BACKGROUND: Pain is a frequent reason for contacting the Emergency Medical Services (EMS), and effective pain management constitutes one of its cornerstones. The aims of this study have been: (a) to describe the prevalence of pain intensity ratings in EMS care of patients with pain-related conditions; (b) to describe pain treatment in the EMS setting in terms of drugs administered and the proportion of patients receiving analgesics and (c) to investigate the relationship between patients' self-reported pain intensity and vital signs.

METHODS: This is a retrospective observational cohort study using data from 394,700 EMS missions conducted 2021 and 2022, as recorded in the Swedish Ambulance Registry. The study focused on patients who contacted the EMS due to pain, trauma, or injury. Pain intensity was recorded using the Numeric Rating Scale (NRS). NRS scores of 5-10 were considered as high-level pain and NRS ≤ 4 as low-level. Descriptive statistics were used to present categorical and continuous variables. Chi-square tests were applied for dichotomous variables, while Kruskal-Wallis tests were used for ordinal data. Logistic regression analysis was carried out to identify factors associated with pain intensity and analgesic treatment. p value < 0.001 was considered statistically significant.

RESULTS: Pain intensity was recorded in 23.6% of cases. Most patients rated their pain as high-level (NRS 5-10, 57.4% of those assessed). Analgesics were administered in 27.5% of cases, with higher administration rates observed when pain intensity was documented. Female sex, higher breathing rates, and higher systolic blood pressure were associated with higher pain intensity, while increasing age was associated with lower odds of reporting high-level pain intensity. No significant association was found between heart rate and pain intensity.

CONCLUSION: This 2-year cohort study highlights significant deficiencies in recorded pain assessment and management in the Swedish EMS. Only 22.5% of the patients had their pain assessed with a validated scale, while 27.5% received analgesics, although pain-related conditions were a common reason for contacting the EMS. The findings indicate a lack of systematic pain assessment which puts many patients at risk of insufficient pain relief.

Background

There is a lack of knowledge regarding the epidemiology of severe trauma assessed by Swedish emergency medical services (EMS).

Aim

To investigate the prevalence of trauma in Sweden assessed by EMS from a national perspective and describe patient demography, aetiology, trauma type, prehospital triage and clinical outcomes.

Methods

Data from two national quality registries, the Swedish Ambulance Registry and the Swedish Trauma Registry (SweTrau) were collected from January 1 to December 31, 2019. Inclusion criteria were an Emergency Symptoms and Signs code equivalent to trauma in the Swedish Ambulance Registry and criteria fulfilled for SweTrau inclusion. Exclusion criteria were patients < 18 years old, those not transported to a hospital and those without a personal identification number.

Results

In total, 53,120 patients with trauma were included (14% of primary EMS missions involving a personal identification number). Of those, 2,278 (4.3%) patients (median age: 45 years; 32% women) were reported in SweTrau to have severe or potentially severe trauma (penetrating: 7%, blunt: 93%). In terms of including all causes of trauma, the code for ‘trauma alert activation’ was most frequent (55%). The most frequent injury mechanism was an injury caused by a car (34%). Most (89%) cases were assigned Priority 1 (life-threatening condition) at the dispatch centre. 62% were regarded as potentially life threatening upon EMS arrival, whereas 29% were assessed as non-life-threatening. Overall, 25% of the patients had new injury severity scores > 15. 12% required invasive treatment, 11% were discharged with severe disability and the 30-day mortality rate was 3.6%.

Conclusion

In this cross-sectional study, 14% of the primary EMS missions for one year were caused by trauma. However, only a small proportion of these cases are severe injuries, and the risk of severe disabilities and death appears to be limited. The most frequent aetiology of a severe trauma is injury caused by a car, and most severe traumas are blunt. Severe traumas are given the highest priority at the dispatch centre in the vast majority of cases, but nearly one-third of these cases are considered a low priority by the EMS nurse. The latter leaves room for improvement.

Background

Pediatric trauma patients constitute a significant portion of the trauma population treated by Swedish Emergency Medical Services (EMS), and trauma remains a notable cause of death among Swedish children. Previous research has identified potential challenges in prehospital assessments and interventions for pediatric patients. In Sweden, there is limited information available regarding pediatric trauma patients in the EMS. The aim of this study was to investigate the prevalence of pediatric trauma patients within the Swedish EMS and describe the prehospital assessments, interventions, and clinical outcomes.

