[Show abstract][Hide abstract] ABSTRACT: To evaluate the feasibility and appropriateness of a prehospital system allowing ambulance nurses to transport older adults directly to geriatric care at a community-based hospital (CH) or to an emergency department (ED).
Journal of the American Geriatrics Society 06/2014; · 3.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the impact of a dual dispatch system, using fire fighters as first responders, in out-of-hospital cardiac arrest (OHCA) on short (30 days) and long term (three years) survival, and, to investigate the potential differences regarding in-hospital factors and interventions between the patient groups, such as the use of therapeutic hypothermia and cardiac catheterization.
OHCAs from 2004 (historical controls) and 2006-2009 (intervention period) were included. During the intervention period, fire fighters equipped with automated external defibrillators (AEDs) were dispatched in suspected OHCA. Logistic regression analyses of outcome data included: the intervention with dual dispatch, sex, age, location, aetiology, witnessed status, bystander-cardiopulmonary resuscitation, first rhythm and therapeutic hypothermia. In total, 2581 OHCAs were included (historical controls n=620, intervention period n=1961). Fire fighters initiated cardiopulmonary resuscitation and connected an AED before emergency medical services' arrival in 41% of the cases. The median time from dispatch to arrival of first responder or emergency medical services shortened from 7.7 in the control period to 6.7 min in the intervention period (p<0.001). The 30-day survival improved from 3.9% to 7.6% (p=0.001), adjusted odds ratio 2.8 (confidence interval 1.6-4.9). Survival to three years increased from 2.4% to 6.5% (p<0.001), adjusted odds ratio 3.8 (confidence interval 1.9-7.6). In the logistic regression analysis including in-hospital factors we found no outcome benefit of therapeutic hypothermia.
The implementation of a dual dispatch system using fire fighters in OHCA was associated with increased 30-day and three-year survival. No major differences in the in-hospital treatment were seen between the studied patient groups.
European heart journal. Acute cardiovascular care. 04/2014;
[Show abstract][Hide abstract] ABSTRACT: The use of supplemental oxygen in the setting of suspected acute myocardial infarction (AMI) is recommended in international treatment guidelines and established in prehospital and hospital clinical routine throughout the world. However, to date there is no conclusive evidence from adequately designed and powered trials supporting this practice. Existing data are conflicting and fail to clarify the role of supplemental oxygen in AMI.
A total of 6,600 normoxemic (oxygen saturation [SpO2] ≥90%) patients with suspected AMI will be randomly assigned to either supplemental oxygen 6 L/min delivered by Oxymask (MedCore Sweden AB, Kista, Sweden) for 6 to 12 hours in the treatment group or room air in the control group. Patient inclusion and randomization will take place at first medical contact, either before hospital admission or at the emergency department. The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry will be used for online randomization, allowing inclusion of a broad population of all-comers. Follow-up will be carried out in nationwide health registries and Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies. The primary objective is to evaluate whether oxygen reduces 1-year all-cause mortality. Secondary end points include 30-day mortality, major adverse cardiac events, and health economy. Prespecified subgroups include patients with confirmed AMI and certain risk groups. In a 3-month pilot study, the study concept was found to be safe and feasible.
The need to clarify the uncertainty of the role of supplemental oxygen therapy in the setting of suspected AMI is urgent. The DETO2X-AMI trial is designed and powered to address this important issue and may have a direct impact on future recommendations.
American heart journal 03/2014; 167(3):322-8. · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although ozone (O3) and other pollutants have been associated with cardiovascular morbidity and mortality, the effects of O3 on out-of-hospital cardiac arrest (OHCA) have rarely been addressed and existing studies have presented inconsistent findings. The objective of this study was to determine the effects of short-term exposure to air pollution including O3 on the occurrence of OHCA, and assess effect modification by season, age, and gender.
A total of 5973 Emergency Medical Service-assessed OHCA cases in Stockholm County 2000-10 were obtained from the Swedish cardiac arrest register. A time-stratified case-crossover design was used to analyse exposure to air pollution and the risk of OHCA. Exposure to O3, PM2.5, PM10, NO2, and NOx was defined as the mean urban background level during 0-2, 0-24, and 0-72 h before the event and control time points. We adjusted for temperature and relative humidity. Ozone in urban background was associated with an increased risk of OHCA for all time windows. The respective odds ratio (confidence interval) for a 10 µg/m(3) increase was 1.02 (1.01-1.05) for a 2-h window, 1.04 (1.01-1.07) for 24-h, and 1.05 (1.01-1.09) for 3 day. The association with 2-h O3 was stronger for events that occurred outdoors: 1.13 (1.06-1.21). We observed no effects for other pollutants and no effect modification by age, gender, or season.
