OBJECTIVES: We compare various aspects in the early chain of care among patients with haemorrhagic stroke and ischaemic stroke.

MATERIALS & METHODS: The Emergency Medical Services (EMS) and nine emergency hospitals, each with a stroke unit, were included. All patients hospitalised with a first and a final diagnosis of stroke between 15 December 2010 and 15 April 2011 were included. The primary endpoint was the system delay (from call to the EMS until diagnosis). Secondary endpoints were: (i) use of the EMS, (ii) delay from symptom onset until call to the EMS; (iii) priority at the dispatch centre; (iv) priority by the EMS; and (v) suspicion of stroke by the EMS nurse and physician on admission to hospital.

RESULTS: Of 1336 patients, 172 (13%) had a haemorrhagic stroke. The delay from call to the EMS until diagnosis was significantly shorter in haemorrhagic stroke. The patient's decision time was significantly shorter in haemorrhagic stroke. The priority level at the dispatch centre did not differ between the two groups, whereas the EMS nurse gave a significantly higher priority to patients with haemorrhage. There was no significant difference between groups with regard to the suspicion of stroke either by the EMS nurse or by the physician on admission to hospital.

CONCLUSIONS: Patients with a haemorrhagic stroke differed from other stroke patients with a more frequent and rapid activation of EMS.

The task of emergency departments (EDs) is to provide safe emergency healthcare while adopting a caring, cost-effective approach. Patients attending EDs have different medical and caring needs and it is assumed that practitioners have the requisite competencies to meet those needs. The aim of the present study is to explore what kind of competencies practitioners and managers describe as necessary for the practitioners to perform their everyday work in EDs. Methods: This study used a qualitative, exploratory design. Interviews were conducted in two EDs. Data were analysed using inductive content analysis. Results: The competence focus in everyday work in EDs is on emergency and life-saving actions. There is a polarisation between medical and caring competencies. There is also tension between professional groups in EDs as well as hierarchical boundaries that influence the ability to develop competencies in everyday work. Medical competencies are valued more and caring competencies are subsequently downgraded. A medical approach to competencies consolidates the view of necessary competencies in everyday work in EDs. Conclusions: The study shows that the competencies that are valued consolidate the prevailing medical paradigm. There is a traditional, one-sided approach to competencies, a hierarchical distinction between professional groups and unclear occupational functions.

Introduction: Through their formal mandate, position and authority, managers are responsible for managing everyday work in Emergency Departments (EDs) as well as striving for excellence and dealing with the individual needs of practitioners and patients. The aim of the present study is to explore managers’experiences of managing everyday work in Swedish EDs. Method: A qualitative and exploratory design has been used in this study. Seven managers were interviewed at two EDs. Data was analysed using qualitative content analysis with focus on latent content. Results: Managers experience everyday work in the ED as lifesaving work. One of the characteristics of their approach to everyday work is their capability for rapidly identifying patients with life-threatening conditions and for treating them accordingly. The practitioners are on stand-by in order to deal with unexpected situations. This implies having to spend time waiting for the physicians’ decisions. Management is characterised by a command and control approach. The managers experience difficulties in meeting the expectations of their staff. They strive to be proactive but instead they become reactive since the prevailing medical, bureaucratic and production-orientated systems constrain them. Conclusion: The managers demonstrate full compliance with the organisational systems. This threatens to reduce their freedom of action and influences the way they perform their managerial duties within and outside the EDs.

In emergency medical services (EMS), the clinical reasoning (CR) of registered nurses (RNs) working in ambulance care plays an important role in providing care and treatment that is timely, accurate, appropriate and safe. However, limited existing knowledge about how CR is formed and influenced by the EMS mission hinders the development of service provision and decision support tools for RNs that would further enhance patient safety. To explore the nature of CR and influencing factors in this context, an inductive case study examined 34 observed patient–RN encounters in an EMS setting focusing on ambulance care. The results reveal a fragmented CR approach involving several parallel decision-making processes grounded in and led by patients’ narratives. The findings indicate that RNs are not always aware of their own CR and associated influences until they actively reflect on the process, and additional research is needed to clarify this complex phenomenon.

Introduction

Clinical reasoning (CR) among healthcare professionals working in emergency medical services (EMS) who focus on ambulance care is a vital part of ensuring timely and safe patient care. The EMS environment continually fluctuates, so clinicians constantly need to adapt to new situations. Organizational support is described as important for CR, but overall, research on organizational influences for CR in an EMS context is lacking. An increased understanding of these influencing factors can assist in the development of EMS by strengthening CR among clinicians. Therefore, the purpose of this study was to investigate the organizational factors influencing EMS clinicians’ CR.

