Objective: To describe the characteristics and outcome in out-of-hospital cardiac arrest (OHCA) in relation to (i) whether OHCA was coded by the dispatcher as a diagnosis or as a symptom and (ii) the delay until the first unit was alerted at the dispatch centre. Methods: OHCA patients in Göteborg, during 17 months, excluding OHCA after calling the rescue team. Results: Among 250 cases, 20% were coded as a diagnosis (i.e. CA) with or without ongoing cardiopulmonary resuscitation (CPR). Dispatch codes for the remaining 200 patients (80%) were mostly symptom related (unconsciousness in 61%, codes related to breathing problems in 10%, other codes in 24% and missing in 5%). Patients in whom the dispatchers coded the call as CA had an earlier start to CPR after collapse (median 2 vs. 10 min; P<0.0001) and a higher rate of bystander CPR (86% vs. 42%; P<0.0001). Furthermore, they tended to have a higher rate of survival to hospital discharge (14.0% vs. 6.5%; P  = 0.09). The median delay until the first unit was alerted was 1.8 min. Survival to hospital discharge was 10.0% if the delay was below median and 6.7% if the delay was above median (P = 0.48). Conclusion: Patients with OHCA who were not coded by dispatchers as such had a long delay to the start of CPR and a low survival. Dispatching according to diagnosis, that is, CA seems to improve these parameters most likely reflecting a more optimal communication between the dispatcher and the caller as well as the rescue team.

The aim of this study was to describe the possibility of influencing components of hospital delay time within the emergency department (ED) among patients with ST-elevation on the initial electrocardiogram (ECG). Nurses recorded seven patient time points: (1) ED admission; (2) ECG recording; (3) decision by nurse/ED physician; (4) cardiologist ED arrival; (5) decision of coronary care unit (CCU) admission; (6) ED departure; (7) CCU arrival. After special training in ECG, nurses in the ED were subsequently delegated to send patients directly to the CCU if showing ST-elevation on the admission ECG without contacting either the physician in ED or the cardiologist on call (intervention). Delay times between hospital admission and admission to the CCU were evaluated during the 9 months prior to and during the 6 months after the start of this intervention. Fifty patients (66% men) participated in the first study during 3 months (prior to intervention). Patients with suspected or confirmed acute myocardial infarction (AMI) in the ED had a median delay time from ED arrival to CCU arrival of 55.5 minutes (34.5 minutes for patients with confirmed AMI; ST elevation on admission). Time interval from decision to admit to CCU and ED departure was an average of 31% of the total delay. A mean of 21% of total delay occurred between ED decision to cardiologist arrival, and 19% during the time interval from cardiologist ED arrival until decision to CCU admission. Among patients receiving thrombolysis, the median delay time from hospital admission to CCU admission was reduced from 40 minutes during the 9 months prior to start of the intervention (nurses sending patients directly to the CCU) to 22 minutes during the 6 months thereafter (p = 0.02). The largest proportion of hospital delay components for acute coronary syndrome patients occurred between the cardiologist's decision to admit to the CCU and departure from the ED, and the interval following the decision by the nurse or physician to the cardiologist ED arrival. When nurses were delegated to transfer patients with ST-elevation on admission directly to the CCU without contacting a physician, the delay time from ED admission to CCU admission was reduced by nearly 50%.

The outcome of out-of-hospital cardiac arrest (CA) following cardiopulmonary resuscitation (CPR) initiated by dispatcher-provided telephone instructions (T-CPR) in the area of Gothenburg, Sweden was studied. During a period of 27 months, 475 cases categorized by the dispatchers at the Emergency Co-ordination and Dispatch Centre as being suspected CA were offered T-CPR and were included in one of the following groups: (1) T-CPR completed (caller without previous CPR training); (2) T-CPR completed (caller with previous CPR training); (3) T-CPR started, but not completed; (4) T-CPR declined by caller due to previous CPR training; (5) T-CPR declined by caller due to other reasons; or, (6) T-CPR not offered. Of the patients, 473 could be followed up and of them 427 fulfilled the criteria for CA on ambulance arrival. Among the latter cases, 10% were hospitalized alive, 4% could be discharged from hospital, and the distribution among groups was: (1) 7%; (2) 18%; (3) 5%; (4) 11%; (5) 3%; and (6) 1%. The study concludes that although more attention should be paid to the detection of CA patients by the dispatchers, when the dispatchers suspected CA, their accuracy was high. Half of the witnesses accepted the offer of T-CPR and one-third completed T-CPR. More efforts and research are needed, however, to increase the percentages of callers completing CPR. The impact of T-CPR on survival might be limited. Indeed, the comparison of 'resuscitable' patients in whom T-CPR played an important role in supporting bystanders (i.e. groups 1 and 2) with 'resuscitable' patients in whom T-CPR was not performed (i.e. groups 3, 5 and 6) suggests an increase in survival from 6% (groups 3, 5 and 6) to 9% (groups 1 and 2).