Short-term exposure to moderate levels of O3 is associated with an increased risk of OHCA.
European Heart Journal 12/2013; · 14.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Registration of data from a major incident or disaster serves several purposes such as to record data for evaluation of response as well as for research. Data needed can often be retrieved after an incident while other must be recorded during the incident. There is a need for a consensus on what is essential to record from a disaster response. The aim of this study was to identify key indicators essential for initial disaster medical response registration. By this is meant nationally accepted processes involved, from the time of the emergency call to the emergency medical communication centre until medical care is provided at the emergency department.
A three round Delphi study was conducted. Thirty experts with a broad knowledge in disaster and emergency response and medical management were invited. In this study we estimated 30 experts to be approximately one third of the number in Sweden eligible for recruitment. Process, structure and outcome indicators for the initial disaster medical response were identified. These were based on previous research and expressed as statements and were grouped into eight categories, and presented to the panel of experts. The experts were instructed to score each statement, using a five point Likert scale, and were also invited to include additional statements. Statements reaching a predefined consensus level of 80% were considered as essential to register.
In total 97 statements were generated, 77 statements reached consensus. The 77 statements covered parts of all relevant aspects involved in the initial disaster medical response. The 20 indicators that did not reach consensus mostly concerned patient related times in hospital, types of support systems and security for health care staff.
The Delphi technique can be used for reaching consensus of data, comprising process, structure and outcome indicators, identified as essential for recording from major incidents and disasters.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 09/2013; 21(1):68. · 1.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Little is known about the long-term survival effects of type-specific bystander CPR in the community. We hypothesized that dispatcher instruction consisting of chest compression alone would be associated with better overall long-term prognosis compared to chest compression plus rescue breathing. METHODS AND RESULTS: The investigation was a retrospective cohort study that combined 2 randomized trials comparing the short-term survival effects of dispatcher CPR instruction consisting either of chest compression alone or chest compression plus rescue breathing. Long-term vital status was ascertained using the respective National and State death records through 31(st) July 2011. We performed Kaplan Meier method and Cox regression to evaluate survival according to the type of CPR instruction. Of the 2496 subjects included in the current investigation, 1243 (50%) were randomized to chest compression alone and 1253 (50%) were randomized to chest compression plus rescue breathing. Baseline characteristics were similar between the two CPR groups. During the 1153.2 person-years of follow-up, there were 2260 deaths and 236 long-term survivors. Randomization to chest compression alone compared to chest compression plus rescue breathing was associated with a lower risk of death after adjustment for potential confounders (adjusted HR=0.91; 95% CI [0.83-0.99], p=0.02). CONCLUSIONS: The findings provide strong support for long-term mortality benefit of dispatcher CPR instruction strategy consisting of chest compression alone rather than chest compression plus rescue breathing among adult cardiac arrest patients requiring dispatcher assistance.
[Show abstract][Hide abstract] ABSTRACT: The elderly population in Sweden is increasing. This will lead to an increased need for healthcare resources and put extra demands on healthcare professionals. Consequently, ambulance personnel will be faced with the challenge of meeting extra demands from increasing numbers of older people with complex and atypical clinical presentations. Therefore we highlight that great problems exist for ambulance personnel to understand and meet these patients' care needs. Using a caring science approach, we apply the patient's perspective, and the aim of this study is to identify and illuminate the conditions that affect elderly people assessed with the assessment category "general affected health condition". Thus, we have analyzed the characteristics belonging to this specific condition. The method is a retrospective audit, involving a qualitative content analysis of a total of 88 emergency service records. The conclusion is that by using caring science, the concept of frailty which is based on a comprehensive understanding of human life can clarify the state of "general affected health condition", as either illness or ill-health. This offers a new assessment category and outlines care and treatment that strengthen and support the health and wellbeing of the individual elderly person. Furthermore, the concept of frailty ought to be included in "The International Statistical Classification of Diseases and Related Health Problems" (ICD-10).
