations that fell below the predicted 10th, 50th, and 90th percentiles. Results:, At the 90th percentile, patients experienced long waiting room times (105,222 minutes), treatment times (393,616 minutes), and boarding times (381,1,228 minutes) across the EDs. We observed a strong interaction effect between acuity level and temporal factors (i.e., time of day and day of week) on waiting room time at all four sites. Acuity level 3 patients waited the longest across the four sites, and their waiting room times were most influenced by temporal factors compared to other acuity level patients. Acuity level and chief complaint were important predictors of all phases of care, and there was a significant interaction effect between acuity and chief complaint. Patients with a psychiatric problem experienced the longest treatment times, regardless of acuity level. Patients who presented with an injury did not wait as long for an ED or inpatient bed. Temporal factors were strong predictors of service completion time, particularly waiting room time. Mode of arrival was the only patient characteristic that substantially affected waiting room time and treatment time. Patients who arrived by ambulance had shorter wait times but longer treatment times compared to those who did not arrive by ambulance. There was close agreement between observed and predicted service completion times at the 10th, 50th, and 90th percentile distributions across the four EDs. Conclusions:, Service completion times varied significantly across the four academic EDs. QR proved to be a useful method for estimating the service completion experience of not only typical ED patients, but also the experience of those who waited much shorter or longer. Building accurate models of ED service completion times is a critical first step needed to identify barriers to patient flow, begin the process of reengineering the system to reduce variability, and improve the timeliness of care provided. [source] Characteristics of non-fatal opioid overdoses attended by ambulance services in AustraliaAUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH, Issue 6 2004Paul Dietze Objective: To examine the feasibility of establishing a database on non-fatal opioid overdose in order to examine patterns and characteristics of these overdoses across Australia. Methods: Unit record data on opioid overdose attended by ambulances were obtained from ambulance services in the five mainland States of Australia for available periods, along with information or case definition and opioid overdose management within these jurisdictions. Variables common across States were examined including the age and sex of cases attended, the time of day and day of week of the attendance, and the transportation outcome (whether the victim was left at the scene or transported to hospital). Results: The monthly rate of non-fatal opioid overdose attended by ambulance was generally highest in Victoria (Melbourne) followed by NSW, with the rates substantially lower in the remaining States over the period January 1999 to February 2001. Non-fatal opioid overdose victims were most likely to be male in all States, with the proportion of males highes in Victoria (77%), and were aged around 28 years with ages lowest in Western Australia (m=26) and highest in NSW (m=30). Most of the attendances occurred in the afternoon/early evening and towards the later days of the working week in all States. The rates of transportation varied according to ambulance service practice across the States with around 94% of cases transported in Western Australia and around 18% and 29% of cases transported in Melbourne and NSW respectively. Conclusions: It is feasible to establish a database of comparable data on non-fatal opioid overdoses attended by ambulances in Australia. This compilation represents a useful adjunct to existing surveillance systems on heroin (and other opioid) use and related harms. [source] Guardian Availability in Children Evaluated in the Emergency Department for Blunt Head TraumaACADEMIC EMERGENCY MEDICINE, Issue 1 2009James F. Holmes MD Abstract Background:, Enrolling children in research studies in the emergency department (ED) is typically dependent on the presence of a guardian to provide written informed consent. Objectives:, The objectives were to determine the rate of guardian availability during the initial ED evaluation of children with nontrivial blunt head trauma, to identify the reasons why a guardian is unavailable, and to compare clinical factors in patients with and without a guardian present during initial ED evaluation. Methods:, This was a prospective study of children (<18 years of age) presenting to a single Level 1 trauma center after nontrivial blunt head trauma