The aim of our research was to study the long-term prognosis among patients discharged alive after an out-of-hospital cardiac arrest (OHCA) in comparison with patients discharged alive after acute myocardial infarction (AMI) without OHCA, and also to study the long-term influence of AMI in connection with OHCA. Our research was conducted in the municipality of Göteborg. We retrospectively studied patients discharged from hospital 1990-91 after an OHCA of cardiac aetiology and patients discharged after an AMI without prehospital cardiac arrest. During 1980-98, we studied all patients discharged alive after OHCA of cardiac aetiology, divided into groups of precipitating AMI and no AMI. The study includes 48 patients discharged alive after an OHCA 1990-91, 30 (62%) of whom had a simultaneous AMI and 1425 patients with an AMI without OHCA. Compared with AMI survivors, survivors of an OHCA of cardiac origin were younger but had more frequently a history of congestive heart failure. Their mortality rate during the subsequent 5 years was 46%, compared with 40% among survivors of an AMI (NS). The 5-year mortality rate among patients with an OHCA precipitated by an AMI was 40%. When correcting for differences at baseline, the adjusted risk ratio for death among patients with an OHCA of cardiac origin was 1.2 (95% CI 0.8-1.8) compared with patients with an uncomplicated AMI. During 1980-98, 215 patients were judged as having an OHCA precipitated by an AMI and 115 patients had an OHCA of cardiac aetiology but no simultaneous AMI. Five-year mortality was 54% and 50% respectively (NS). It is concluded that survivors of an OHCA of cardiac origin differed from survivors of an uncomplicated AMI in that they were younger and more frequently had a history of cardiovascular disease. Their 5-year mortality after discharge was similar to that of survivors of an AMI without a prehospital cardiac arrest, even after adjusting for differences at baseline.

The aim of this study was to evaluate short- and long-term outcome prior to and after the introduction of a more intensified treatment in the ambulance of patients with acute severe heart failure. Consecutive patients with acute severe heart failure transported by the mobile coronary care unit (MCCU) in the community of Göteborg prior to and after the introduction of an intensified treatment (nitroglycerine, continuous positive airway pressure (CPAP) and furosemide). One hundred and fifty-eight patients were evaluated during each period. The median age was 77 and 76.5 years, respectively, and 52% and 42% were women. The proportion of patients given nitroglycerine in the ambulance was 4% and 68% in the two periods; the proportion of patients treated with furosemide was 13% and 84%, respectively. CPAP was used in less than 1% during period 1 and in 91% during period 2. On admission of the ambulance 60% had fulminant pulmonary oedema during period 1 versus 78% during period 2 (p<0.0001). On admission to hospital the opposite was found, 93% during period 1 versus 76% during period 2 (p<0.0001). The median serum creatinine kinase (CK-MB) maximum activity was 13 microkat/l during period 1 and 8 microkat/l during period 2 (p = 0.007). However, the mortality during the first year remained high during both periods (39.2% and 35.8%, p = 0.64). It is concluded that a more intensive treatment in the ambulance of patients with acute severe heart failure seems to have resulted in an improvement in symptoms during transport and less myocardial damage. However, no significant improvement in long-term mortality was observed.

OBJECTIVES: To evaluate whether a computer-based decision support system could be useful for the emergency medical system when identifying patients with acute myocardial infarction (AMI) or life-threatening conditions and thereby improve the allocation of life support level. METHODS: Patients in the Municipality of Göteborg who dialled the dispatch centre due to chest pain during a period of 3 months. To analyse the relationship between patient characteristics (according to a case record form used during an interview) and the response variables (AMI or life-threatening condition), multivariate logistic regression was used. For each patient, the probability of AMI/life-threatening condition was estimated by the model. We used these probabilities retrospectively to allocate advanced life support or basic life support. This model allocation was then compared with the true allocation made by the dispatchers. RESULTS: The sensitivity, that is, the percentage of AMI patients allocated to advanced life support, was 85.7% in relation to the true allocation made by the dispatchers. The corresponding sensitivity regarding allocation made by the model was 92.4% (P=0.17). The specificity was also slightly higher for the model allocation than the dispatcher allocation. Among the 15 patients with AMI who were allocated to basic life support by the dispatchers, nine died (eight during and one after hospitalization). Among the eight patients with AMI allocated to basic life support by the model, only one patient died (in hospital) (P=0.02). CONCLUSION: A computer-based decision support system including a prevalence function could be a valuable tool for allocating the level of life support. The case record form, however, used for the interview can be refined and a model based on a larger sample and confirmed in a prospective study is recommended.