Methods

This retrospective observational study was conducted in a region of Southwestern Sweden. A random sample from ambulance and hospital records from the year 2019 was selected. Inclusion criteria were children aged 0–16 years who were involved in trauma and assessed by EMS clinicians.

Results

A total of 440 children were included in the study, representing 8.4% of the overall trauma cases. The median age was 9 years (IQR 3–12), and 60.5% were male. The leading causes of injury were low (34.8%) and high energy falls (21%), followed by traffic accidents. The children were assessed as severely injured in 4.5% of cases. A quarter of the children remained at the scene after assessment. Complete vital signs were assessed in 29.3% of children, and 81.8% of children were assessed according to the ABCDE structure. The most common intervention performed by prehospital professionals was the administration of medication. The mortality rate was 0.2%.

Conclusions

Pediatric trauma cases accounted for 8.4% of the overall trauma population with a variations in injury mechanisms and types. Vital sign assessments were incomplete for a significant proportion of children. The adherence to the ABCDE structure, however, was higher. The children remained at the scene after assessment requires further investigation for patient safety.

Introduction

Due to a systemic modification in Swedish emergency medical services (EMS) staffing in recent years, the nature of the Swedish EMS has changed. Transport to an emergency department (ED) is no longer the only option. Referrals and non-conveyance form a growing part of EMS assignments. Trauma is one of the most common causes of death and accounts for 17% of Swedish EMS assignments. The aim of this study was to describe the characteristics and clinical outcomes of non-conveyed trauma patients who were assessed, treated and triaged by the EMS to gain a better understanding of, and to optimise, transport and treatment decisions.

Methods

The study had a descriptive, retrospective and epidemiologic design and was conducted by reviewing EMS and hospital records for 837 non-conveyed trauma patients in the southwest of Sweden in 2019.

Results

Three in four non-conveyed trauma patients did not seek further medical care within 72 h following EMS assessment. The patients who were admitted to hospital later were often older, had suffered a fall and had a medical history. Half of all the incidents occurred in a domestic environment, and head trauma was the major complaint. Less than 1% of the studied patients died.

Conclusion

Most of the non-conveyed trauma patients did not seek further medical care after being discharged at the scene. Falling was the most common trauma event, and for the older population, this meant a higher risk of hospital admission. The reasons for falls should therefore be investigated thoroughly prior to non-conveyance decisions. Future studies should focus on the reasons for non-conveyance and measure the morbidity and invalidity outcomes rather than mortality.

Background

Globally, injuries are a major health problem, and in Sweden, injuries are the second most common reason for ambulance dispatch. However, there is a knowledge gap regarding the epidemiology of injuries requiring assessment by emergency medical services (EMS) in Sweden. The aim of the present study was to describe the prehospital population with injuries that have been assessed and treated by EMS.

Methods

A randomly selected retrospective sample was collected from 1 January through 31 December 2019 in a region in southwestern Sweden. Data were collected from ambulance and hospital medical records.

Results

Among 153,724 primary assignments, 26,697 (17.4%) were caused by injuries. The study cohort consisted of 5,235 patients, of whom 50.5% were men, and the median age was 63 years. The most common cause of injury was low-energy fall (51.4%), and this was the cause in 77.8% of those aged > 63 years and in 26.7% of those aged ≤ 63 years. The injury mechanism was a motor vehicle in 8.0%, a motorcycle in 2.1% and a bicycle in 4.0%. The most common trauma location was the residential area (55.5% overall; 77.9% in the elderly and 34.0% in the younger group). In the prehospital setting, the most frequent clinical sign was a wound (33.2%), a closed fracture were seen in 18.9% and an open fracture in 1.0%. Pain was reported in 74.9% and 42.9% reported severe pain. Medication was given to 42.4% of patients before arrival in the hospital. The most frequent triage colour according to the RETTS was orange (46.7%), whereas only 4.4% were triaged red. Among all patients, 83.6% were transported to the hospital, and 27.8% received fracture treatment after hospital admission. The overall 30-day mortality rate was 3.4%.