over a 10-month period. Physicians documented patient history and physical examination findings onto a structured data form after initial evaluation. The data form contained data points regarding the presence or absence of the patient's guardian during the initial ED evaluation. For those children for whom the guardian was not available during the initial ED evaluation, the physicians completing the data forms documented the reasons for the absence. Results:, The authors enrolled 602 patients, of whom 271 (45%, 95% confidence interval [CI] = 41% to 49%) did not have a guardian available during the initial ED evaluation. In these 271 patients, 261 had reasons documented for lack of guardian availability, 43 of whom had multiple reasons. The most common of these was that the guardian did not ride in the ambulance (51%). Those patients without a guardian available were more likely to be older (mean age, 11.4 years vs. 7.6 years; p < 0.001), be victims of a motor vehicle collision (MVC; 130/268 [49%] vs. 35/328 [11%]; p < 0.001), have a Glasgow Coma Scale (GCS) score <14 (21/269 [7.8%] vs. 11/331 [3.3%]; p = 0.02), and undergo cranial computed tomography (CT) scanning (224/271 [83%] vs. 213/331 [64%]; p < 0.001). Multivariate analysis identified similar independent risk factors for lack of guardian presence. Conclusions:, Nearly one-half of children with nontrivial blunt head trauma evaluated in the ED may not have a guardian available during their initial ED evaluation. Patients whose guardians are not available at the time of initial ED evaluation are older and have more severe mechanisms of injury and more serious head trauma. ED research studies of pediatric trauma patients that require written informed consent from a guardian at the time of initial ED evaluation and treatment may have difficulty enrolling targeted sample size numbers and will likely be limited by enrollment bias. [source] The Financial Impact of Ambulance Diversion on Inpatient Hospital Revenues and ProfitsACADEMIC EMERGENCY MEDICINE, Issue 1 2009Daniel A. Handel MD Abstract Objectives:, The objective was to study the association between ambulance diversion and weekly inpatient hospital revenues and profits. Methods:, This was a retrospective review of administrative data from one academic medical center from July 1, 2003, to December 31, 2006. Given the high amount of daily variability, inpatient hospital revenues and profits were collapsed by week and evaluated in four categories: no diversion, mild diversion (from >0 and <10 hours), moderate diversion (>10 and <20 hours), and high diversion (>20 hours). Revenues and profits for two categories of patients admitted to the hospital were calculated: 1) patients admitted from the emergency department (ED; i.e., those arriving by ambulance and by other means) and 2) electively admitted patients. Results:, A total of 166,460 ED patients were included in the analysis. Inpatient hospital revenues were included from 85,111 patients, 28,665 of which were admissions from the ED (33.7%). For patients admitted from the ED, the average weekly revenues during periods of high diversion were $265K higher than periods of no diversion. For patients admitted on an elective basis, revenues were significantly higher when comparing periods of mild divert to high diversion (an additional $415K weekly). The overall increase in profitability was significant for periods of severe divert compared to no divert ($119K per week). Conclusions:, Periods of greater diversion are associated with higher inpatient revenues and profits for ED, electively admitted patients, and the overall inpatient hospital population. Therefore, no financial disincentive exists from an inpatient perspective for the boarding of admitted patients in the ED and increasing periods of diversion. Efforts to decrease ambulance diversion must therefore be based on other rationales, like patient safety, quality of care, and improving access to care, or new models of reimbursement that reward hospitals for reducing ambulance diversion. [source] Reducing Ambulance Response Times Using Geospatial,Time Analysis of Ambulance DeploymentACADEMIC EMERGENCY MEDICINE, Issue 9 2010Marcus Eng Hock Ong MBBS (S'pore) ACADEMIC EMERGENCY MEDICINE 2010; 17:951,957 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, This study aimed to determine if a deployment strategy based on geospatial,time analysis is able to reduce ambulance response times for out-of-hospital cardiac arrests (OOHCA) in an urban emergency medical services (EMS) system. Methods:, An observational prospective study examining geographic locations of all OOHCA in Singapore was conducted. Locations of cardiac arrests were spot-mapped using a geographic information system (GIS). A