Objectives: To evaluate whether a computer-based decision support system could be useful for the emergency medical system when identifying patients with acute myocardial infarction (AMI) or life-threatening conditions and thereby improve the allocation of life support level. Methods: Patients in the Municipality of Göteborg who dialled the dispatch centre due to chest pain during a period of 3 months. To analyse the relationship between patient characteristics (according to a case record form used during an interview) and the response variables (AMI or life-threatening condition), multivariate logistic regression was used. For each patient, the probability of AMI/life-threatening condition was estimated by the model. We used these probabilities retrospectively to allocate advanced life support or basic life support. This model allocation was then compared with the true allocation made by the dispatchers. Results: The sensitivity, that is, the percentage of AMI patients allocated to advanced life support, was 85.7% in relation to the true allocation made by the dispatchers. The corresponding sensitivity regarding allocation made by the model was 92.4% (P=0.17). The specificity was also slightly higher for the model allocation than the dispatcher allocation. Among the 15 patients with AMI who were allocated to basic life support by the dispatchers, nine died (eight during and one after hospitalization). Among the eight patients with AMI allocated to basic life support by the model, only one patient died (in hospital) (P=0.02). Conclusion: A computer-based decision support system including a prevalence function could be a valuable tool for allocating the level of life support. The case record form, however, used for the interview can be refined and a model based on a larger sample and confirmed in a prospective study is recommended.

The aim of this survey was to explore treatment routines with regard to early heart attack care at various hospitals in Sweden. All the hospitals in Sweden with a coronary care unit or its equivalent were sent a postal enquiry about early heart attack care including use of various medications and educational level of health care providers. In all, 84 of 86 hospitals (98%) answered the enquiry. Prior to hospital admission, 10% of the hospitals used thrombolytic agents, 10% used beta-blockers and 55% used aspirin. In only 4% of hospitals was thrombolytic treatment initiated in the emergency department and in 17% beta-blockers were initiated. The proportion of acute myocardial infarction (AMI) patients who received thrombolytic treatment varied from 10% to more than 80%, with a mean value of 41%. The proportion of AMI patients who received intravenous beta-blockade varied from 0 to 93%, with a mean value of 24%. This survey indicates that the vast majority of hospitals in Sweden use thrombolytic agents in more than 30% of AMI patients and aspirin in more than 80% of AMI patients. The use of intravenous beta-blockade is lower than expected. Considering the strong association between the delay before instituting therapy and outcome, it is surprising that treatment is not initiated more frequently outside hospital or in the emergency department.

OBJECTIVES: To evaluate whether a computer-based decision support system could be useful for the emergency medical system when identifying patients with acute myocardial infarction (AMI) or life-threatening conditions and thereby improve the allocation of life support level. METHODS: Patients in the Municipality of Göteborg who dialled the dispatch centre due to chest pain during a period of 3 months. To analyse the relationship between patient characteristics (according to a case record form used during an interview) and the response variables (AMI or life-threatening condition), multivariate logistic regression was used. For each patient, the probability of AMI/life-threatening condition was estimated by the model. We used these probabilities retrospectively to allocate advanced life support or basic life support. This model allocation was then compared with the true allocation made by the dispatchers. RESULTS: The sensitivity, that is, the percentage of AMI patients allocated to advanced life support, was 85.7% in relation to the true allocation made by the dispatchers. The corresponding sensitivity regarding allocation made by the model was 92.4% (P=0.17). The specificity was also slightly higher for the model allocation than the dispatcher allocation. Among the 15 patients with AMI who were allocated to basic life support by the dispatchers, nine died (eight during and one after hospitalization). Among the eight patients with AMI allocated to basic life support by the model, only one patient died (in hospital) (P=0.02). CONCLUSION: A computer-based decision support system including a prevalence function could be a valuable tool for allocating the level of life support. The case record form, however, used for the interview can be refined and a model based on a larger sample and confirmed in a prospective study is recommended.