International emergency nursing 10/2012; 20(4):228-35.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Disaster medicine is a fairly young scientific discipline and there is a need for the development of new methods for evaluation and research. This includes full-scale disaster exercisers. A standardized concept on how to evaluate these exercises, could lead to easier identification of pitfalls caused by system-errors in the organization. The aim of this study was to demonstrate the feasibility of using a combination of performance and outcome indicators so that results can be compared in standardized full-scale exercises. METHODS: Two multidisciplinary, full-scale exercises were studied in 2008 and 2010. The panorama had the same setup. Sets of performance indicators combined with indicators for unfavorable patient outcome were recorded in predesigned templates. Evaluators, all trained in a standardized way at a national disaster medicine centre, scored the results on predetermined locations; at the scene, at hospital and at the regional command and control. RESULTS: All data regarding the performance indicators of the participants during the exercises were obtained as well as all data regarding indicators for patient outcome. Both exercises could therefore be compared regarding performance (processes) as well as outcome indicators. The data from the performance indicators during the exercises showed higher scores for the prehospital command in the second exercise 15 points and 3 points respectively. Results from the outcome indicators, patient survival and patient complications, demonstrated a higher number of preventable deaths and a lower number of preventable complications in the exercise 2010. In the exercise 2008 the number of preventable deaths was lower and the number of preventable complications was higher. CONCLUSIONS: Standardized multidisciplinary, full-scale exercises in different settings can be conducted and evaluated with performance indicators combined with outcome indicators enabling results from exercises to be compared. If exercises are performed in a standardized way, results may serve as a basis for lessons learned. Future use of the same concept using the combination of performance indicators and patient outcome indicators may demonstrate new and important evidence that could lead to new and better knowledge that also may be applied during real incidents.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 08/2012; 20(1):58. · 1.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND PURPOSE: Early initiated treatment of stroke increases the chances of a good recovery. This randomized controlled study evaluates how an increased priority level for patients with stroke, from level 2 to 1, from the Emergency Medical Communication Center influences thrombolysis frequency, time to stroke unit, and whether other medical emergencies reported negative consequences. METHODS: Patients aged 18 to 85 years in Stockholm, Sweden, with symptoms of stroke within 6 hours were randomized from the Emergency Medical Communication Center or emergency medical services to an intervention group, priority level 1, immediate call of an ambulance, or to a control group with standard priority level, that is, priority level 2 (within 30 minutes). Before study start, an educational program on identification of stroke and importance of early initiated treatment was directed to all medical dispatchers and ambulance and emergency department personnel. RESULTS: During 2008, 942 patients were randomized of which 53% (n=496) had a final stroke/transient ischemic attack diagnosis. Patients in the Emergency Medical Communication Center randomized intervention group reached the stroke unit 26 minutes earlier than the control group (P<0.001) after the emergency call. Thrombolysis was given to 24% of the patients in the intervention group compared with 10% of the control subjects (P<0.001). The higher priority level showed no negative effect on other critical ill patients requiring priority level 1 prehospital attention. CONCLUSIONS: This randomized study shows negligible harm to other medical emergencies, a significant increase in thrombolysis frequency, and a shorter time to the stroke unit for patients with stroke upgraded to priority level 1 from the Emergency Medical Communication Center and through the acute chain of stroke care.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To develop a feasible and safe prehospital decision support system (DSS) for the emergency medical services (EMS), facilitating safe steering of geriatric patients to an optimal level of healthcare. METHODS: The development process involves four consecutive steps. The first step was gathering data from patients transported by EMS, with the electronic patient care record, to retrospectively identify appropriate patient categories for steering. The second step was to allow a group of medical experts to give advice and suggestions for further development of the DSS. The third step was validation of the decision support tool and the fourth step was validation of the entire prehospital DSS in a pilot study. RESULTS: The patient categories relevant to steering were those medical conditions that the geriatric clinicians felt confident in receiving from the EMS. A prehospital DSS was then developed for these 11 medical conditions. The evaluation and validation of the DSS showed a high degree of compliance with the patients' final level of healthcare. The pilot study included 110 randomized patients; 33.9% were triaged to an alternative level of healthcare, that is geriatric care or primary care. No medical inaccuracies or secondary transports from alternative care to the hospital emergency department were identified. CONCLUSION: Using this prehospital DSS - developed for 11 medical conditions - the Swedish prehospital nurse can safely decide on the level of healthcare to which an elderly patient can be steered.
European Journal of Emergency Medicine 07/2012; · 0.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In mass-casualty situations, communications and information management to improve situational awareness is a major challenge for responders. In this study, the feasibility of a prototype system that utilizes commercially available, low-cost components, including Radio Frequency Identification (RFID) and mobile phone technology, was tested in two simulated mass-casualty incidents.