Methods

Using a qualitative single case study design, an EMS organization in southwestern Sweden was explored. Data were collected from participant observations of patient encounters, individual and group interviews with clinicians and organizational representatives, and organizational document audits. Data were analyzed using qualitative content analysis and triangulation of data sources.

Results

The results revealed several organizational influencing factors. Collaboration and information sharing internally and externally were emphasized as essential components influencing CR. Additionally, the structure for the clinicians’ ‘room for action’ appeared confused and created uncertainties for CR related to decision mandates.

Conclusion

The conclusion is that organizational factors do play an important role in clinicians’ CR. Moreover, the EMS community needs to develop suitable forums for discussing and developing these influencing factors across organizational hierarchies. Finally, clarification is needed on clinicians’ ‘room for action’ within their own organization but also with possible collaborators.

Abstract: Clinical reasoning is the process of gathering and understanding information conducted by clinicians in the emergency medical services (EMS) so as to make informed decisions. Research on clinical reasoning spans several disciplines, but a comprehensive view of the process is lacking. To our knowledge, no review of clinical reasoning in the EMS has been conducted.

Aim: The aim was to investigate the nature, deployment, and factors influencing EMS clinicians’ clinical reasoning by means of a review.

Method: Data was collected through searches in electronic databases, networking among research teams ,colleagues and friends, “grey literature,” and through ancestry searches. A total of 38 articles were deemed eligible for inclusion and were analyzed using descriptive thematic analysis. The analysis resulted in an overarching finding -namely, the importance for EMS clinicians to adjust for perceived control in unpredictable situations. Within this finding, 3 themes emerged in terms of EMS clinicians’ clinical reasoning: (1) maintaining a holistic view of the patient; (2) keeping an open mind; and (3) improving through criticism. Seven subthemes subsequently emerged from these three themes.

Results: This review showed that EMS clinicians’ clinical reasoning begins with the information that they are given about a patient. Based on this information, clinicians calculate the best route to the patient and which equipment to use, and they also assess potential risks. They need to be constantly aware of what is happening on the scene and with the patient and strive to control the situation. This striving also enables EMS clinicians to work safely and effectively in relation to the patient, their relatives, other clinicians, associated organizations, and the wider community. A lack of contextually appropriate guidelines results in the need for creativity and forces EMS clinicians to use “workarounds” to solve issues beyond the scope of the guidelines available. In addition, they often lack organizational support and fear repercussions such as litigation, unemployment, or blame by their EMS or healthcare organization or by patients and relatives.

Conclusion: Clinical reasoning is influenced by several factors. Further research is needed to determine which influencing factors can be addressed through interventions to minimize their impact on patient outcomes.

Aims and objectives: The aim of this study was to describe and explain elderly patients’ lived experiences of prehospital emergency care in cases of suspected hip fractures after falling. Background: Hip fractures represent a major health problem for older people and are a common assignment for the Emergency Medical Services (EMS), but there is little information on how patients experience prehospital emergency care. Design: A reflective lifeworld approach based on phenomenological epistemology was used in an interview study within the context of healthcare science. Methods: Ten elderly patients were interviewed. These depth interviews were tape-recorded, transcribed verbatim and analysed for meanings. Results: The comprehensive understanding of the phenomenon is: ‘Happy to have been rescued, despite bad experiences as well as good’. The elderly patient is offered care in an open and friendly atmosphere concurrently with feeling anxiety about the treatment. Intervention with streamlined care and treatment can thus simultaneously be beneficial as well as doing harm. Patients experience confusion and the need to ask questions about what really happened in the ambulance. Bad experiences remain unexplained. This study is based on three themes with relevant sub-themes: efficiency, concerned encounters and suffering from care. Conclusions: Our study contribute to this field of discussion, showing that administering drugs which cause side effects in already fragile older people is compatible with neither evidence-based care nor evidenced-based medicine. The side effects of pain relief – however efficient that pain relief may be – are taken seriously. Relevance to clinical practice: Pain relief in the EMS should be individualised. Responsibility for patients’ safety regarding pain relief is emphasised. This development should focus on care that is already good and gradually eradicate compassionless care. Keywords: caring science, hip fracture, lived experiences, phenomenology, emergency medical services, ambulance, care pathway, prehospital emergency nurse