The very early handling of patients with suspected acute myocardial infarction (AMI) is of critical importance to the outcome. The aim of this study was to relate the dispatcher's initial suspicion of AMI, among patients who call for an ambulance due to chest pain, to the subsequent diagnosis and outcome. All patients who called for an ambulance in Gothenburg due to acute chest pain during a 2-month period were included in the study. In all, 503 patients fulfilled the inclusion criteria, and information on the dispatcher's initial suspicion of AMI was available in 484 patients. There was at least a strong suspicion of AMI in 36%, a moderate suspicion of AMI in 34% and only a vague or no suspicion in 30%. Among patients with at least a strong suspicion of AMI, 29% subsequently developed infarcation, compared with 18% among patients with a moderate suspicion of AMI and 15% among patients with only a vague or no suspicion (p < 0.001). However, the priority level was similar in patients with and without a life-threatening condition, and the mortality rate remained similar in patients with a strong suspicion and those without a strong suspicion of AMI. Thus, among patients who called for an ambulance due to acute chest pain there was a direct relationship between the dispatcher's suspicion of AMI and the subsequent diagnosis, but the mortality rate was similar in the different groups.

Many previous studies have shown that there is a gender difference in terms of the use of diagnostic procedures and the treatment of patients with chest pain. The mechanisms behind these observations are less well described. This survey describes gender differences in the aetiology of chest pain and symptoms associated with acute myocardial infarction (AMI). Among the patients with symptoms of acute chest pain, in the emergency medical department women less frequently develop an AMI and are less frequently given a diagnosis of ischaemic heart disease. Among patients developing an AMI, women differ from men by less frequently reporting chest pain, more frequently reporting nausea, vomiting, abdominal complaints, fatigue and dyspnoea and less frequently reporting sweating. With regard to the localization of pain in AMI, women differ from men by more frequently reporting pain in the back, neck and jaw. In terms of electrocardiographic changes, women seem to have less marked ST deviations than men. However, we do not believe that these differences between women and men are substantial enough and, as a result, we do not recommend that the initial medical care of patients seeking medical attention with chest pain or other symptoms raising a suspicion of AMI should be differentiated with regard to gender. The differences described here might partly explain the prolonged delay until hospital admission in women suffering from AMI.

The aim of this study was to describe the characteristics and long-term outcome for patients suffering from acute chest pain in relation to whether or not they were transported to hospital by ambulance. All patients with acute chest pain who were admitted over a 21-month period to the emergency department at Sahlgrenska Hospital in Göteborg with symptoms of acute chest pain were included in the study. Consecutive patients were prospectively registered and followed with regard to mortality and morbidity over 5 years. In all, 4270 patients took part in the evaluation, of whom 1445 (34%) were transported by ambulance. Patients transported by ambulance were older (p < 0.0001) and had a higher prevalence of previous myocardial infarction, angina pectoris, hypertension, diabetes mellitus, and congestive heart failure (p < 0.0001 for all) than the others. They more frequently developed acute myocardial infarction (28% vs. 11%; p < 0.0001) and there was a final diagnosis of either confirmed or possible myocardial infarction/ischaemia in 69% compared with 38% for patients not transported by ambulance (p < 0.0001). The 5-year mortality among ambulance-transported patients was 41% vs. 16% among those who were not (p < 0.0001). When correcting for dissimilarities at baseline including final diagnosis the adjusted risk ratio for death among ambulance transported patients was 1.44 (95% confidence limit 1.26-1.65). However, we did not correct for severe non-cardiac diseases. It is concluded that among patients admitted to the emergency department with acute chest pain, those transported by ambulance had a much higher mortality during the subsequent 5 years than those who were not transported by ambulance. This was not entirely explained by observed differences at baseline. This information should be considered when ambulance organizations are being constructed.