progressive strategy of satellite ambulance deployment was implemented, increasing ambulance bases from 17 to 32 locations. Variation in ambulance deployment according to demand, based on time of day, was also implemented. The total number of ambulances and crews remained constant over the study period. The main outcome measure was ambulance response times. Results:, From October 1, 2001, to October 14, 2004, a total of 2,428 OOHCA patients were enrolled into the study. Mean ± SD age for arrests was 60.6 ± 19.3 years with 68.0% male. The overall return of spontaneous circulation (ROSC) rate was 17.2% and survival to discharge rate was 1.6%. Response time decreased significantly as the number of fire stations/fire posts increased (Pearson ,2 = 108.70, df = 48, p < 0.001). Response times for OOHCA decreased from a monthly median of 10.1 minutes at the beginning to 7.1 minutes at the end of the study. Similarly, the proportion of cases with response times < 8 minutes increased from 22.3% to 47.3% and < 11 minutes from 57.6% to 77.5% at the end of the study. Conclusions:, A simple, relatively low-cost ambulance deployment strategy was associated with significantly reduced response times for OOHCA. Geospatial,time analysis can be a useful tool for EMS providers. [source] Effects of Presentation and Electrocardiogram on Time to Treatment of HyperkalemiaACADEMIC EMERGENCY MEDICINE, Issue 3 2008Kalev Freeman MD Abstract Objectives:, To assess the time to treatment for emergency department (ED) patients with critical hyperkalemia and to determine whether the timing of treatment was associated with clinical characteristics or electrocardiographic abnormalities. Methods:, The authors performed a retrospective chart review of ED patients with the laboratory diagnosis of hyperkalemia (potassium level > 6.0 mmol/L). Patients presenting in cardiac arrest or who were referred for hyperkalemia or dialysis were excluded. Patient charts were reviewed to find whether patients received specific treatment for hyperkalemia and, if so, what clinical attributes were associated with the time to initiation of treatment. Results:, Of 175 ED visits that occurred over a 1-year time period, 168 (96%) received specific treatment for hyperkalemia. The median time from triage to initiation of treatment was 117 minutes (interquartile range [IQR] = 59 to 196 minutes). The 7 cases in which hyperkalemia was not treated include 4 cases in which the patient was discharged home, with a missed diagnosis of hyperkalemia. Despite initiation of specific therapy for hyperkalemia in 168 cases, 2 patients died of cardiac arrhythmias. Among the patients who received treatment, 15% had a documented systolic blood pressure (sBP) < 90 mmHg, and 30% of treated patients were admitted to intensive care units. The median potassium value was 6.5 mmol/L (IQR = 6.3 to 7.1 mmol/L). The predominant complaints were dyspnea (20%) and weakness (19%). Thirty-six percent of patients were taking angiotensin-converting enzyme (ACE) inhibitors. Initial electrocardiograms (ECGs) were abnormal in 83% of patient visits, including 24% of ECGs with nonspecific ST abnormalities. Findings of peaked T-wave morphology (34%), first-degree atrioventricular block (17%), and interventricular conduction delay (12%) did not lead to early treatment. Vital sign abnormalities, including hypotension (sBP < 90 mmHg), were not associated with early treatment. The chief complaint of "unresponsive" was most likely to lead to early treatment; treatment delays occurred in patients not transported by ambulance, those with a chief complaint of syncope and those with a history of hypertension. Conclusions:, Recognition of patients with severe hyperkalemia is challenging, and the initiation of appropriate therapy for this disorder is frequently delayed. [source] Reduction in Ambulance Transports during a Public Awareness Campaign for Appropriate Ambulance UseACADEMIC EMERGENCY MEDICINE, Issue 3 2008Kenji Ohshige MD Abstract Objectives:, This study aimed to characterize the change in the upward trend in monthly ambulance transports that occurred during a citywide campaign for appropriate ambulance use. This study also investigated whether the number of ambulance transports for individuals with nonserious conditions decreased separately from the decrease in ambulance transports for individuals with serious conditions. Methods:, A retrospective time series survey was carried out on the number of ambulance transports that occurred per month over a 10-year period (1997,2006). This study focused on individuals transported by ambulance because of illness. Seasonal decomposition was applied to adjust for the seasonal effect on ambulance transport. The shift in the trend during the