Förord av Björn Brorström, Prorektor Högskolan i Borås Ett professionslärosäte bedriver utbildning och forskning på vetenskaplig grund. Vetenskapliga metoder tillämpas och framkomna resultat prövas för att säkra tillförlitlighet och relevans. Förmågan att problematisera, formulera frågor och välja lämpliga metoder för att besvara frågor är egenskaper för god forskning och utmärkande för en stark utbildnings- och forskningsmiljö. Vid ett professionslärosäte finns samtidigt en stark strävan efter att i utbildning och forskning ta till vara den kunskap och de erfarenheter som professioner besitter och därigenom säkra en hög grad av praktisk relevans. Växelverkan mellan teori och praktik och erfarenhetsutbyte mellan forskare och praktiker är ständigt pågående. Det finns ingen avslutning på processen utan den pågår utan avbrott. En nödvändig förutsättning för ett fruktbart samarbete är en ömsesidig respekt och vilja att stödja och ifrågasätta varandra. Forskaren måste vara beredd på kritik för bristen på praktisk relevans och professionsföreträdaren måste vara beredd på att förtrogenhetskunskapens lämplighet ifrågasätts. Det är en fråga om med- och mothåll från båda håll i syfte att långsiktigt utveckla teori och praktik. Det är en utmaning att utveckla, etablera och därefter kontinuerligt försvara och förbättra professionslärosätet. Ett led i utvecklingen är att inom ramen för Högskolan i Borås föra en debatt om innebörden av ett professionslärosäte och vad vi behöver göra för att förbättra verksamheten. På uppdrag av rektor Lena Nordholm har medarbetare vid Bibliotekshögskolan utvecklat och ansvarat för en seminarieserie benämnd Profession och vetenskap. Seminarierna spände över ett brett fält. En av många viktiga frågor som diskuterades flitigt var huruvida vi ska forska om professioner, i för eller med, eller kanske alltihop samtidigt. Bidragen publiceras nu i denna antologi som ges ut inom ramen för Högskolan i Borås rapportserie Vetenskap för profession. Rapporten Profession och vetenskap – idéer och strategier för ett professionslärosäte, som redigerats av universitetsadjunkt Maria Lindh, kommer att få stor betydelse inom lärosätet och i vårt samarbete med företrädare för näringsliv, kulturliv och offentlig verksamhet. Jag ser det som en intressant fortsättning att anordna ett antal seminarier med inbjudna representanter för professioner där artiklarna i denna rapport kan ligga till grund för erfarenhetsutbyte och diskussioner.

Syftet med detta kapitel är att bidra med fördjupad förståelse av begreppet vårdrum och samtidigt presentera en vårdvetenskaplig ram. I detta kapitel beskrivs skadeplatsens oordnade miljö och skiftande villkor, kännetecken och utmaningar som finns för ambulanspersonal att planera för och upprätta vårdrum för patienter som utsatts för trauma, i samverkan med räddnings- tjänst och polis. Därefter beskrivs villkor för patienternas och de närståen- des vårdrum på akutmottagningen. I kapitlet ges exempel på hur vårdande rum kan främjas och upprättas samt hur vårdrummet kan upplevas av de närvarande, vilket gestaltas utifrån forskning och erfarenheter som gjorts av vårdare, patienter och närstående. Kapitlet bygger främst på vårdveten- skaplig forskning.

Emergency care nurses (ECNs) face several challenges when they assess patients with different symptoms, signs, and conditions to determine patients’ care needs. Patients’ care needs do not always originate from physical or biomedical dysfunctions. To provide effective patient-centred care, ECNs must be sensitive to patients’ unique medical, physical, psychological, social, and existential needs. Clinical practice guidelines (CPGs) provide guidance for ECNs in such assessments. The aim of this study was to evaluate the quality of CPGs for comprehensive patient assessments in emergency care. A quality evaluation study was conducted in Sweden in 2017. Managers from 97 organizations (25 emergency medical services and 72 emergency departments) were contacted, covering all 20 Swedish county councils. Fifteen guidelines were appraised using the validated Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool. The results revealed that various CPGs are used in emergency care, but none of the CPGs support ECNs in performing a comprehensive patient assessment; rather, the CPGs address parts of the assessment primarily related to biomedical needs. The results also demonstrate that the foundation for evidence-based CPGs is weak and cannot confirm that an ECN has the prerequisites to assess patients and refer them to treatment, such as home-based self-care. This may indicate that Swedish emergency care services utilize non-evidence-based guidelines. This implies that ECN managers and educators should actively seek more effective ways of highlighting and safeguarding patients’ various care needs using more comprehensive guidelines.

Increased knowledge is needed about what self-care means from the patients’ perspective, especially since the patient population with type 2 diabetes has been rising. The aim was to describe self-care, as experienced by patients with newly diagnosed type 2 diabetes. This study adopted a phenomenological approach. Eight patients were interviewed. A combination of photos and interviews were used. The essential meaning of self-care was found to be an existential struggle that evokes feelings of being in-between one’s old unhealthy life and a new healthier one. In this in-between condition, tension exits between contradictorily emotions of anxiety, hopelessness and hope. This struggle also means questioning one’s identity. It is important that diabetes nurses create an opening for reflection and dare to challenge their patients to reflect on this existential struggle.