The aim of this study was to compare the characteristics and outcome for patients coming to the emergency department with acute chest pain in a city university hospital, representing an urban area, and a county hospital, representing a rural area. This was a retrospective survey of all chest pain patients at Sahlgrenska University Hospital, Göteborg, covering an area with 706 inhabitants/km2, and at Uddevalla County Hospital, Uddevalla, covering an area with 34 inhabitants/km2, over a period of 6 months. In all 2,297 patients were registered at Sahlgrenska University Hospital and 1062 at Uddevalla Hospital (per 100,000 inhabitants and year 1,502 and 1,342 patients, respectively). The patients in the urban area were more frequently sent home from the emergency department than in the rural area (30% versus 23%; p < 0.0001). Patients in the urban area had a lower prevalence of previous cardiovascular diseases. An obvious acute myocardial infarction (AMI) or a strong suspicion of AMI at initial evaluation was less frequent in the urban area whereas no suspicion of AMI was twice as common (46% versus 24%; p < 0.0001). Furthermore, there was a difference in the use of medications; various cardiovascular drugs were more frequently used in the rural area. Despite these differences at baseline the 30-day mortality was similar (3.5% in the urban area and 3.6% in the rural area; NS), as well as the 2-year mortality (14.0% and 12.7%, respectively; NS). It is concluded that the number of patients admitted to the emergency department with acute chest pain/100,000 was slightly higher in the urban than in the rural area. Patients in the urban area differed from those in the rural area having a lower prevalence of previous cardiovascular diseases, a lower initial suspicion of AMI, they were less frequently hospitalized and less frequently prescribed various cardiovascular drugs. Mortality did not differ between the two cohorts.

The aim of this study was to describe mortality, mode of death and risk indicators for death during 5 years of follow-up among men and women coming to the emergency department with chest pain or other symptoms raising suspicion of acute myocardial infarction (AMI). During the 21 months of the study, all patients who came to the medical emergency department of one single hospital with chest pain or other symptoms suggestive of AMI were prospectively followed for 5 years. A total of 5362 patients came on 7157 occasions; men accounted for 55% of the admissions. The 5-year mortality rate was 25.6% for men compared with 25.7% for women. The women were older and had a higher prevalence of known congestive heart failure and hypertension, whereas the prevalence of previous myocardial infarction was higher in men. When correcting for dissimilarities in age and clinical history, male gender appeared as an independent predictor of death. In terms of mode of death men differed from women: more frequently dying at home, more frequently dying in association with ventricular fibrillation and less frequently dying in association with congestive heart failure. However, these differences were to some extent explained by differences in age. Independent risk indicators for death during 5 years of follow-up differed in men and women. It was concluded that in a consecutive series of patients with chest pain or other symptoms suggesting AMI in the emergency department, male gender was an independent risk indicator for death during a 5-year follow-up. This might be explained by a higher occurrence of coronary artery disease in men than in women in this patient population.

This paper describes the rate of re-admission and the characteristics of patients who were re-admitted after having been discharged directly from the emergency department at Sahlgrenska Hospital when they presented with acute chest pain or other symptoms suggestive of acute myocardial infarction. A total of 1463 patients were admitted and directly discharged during the 15 month recruitment period, of whom 222 (15%) were re-admitted at least once and 72 (5%) were re-admitted more than once during the subsequent 6 to 21 months. However, among patients not being re-admitted, 63% reported recurrency of symptoms one year after discharge. Re-admitted patients differed from those who were not re-admitted by: being older (p < 0.001); they more frequently had a history of cardiovascular diseases (p < 0.001); they more frequently had a pathological electrocardiogram (p < 0.001); and they were more frequently judged to have angina pectoris (p < 0.001). Among re-admitted patients, about half were hospitalized but only 10% developed AMI. In conclusion, among patients who were discharged directly from the emergency department with acute chest pain, 15% were re-admitted with similar symptoms only. A minority, however, developed acute myocardial infarction. A high proportion of patients not being re-admitted had recurrency of symptoms.

The earlier infarct-limiting therapy is started the better is the outcome among patients suffering from a threatened myocardial infarction. The introduction of a prehospital electrocardiogram has improved triage of patients with acute chest pain. With regard to medication, fibrinolytic agents have the best documentation. Their use when frequently followed by a percutaneous coronary intervention at a later stage may be a good alternative among patients with ST-elevation myocardial infarction. Other treatments of potential value in the prehospital setting are oxygen, narcotic analgesics, nitrates, aspirin, heparin, low molecular weight heparin, glycoprotein IIB, IIIA blockers, clopidogrel and beta-blockers. We need further studies, however, for most of these treatments including cost-benefit analysis, analysis of various logistic aspects and safety in order to confirm their value.