campaign period (April 2005,December 2006) was examined by means of linear regression analysis. Results:, The number of individuals transported by ambulance decreased during the campaign period. A decrease in the number of ambulance transports was observed for both nonserious and serious conditions. During the campaign period, the number of ambulance transports per month was estimated to have decreased by 530 (approximately 7%; 95% confidence interval [CI] = ,729 to ,331) for individuals with nonserious conditions and by 37 (approximately 8%; 95% CI = ,53 to ,22) for individuals with serious conditions. Conclusions:, A campaign to educate the public on appropriate ambulance use may reduce ambulance calls for both nonserious and serious conditions. [source] Prehospital Ultrasound by Paramedics: Results of Field TrialACADEMIC EMERGENCY MEDICINE, Issue 6 2010William Heegaard MD Abstract Objectives:, The objective was to determine if 9-1-1 paramedics trained in ultrasound (US) could adequately perform and interpret the Focused Assessment Sonography in Trauma (FAST) and the abdominal aortic (AA) exams in the prehospital care environment. Methods:, Paramedics at two emergency medical services (EMS) agencies received a 6-hour training program in US with ongoing refresher education. Paramedics collected US in the field using a prospective convenience methodology. All US were performed in the ambulance without scene delay. US exams were reviewed in a blinded fashion by an emergency sonographer physician overreader (PO). Results:, A total of 104 patients had an US performed between January 1, 2008, and January 1, 2009. Twenty AA exams were performed and all were interpreted as negative by the paramedics and the PO. Paramedics were unable to obtain adequate images in 7.7% (8/104) of the patients. Eighty-four patients had the FAST exam performed. Six exams (6/84, 7.1%) were read as positive for free intraperitoneal/pericardial fluid by both the paramedics and the PO. FAST and AA US exam interpretation by the paramedics had a 100% proportion of agreement with the PO. Conclusions:, This pilot study shows that with close supervision, paramedics can adequately obtain and interpret prehospital FAST and AA US images under protocol. These results support a growing body of literature that indicates US may be feasible and useful in the prehospital setting. ACADEMIC EMERGENCY MEDICINE 2010; 17:624,630 © 2010 by the Society for Academic Emergency Medicine [source] Sequential Analysis of Pretreatment Delays In Stroke ThrombolysisACADEMIC EMERGENCY MEDICINE, Issue 9 2010Tuukka Puolakka BM ACADEMIC EMERGENCY MEDICINE 2010; 17:965,969 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, The aim was to determine if an intensive restructuring of the approach to acute stroke improved time to thrombolysis over a 3-year study period and to determine whether delay modifications correlated with increased thrombolytic intervention or functional outcome. Methods:, The study examined the pretreatment process to define specific time intervals (delays) of interest in the acute management of 289 consecutive ischemic stroke patients who were transported by the emergency medical services (EMS) and received intravenous (IV) thrombolytic therapy in the emergency department (ED) of Helsinki University Central Hospital. Time interval changes of the 3-year period and use of thrombolytics was measured. Functional outcome, measured with the modified Rankin Scale (mRS) at 3 months, was assessed with multivariable statistical analysis. Results:, During implementation of the restructuring program from 2003 to 2005, the median total time delay from symptom onset to drug administration dropped from 149 to 112 minutes (p < 0.0001). Prehospital delays did not change significantly during the study period. The median delay in calling an ambulance remained at 13 minutes, and the total median prehospital delay stayed at 71 minutes. In-hospital delays decreased from 67 to 34 minutes (p < 0.0001). The median call delay was 25 minutes in patients with mild symptoms (National Institute of Health Stroke Scale [NIHSS] score < 7) and 8 minutes with severe symptoms (NIHSS > 15). In the multivariate model, stroke severity (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.78 to 0.88, p < 0.0001), age (OR = 0.57, 95% CI = 0.42 to 0.77, p < 0.0001), and in-hospital delay (OR = 0.47, 95% CI = 0.22 to 0.97, p = 0.04) were suggesting a good outcome. Conclusions:, Restructuring of the teamwork between the EMS personnel and the reorganized ED significantly reduced in-hospital, but not prehospital, delays. The present data suggest that a decreased in-hospital delay improves the accessibility of the benefits of thrombolysis. [source] | ||||||||||||||||||||||