The feasibility and the direct benefits of the system were evaluated in two simulated mass-casualty situations: one in Finland involving a passenger ship accident resulting in multiple drowning/hypothermia patients, and another at a major airport in Sweden using an aircraft crash scenario. Both simulations involved multiple agencies and functioned as test settings for comparing the disaster management's situational awareness with and without using the RFID-based system. Triage documentation was done using both an RFID-based system, which automatically sent the data to the Medical Command, and a traditional method using paper triage tags. The situational awareness was measured by comparing the availability of up-to date information at different points in the care chain using both systems.
Information regarding the numbers and status or triage classification of the casualties was available approximately one hour earlier using the RFID system compared to the data obtained using the traditional method.
The tested prototype system was quick, stable, and easy to use, and proved to work seamlessly even in harsh field conditions. It surpassed the paper-based system in all respects except simplicity of use. It also improved the general view of the mass-casualty situations, and enhanced medical emergency readiness in a multi-organizational medical setting. The tested technology is feasible in a mass-casualty incident; further development and testing should take place.
Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 04/2012; 27(1):81-7.
[Show abstract][Hide abstract] ABSTRACT: Among patients who survive after out-of-hospital cardiac arrest (OHCA), a large proportion are recruited from cases witnessed by the Emergency Medical Service (EMS), since the conditions for success are most optimal in this subset.
To evaluate outcome after EMS-witnessed OHCA in a 20-year perspective in Sweden, with the emphasis on changes over time and factors of importance.
All patients included in the Swedish Cardiac Arrest Register from 1990 to 2009 were included.
There were 48,349 patients and 13.5% of them were EMS witnessed. There was a successive increase in EMS-witnessed OHCA from 8.5% in 1992 to 16.9% in 2009 (p for trend<0.0001). Among EMS-witnessed OHCA, the survival to one month increased from 13.9% in 1992 to 21.8% in 2009 (p for trend<0.0001). Among EMS-witnessed OHCA, 51% were found in ventricular fibrillation, which was higher than in bystander-witnessed OHCA, despite a lower proportion with a presumed cardiac aetiology in the EMS-witnessed group. Among EMS-witnessed OHCA overall, 16.0% survived to one month, which was significantly higher than among bystander-witnessed OHCA. Independent predictors of a favourable outcome were: (1) initial rhythm ventricular fibrillation; (2) cardiac aetiology; (3) OHCA outside home and (4) decreasing age.
In Sweden, in a 20-year perspective, there was a successive increase in the proportion of EMS-witnessed OHCA. Among these patients, survival to one month increased over time. EMS-witnessed OHCA had a higher survival than bystander-witnessed OHCA. Independent predictors of an increased chance of survival were initial rhythm, aetiology, place and age.
[Show abstract][Hide abstract] ABSTRACT: Cardiac-related injuries caused by blunt chest trauma remain a severe problem. The aim of this study was to investigate pathophysiological changes in the heart that might arise after behind armor blunt trauma or impacts of nonlethal projectiles.
Sixteen pigs were shot directly at the sternum with "Sponge Round eXact I Mpact" (nonlethal ammunition; diameter 40 mm and weight 28 g) or hard-plastic ammunition (diameter 65 mm and weight 58 g) to simulate behind armor blunt trauma. To evaluate the influence of the shot location, seven additional pigs where exposed to an oblique heart shot. Physiologic parameters, electrocardiography, echocardiogram, the biochemical marker troponin I (TnI), and myocardial injuries were analyzed.
Nonlethal kinetic projectiles (101-108 m/s; 143-163 J) did not cause significant pathophysiological changes. Five of 18 pigs shot with 65-mm plastic projectiles (99-133 m/s; 284-513 J) to the front or side of the thorax died directly after the shot. No major physiologic changes could be observed in surviving animals. Animals shot with an oblique heart shot (99-106 m/s; 284-326 J) demonstrated a small, but significant decrease in saturation. Energy levels over 300 J caused increased TnI and myocardial damages in most of the pigs.
This study indicates that nonlethal kinetic projectiles "eXact iMpact" does not cause heart-related damage under the examined conditions. On impact, sudden heart arrest may occur independently from the cardiac's electrical cycle. The cardiac enzyme, TnI, can be used as a reliable diagnostic marker to detect heart tissue damages after blunt chest trauma.