Objectives: To evaluate the setting of priorities and patients' need for the ambulance service. Methods: A prospective, consecutive study was conducted during a 6-week period. The ambulance staff completed a questionnaire assessing each patient's need for prehospital care. In addition to the questionnaire, data were extracted from the ambulance medical records for each case. Results: The study included 1977 ambulance assignments. The results show that there is a substantial safety margin in the priority assessments made by the emergency medical dispatch operators, where the ambulance staff support the safety margin for initial priorities, despite the lack of at-the-scene confirmation. At-the-scene assessments indicated that 10% of all patients had potentially life-threatening conditions or no signs of life, but the advanced life support units were not systematically involved in these serious cases. The results even showed that one-third of the patients for whom an ambulance was assigned did not need the ambulance service according to the assessment made by the ambulance staff. Conclusion: Using the criteria-based dispatch protocol, the personnel at the emergency medical dispatch centres work with a safety margin in their priority assessments for ambulance response. Generally, this 'overtriage' and safety margin for initial priority settings were supported as appropriate by the ambulance staff. According to the judgement of the ambulance staff, one-third of all the patients who were assigned an ambulance response did not require ambulance transport.

OBJECTIVES: To evaluate the setting of priorities and patients' need for the ambulance service. METHODS: A prospective, consecutive study was conducted during a 6-week period. The ambulance staff completed a questionnaire assessing each patient's need for prehospital care. In addition to the questionnaire, data were extracted from the ambulance medical records for each case. RESULTS: The study included 1977 ambulance assignments. The results show that there is a substantial safety margin in the priority assessments made by the emergency medical dispatch operators, where the ambulance staff support the safety margin for initial priorities, despite the lack of at-the-scene confirmation. At-the-scene assessments indicated that 10% of all patients had potentially life-threatening conditions or no signs of life, but the advanced life support units were not systematically involved in these serious cases. The results even showed that one-third of the patients for whom an ambulance was assigned did not need the ambulance service according to the assessment made by the ambulance staff. CONCLUSION: Using the criteria-based dispatch protocol, the personnel at the emergency medical dispatch centres work with a safety margin in their priority assessments for ambulance response. Generally, this 'overtriage' and safety margin for initial priority settings were supported as appropriate by the ambulance staff. According to the judgement of the ambulance staff, one-third of all the patients who were assigned an ambulance response did not require ambulance transport.

OBJECTIVE: The purpose of this report was to describe the characteristics of patients transported by ambulance, in spite of being evaluated by the ambulance staff at the scene as not requiring prehospital care. A second aim was to compare these patients with those judged as being in need of this care. METHODS: Three ambulance service districts located in different rural and metropolitan geographical areas were included in the study and all three were covered by a single emergency dispatch centre. Following the dispatch of ambulances, the staff assessed and recorded the medical needs of the patients at the scene, according to a questionnaire developed for the study. In addition to the questionnaire, data were extracted from the ambulance medical records database for each patient. If the patients were just transported by ambulance without receiving any other prehospital intervention, they were assessed as not being in need of the emergency service. The evaluation included events at the scene and during transportation. The ambulance staff making the needs assessments were emergency medical technicians and registered nurses. In this report, 604 patients who did not require prehospital care are described and compared with the remaining group of patients who required this care (1373). For analysis, descriptive statistics were used to analyse the data. RESULTS: The ambulance staff assessed that, among patients reported by the emergency medical dispatch centre as having abdominal or urinary problems, 42% did not need the ambulance service. Even among intrahospital transports (patients for whom medical personnel made the request for an ambulance), 45% did not require ambulance transport, as judged by the ambulance staff. Among patients reported by the emergency medical dispatch centre as having chest pain or other heart symptoms or trauma/accidents, respectively, only small percentages (18%) and (17%) did not require the ambulance service, as assessed by the ambulance staff. Most of the patients without obvious medical needs had been allocated an ambulance response for nonurgent conditions, that is priority level 2 or 3, but patients without medical needs were even found at the highest priority level 1. Of the patients who did not require an ambulance, more than half (55%) would have been able to get to a hospital in their own car or by taxi, whereas the remainder of the patients needed a transport vehicle in which they could lie down, but which was not equipped and staffed like an ambulance. CONCLUSION: Among the patients transported by the emergency medical service system in the study areas, a significant percentage were judged by the ambulance staff as not being in need of prehospital interventions. The majority were transported by a fully equipped emergency medical ambulance to an emergency medical department at a hospital, without requiring any prehospital interventions either at the scene or during transportation. The emergency medical service organization has to develop clear criteria for the utilization of ambulance services that can be accepted and implemented by the dispatch centres and by healthcare personnel. These criteria need to include safety margins and at the same time enable the appropriate use of resources.