Conclusion

Among EMS assignments in southwestern Sweden, 17% were caused by injury equally distributed between women and men. More than half of these cases were caused by low-energy falls, and the most common trauma location was a residential area. The majority of the victims had pain upon arrival of the EMS, and a large proportion appeared to have severe pain.

HUVUDBUDSKAP

• Över 100 avhandlingar har i dagsläget skrivits om den prehospitala akutsjukvården i Sverige.
• Dessa täcker ett omfattande kunskapsfält, allt ifrån prognostiska faktorer vid akut sjukdom till ambulans personalens psykiska och fysiska hälsa.
• Endast ett kunskapsområde har belysts mera om fattande, och det är hjärt–lungräddning vid plötsligt hjärtstopp.
• Vården av patienter med psykisk ohälsa har inte belysts i någon avhandling.
• Det finns stora kunskapsluckor, och vidare forskning inom området behövs.

Background

Patients who call for emergency medical services (EMS) due to abdominal pain suffer from a broad spectrum of diseases, some of which are time sensitive. As a result of the introduction of the concept of ‘optimal level of care‘, some patients with abdominal pain are triaged to other levels of care than in an emergency department (ED). We hypothesised that it could be challenging in a patient safety perspective.

Aim

This study aims to describe consecutive patients who call for EMS due to abdominal pain and are triaged to self-care by EMS clinicians.

Methods

This was an observational study performed in an EMS organisation in Western Sweden during 2020. The triage tool Rapid Emergency Triage and Treatment System (RETTS), which included Emergency Signs and Symptom (ESS) codes, was used to find medical records where patients with abdominal pain have been triaged to self-care and 194 patients was included in the study.

Results

Of total 48,311 ambulance missions, A total of 1747 patients were labelled with ESS code six (abdominal pain), including 223 (12.8%) who were given the code for self-care and 194 who were further assessed by the research group. Of these patients, 32 (16.3%) had a return visit within 96 hours due to the same symptoms and 11 (5.6%) were hospitalised. In six of these patients, the EMS triage was evaluated retrospectively and assessed as inappropriate. These patients had a final diagnosis of ruptured abdominal aneurysm (n = 1), acute appendicitis with peritonitis (n = 2) and acute pancreatitis (n = 3). All these patients required extensive evaluation and different treatments, including acute surgery, antibiotics and fluid therapy.

Conclusion

Amongst the 1747 patients assessed by EMS due to abdominal pain, 223 (12.8%) were triaged to self-care. Of the 194 patients who were further assessed, 16.3% required a return visit to the ED within 96 hours and 5.6% were hospitalised. Six patients had obvious time-sensitive conditions. Our study highlights the difficulties in the early assessment of abdominal pain and the requirement for an accurate decision support tool.

Background

The ambulance service is facing an increased number of calls and ambulance assignments. Between 12 and 42% of all assignments result in non-conveyance to the Accident and Emergency Department. However, there is limited knowledge regarding satisfaction among patients and significant others when patients are assessed as non-urgent and discharged at the scene. Therefore, the aim of the study was to explore and compare satisfaction with the ambulance service among patients and significant others when the patient was discharged at the scene.

Methods

The present study was designed as a cross-sectional exploratory survey with a consecutive sample employing the Consumer Emergency Care Satisfaction Scale questionnaire on patients and significant others.

Results

A total of 162 questionnaires were analysed, 87 patients and 75 significant others. Overall, satisfaction was high with no significant difference between patients and significant others, although 17-19% were dissatisfied with the discharge information.

Conclusions

Generally, patients and significant others are satisfied with the care provided by the Ambulance Service when discharged at the scene and thus not conveyed the Accident and Emergency Department. The participants were especially satisfied with Specialist Ambulance Nurses’ interpersonal skills, e.g., making time and providing thorough information. Guidelines for assignments involving non-conveyance, as well as information, instructions and what to expect when discharged at the scene can be improved. 

Background

The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from “time-sensitive conditions” delaying diagnosis and treatment. Thus, four questions arise:

1) How often are time-sensitive cases referred to primary care or self-care advice?

2) How can we measure and define the level of inappropriate clinical decision-making?

3) What is acceptable?

4) How to increase patient safety?

Main text

To what extent time-sensitive cases are non-conveyed varies. About 5–25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1–3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%.

The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome.

In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories.

There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another.

Conclusion

A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.