The Journal of trauma 11/2011; 71(5):1134-43. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: AIMS: Out-of-hospital cardiac arrest is fatal without treatment, and time to defibrillation is an extremely important factor in relation to survival. We performed a cost-benefit analysis of dual dispatch defibrillation by ambulance and fire services in the County of Stockholm, Sweden. METHODS AND RESULTS: A cost-benefit analysis was performed to evaluate the effects of dual dispatch defibrillation. The increased survival rates were estimated from a real-world implemented intervention, and the monetary value of a life ( 2.2 million) was applied to this benefit by using results from a recent stated-preference study. The estimated costs include defibrillators (including expendables/maintenance), training, hospitalisation/health care, fire service call-outs, overhead resources and the dispatch centre. The estimated number of additional saved lives was 16 per year, yielding a benefit-cost ratio of 36. The cost per quality-adjusted life years (QALY) was estimated to be 13,000, and the cost per saved life was 60,000. CONCLUSIONS: The intervention of dual dispatch defibrillation by ambulance and fire services in the County of Stockholm had positive economic effects. For the cost-benefit analysis, the return on investment was high and the cost-effectiveness showed levels below the threshold value for economic efficiency used in Sweden. The cost-utility analysis categorises the cost per QALY as medium.
The European Journal of Health Economics 07/2011; · 2.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a national perspective, to describe survival among patients found in ventricular fibrillation or pulseless ventricular tachycardia witnessed by a bystander and with a presumed cardiac aetiology and answer two principal questions: (1) what are the changes over time? and (2) which are the factors of importance?
Observational register study.
All patients included in the Swedish Out of Hospital Cardiac Arrest Register between 1 January 1990 and 31 December 2009 who were found in bystander-witnessed ventricular fibrillation with a presumed cardiac aetiology. Interventions Bystander cardiopulmonary resuscitation (CPR) and defibrillation.
Survival to 1 month.
In all, 7187 patients fulfilled the set criteria. Age, place of out-of-hospital cardiac arrest (OHCA) and gender did not change. Bystander CPR increased from 46% to 73%; 95% CI for OR 1.060 to 1.081 per year. The median delay from collapse to defibrillation increased from 12 min to 14 min (p for trend 0.0004). Early survival increased from 28% to 45% (95% CI 1.044 to 1.065) and survival to 1 month increased from 12% to 23% (95% CI 1.058 to 1.086). Strong predictors of early and late survival were a short interval from collapse to defibrillation, bystander CPR, female gender and OHCA outside the home.
In a long-term perspective in Sweden, survival to 1 month after ventricular fibrillation almost doubled. This was associated with a marked increase in bystander CPR. Strong predictors of outcome were a short delay to defibrillation, bystander CPR, female gender and place of collapse.
[Show abstract][Hide abstract] ABSTRACT: Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction compares favorably to thrombolysis. In previous studies the benefit has been restricted to the early postinfarction period with no additional risk decrease beyond this period. Long-term outcome after use of third-generation thrombolytics and modern adjunctive pharmaceutics in the 2 treatment arms has not been investigated. This study was conducted to compare 5-year outcome after updated regimens of PPCI or thrombolysis. Patients with ST-elevation myocardial infarction were randomized to enoxaparin and abciximab followed by PPCI (n = 101) or enoxaparin followed by reteplase (n = 104), with prehospital initiation of therapy in 42% of patients. Data on survival and major cardiac events were obtained from Swedish national registries after 5.3 years. PPCI resulted in a better outcome with respect to the composite of death or recurrent myocardial infarction (hazard ratio 0.54, confidence interval 0.31 to 0.95) compared to thrombolysis. This was attributed to a significant decrease in cardiac deaths (hazard ratio 0.16, confidence interval 0.04 to 0.74). The difference evolved continuously over the 5-year follow-up. After adjustment for covariates, a significant benefit remained with respect to cardiac death or recurrent infarction but not for the composite of total survival or recurrent myocardial infarction (p = 0.07). The observed differences were not seen in patients in whom therapy was initiated in the prehospital phase. In conclusion, PPCI in combination with enoxaparin and abciximab compares favorably to thrombolysis in combination with enoxaparin with a risk decrease that stretches beyond the early postinfarction period. Prehospital thrombolysis may, however, match PPCI in long-term outcome.
The American journal of cardiology 12/2010; 106(12):1685-91. · 3.58 Impact Factor