OBJECTIVES: To evaluate the setting of priorities and patients' need for the ambulance service. METHODS: A prospective, consecutive study was conducted during a 6-week period. The ambulance staff completed a questionnaire assessing each patient's need for prehospital care. In addition to the questionnaire, data were extracted from the ambulance medical records for each case. RESULTS: The study included 1977 ambulance assignments. The results show that there is a substantial safety margin in the priority assessments made by the emergency medical dispatch operators, where the ambulance staff support the safety margin for initial priorities, despite the lack of at-the-scene confirmation. At-the-scene assessments indicated that 10% of all patients had potentially life-threatening conditions or no signs of life, but the advanced life support units were not systematically involved in these serious cases. The results even showed that one-third of the patients for whom an ambulance was assigned did not need the ambulance service according to the assessment made by the ambulance staff. CONCLUSION: Using the criteria-based dispatch protocol, the personnel at the emergency medical dispatch centres work with a safety margin in their priority assessments for ambulance response. Generally, this 'overtriage' and safety margin for initial priority settings were supported as appropriate by the ambulance staff. According to the judgement of the ambulance staff, one-third of all the patients who were assigned an ambulance response did not require ambulance transport.

OBJECTIVE: The purpose of this report was to describe the characteristics of patients transported by ambulance, in spite of being evaluated by the ambulance staff at the scene as not requiring prehospital care. A second aim was to compare these patients with those judged as being in need of this care. METHODS: Three ambulance service districts located in different rural and metropolitan geographical areas were included in the study and all three were covered by a single emergency dispatch centre. Following the dispatch of ambulances, the staff assessed and recorded the medical needs of the patients at the scene, according to a questionnaire developed for the study. In addition to the questionnaire, data were extracted from the ambulance medical records database for each patient. If the patients were just transported by ambulance without receiving any other prehospital intervention, they were assessed as not being in need of the emergency service. The evaluation included events at the scene and during transportation. The ambulance staff making the needs assessments were emergency medical technicians and registered nurses. In this report, 604 patients who did not require prehospital care are described and compared with the remaining group of patients who required this care (1373). For analysis, descriptive statistics were used to analyse the data. RESULTS: The ambulance staff assessed that, among patients reported by the emergency medical dispatch centre as having abdominal or urinary problems, 42% did not need the ambulance service. Even among intrahospital transports (patients for whom medical personnel made the request for an ambulance), 45% did not require ambulance transport, as judged by the ambulance staff. Among patients reported by the emergency medical dispatch centre as having chest pain or other heart symptoms or trauma/accidents, respectively, only small percentages (18%) and (17%) did not require the ambulance service, as assessed by the ambulance staff. Most of the patients without obvious medical needs had been allocated an ambulance response for nonurgent conditions, that is priority level 2 or 3, but patients without medical needs were even found at the highest priority level 1. Of the patients who did not require an ambulance, more than half (55%) would have been able to get to a hospital in their own car or by taxi, whereas the remainder of the patients needed a transport vehicle in which they could lie down, but which was not equipped and staffed like an ambulance. CONCLUSION: Among the patients transported by the emergency medical service system in the study areas, a significant percentage were judged by the ambulance staff as not being in need of prehospital interventions. The majority were transported by a fully equipped emergency medical ambulance to an emergency medical department at a hospital, without requiring any prehospital interventions either at the scene or during transportation. The emergency medical service organization has to develop clear criteria for the utilization of ambulance services that can be accepted and implemented by the dispatch centres and by healthcare personnel. These criteria need to include safety margins and at the same time enable the appropriate use of resources.

This study aimed to test the hypothesis that there is a difference in mortality between patients hospitalized with acute chest pain in a university hospital and those hospitalized in a county hospital, and to describe differences in characteristics and use of medical resources in these two settings. All patients hospitalized at Sahlgrenska University Hospital in Göteborg (with a catchment population of 706 inhabitants/km2) and Uddevalla County Hospital (with a catchment population of 34 inhabitants/km2) with symptoms of acute chest pain during a registration period of 6 months were included in the study. A total of 1592 patients in the city hospital and 822 in the county hospital fulfilled the given criteria for inclusion. Patients in the urban area differed from those in the rural area in that they had a lower prevalence of previous angina pectoris and hypertension and a higher prevalence of previous cancer, previous percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) and current smoking. On admission to hospital, patients in the urban area less frequently showed clinical signs of congestive heart failure and acute ischaemia on the electrocardiogram (ECG) but more frequently had a pathological ECG without signs of ischaemia and more frequently had a heart rate >100 beats/min. The use of medical resources differed between the two hospitals. Revascularization was more frequent in the city hospital and the use of [beta]-blockers in the county hospital. The overall 30 day mortality was 4.7% in the urban area and 4.3% in the rural area (P=0.74). When correcting for differences at baseline, the risk ratio for death in the county hospital versus the city hospital was 0.84 (95% confidence interval 0.51–1.40, P=0.53). In conclusion, among patients hospitalized with acute chest pain in a city university and a county hospital the mortality during the subsequent 30 days did not differ. However, there were differences in terms of the use of medical resources and in previous history, chronic medication prior to hospital admission and status on admission between the two cohorts.

The aim of this research was to describe men and women who were discharged from the emergency department after having an initial suspicion of acute myocardial infarction ruled out in terms of patient characteristics, symptom reevaluation, electrocardiogram and exercise stress test. Consecutive patients below the age of 65 years who came to the emergency department of Sahlgrenska Hospital with acute chest pain or other symptoms raising suspicion of acute myocardial infarction for whom the suspicion was ruled out either directly in the emergency department or less than 1 day after hospital admission were included in the study. Four hundred and eighty-four patients participated, of whom 295 (61%) were men. Men had a higher prevalence of ischaemic heart disease. The cause of pain was judged similarly at reevaluation compared with in the emergency department in 53% of the cases. Only in 4.6% of the cases were the symptoms judged to be caused by myocardial ischaemia on both occasions. At the initial visit 36.0% of the patients were judged to have uncertain cause of the symptoms. This proportion was lowered to 26.4% at reevaluation. The exercise electrocardiogram at reevaluation revealed clinical and electrocardiographic signs indicating definite myocardial ischaemia in 2.6% of the cases. Early follow-up of patients discharged from the emergency department after acute myocardial infarction was ruled out revealed that a low proportion showed signs of myocardial ischaemia. In about half of the cases the judgement differed from that being made in the emergency department.

This paper evaluates the impact of an early revisit including symptom evaluation and an exercise electrocardiogram on recurrency of symptoms and readmissions during 1 year of follow-up among patients coming to hospital with chest pain or an initial suspicion of acute myocardial infarction (AMI) but in whom the suspicion was quickly ruled out. Patients below the age of 65 admitted to the emergency department (ED) at Sahlgrenska Hospital due to chest pain or other symptoms raising a suspicion of AMI who were either directly discharged from the ED or discharged within 1 day after having AMI ruled out. Patients were allocated to two groups: (1) patients being re-evaluated in a chest pain clinic less than a week after discharge from hospital (intervention group) and (2) patients handled routinely with no formalized follow-up (control group). The intervention group (n=484) and the control group (n=374) were comparable at baseline. During 1 year of follow-up, patients in the intervention group had a lower rate of readmissions to the ED than patients in the control group (17.4% versus 24.9%, p < 0.05) and a lower rate of rehospitalizations (15.9% versus 23.3%, p < 0.05). The proportion of patients being on sick leave at any time during the follow-up did not differ and neither did the recurrency of symptoms. The introduction of a chest pain clinic for patients early discharged from hospital after having AMI ruled out indicated beneficiency in terms of a lower rate of readmissions to the ED and a lower requirement of rehospitalizations. However, a methodological weakness in the randomization procedure suggest carefulness in interpretation.

Since it is suggested that only effective cardiopulmonary resuscitation (CPR) improves survival rates, quality control of training outcomes is important and comparisons between different training methods are desirable. The aim of this study was to test a model of quality assurance, consisting of a computer program combined with the Brennan et al. checklist, for evaluation of CPR performance. A small group of trained medical professionals (cardiac care unit nurses) (n = 10) was used in this pilot study. The result points out several points of concern: half of the participants did not open the airway prior to breathing control. Over 90% of all inflations were 'too fast' and 71% were 'too much'. Only 6.5% of the inflations were correct. On average, the participants made 5.4 inflations per minute. Concerning chest compressions, 40% were 'too deep' while only 4% were 'too shallow'. In spite of the fact that the participants had an average rate at 95 compressions per minute the number of compressions varied between 32 and 51 during 1 minute. When new guidelines are discussed, it would be beneficial if they were tested by a number of people to investigate if following the guidelines is at all possible.

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. Keywords: ambulance, assessment, emergency medical service, geriatrics, prehospital nurse, triage