OBJECTIVES: In acute stroke, the risk of death and neurological sequelae are obvious threats. The aim of the study was to evaluate the association between various clinical factors identified by the emergency medical service (EMS) system before arriving at hospital and the risk of death during the subsequent year among patients with a confirmed stroke.

MATERIAL AND METHODS: All patients with a diagnosis of stroke as the primary diagnosis admitted to a hospital in western Sweden (1.6 million inhabitants) during a four-month period were included. There were no exclusion criteria.

RESULTS: In all, 1,028 patients with a confirmed diagnosis of stroke who used the EMS were included in the analyses. Among these patients, 360 (35%) died during the following year. Factors that were independently associated with an increased risk of death were as follows: (1) high age, per year OR 1.07; 95% CI 1.05-1.09; (2) a history of heart failure, OR 2.08; 95% CI 1.26-3.42; (3) an oxygen saturation of <90%, OR 8.05; 95% CI 3.33-22.64; and (4) a decreased level of consciousness, OR 2.19; 95% CI 1.61-3.03.

CONCLUSIONS: Among patients with a stroke, four factors identified before arrival at hospital were associated with a risk of death during the following year. They were reflected in the patients' age, previous clinical history, respiratory function, and the function of the central nervous system.

BACKGROUND: Symptoms related to stroke diverge and may mimic many other conditions.

AIMS: To evaluate clinical findings among patients with a clinical suspicion of stroke in a prehospital setting and find independent predictors of a final diagnosis of stroke or transient ischemic attack (TIA) METHODS: An observational multi-centre study including nine emergency hospitals in western Sweden. All patients transported to hospital by ambulance and in whom a suspicion of stroke was raised by the EMS clinician before hospital admission during a four-month period were included.

RESULTS: Of 1,081 patients, a diagnosis of stroke was confirmed at hospital in 680 patients (63%), while 69 (6%) were diagnosed as TIA and 332 patients (31%) received other final diagnoses. In a multiple logistic regression analysis, factors independently associated with a final diagnosis of stroke or TIA were increasing age, odds ratio (OR) per year: 1.02, p=0.007, a history of myocardial infarction (OR: 1.77, p= 0.01), facial droop (OR: 2.81, p<0.0001), arm weakness (OR: 2.61, p<0.0001), speech disturbance (OR: 1.92, p<0.0001) and high systolic blood pressure (OR: 1.50, p=0.02), while low oxygen saturation was significantly associated with other diagnoses (OR: 0.41, p=0.007). More than half of all patients among patients with both stroke/TIA and other final diagnoses died during the five-year follow-up.

CONCLUSIONS: Seven factors including the three symptoms included in the Face Arm Speech Test (FAST) were significantly associated with a final diagnosis of stroke or TIA in a prehospital assessment of patients with a suspected stroke. This article is protected by copyright. All rights reserved.

Background Sepsis is a life-threatening condition where the risk of death has been reported to be even higher than that associated with the major complications of atherosclerosis, i.e. myocardial infarction and stroke. In all three conditions, early treatment could limit organ dysfunction and thereby improve the prognosis. Aim To describe what has been published in the literature a/ with regard to the association between delay until start of treatment and outcome in sepsis with the emphasis on the pre-hospital phase and b/ to present published data and the opportunity to improve various links in the pre-hospital chain of care in sepsis. Methods A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results In overall terms, we found a small number of articles (n=12 of 1,162 unique hits) which addressed the prehospital phase. For each hour of delay until the start of antibiotics, the prognosis appeared to become worse. However, there was no evidence that prehospital treatment improved the prognosis. Studies indicated that about half of the patients with severe sepsis used the emergency medical service (EMS) for transport to hospital. Patients who used the EMS experienced a shorter delay to treatment with antibiotics and the start of early goal-directed therapy (EGDT). Among EMS-transported patients, those in whom the EMS staff already suspected sepsis at the scene had a shorter delay to treatment with antibiotics and the start of EGDT. There are insufficient data on other links in the prehospital chain of care, i.e. patients, bystanders and dispatchers. Conclusion Severe sepsis is a life-threatening condition. Previous studies suggest that, with every hour of delay until the start of antibiotics, the prognosis deteriorates. About half of the patients use the EMS. We need to know more about the present situation with regard to the different links in the prehospital chain of care in sepsis.

Aim: To describe prehospital emergency care as a potential doctoral research education subject based on doctoral theses that have been written and defended in Sweden. 

Method: Systematic and manual searches have been done via MEDLINE (PubMed) and contact with higher education institutions in Sweden. 

Results: In total, 80 doctoral theses and two licentiate theses were identified within the prehospital emergency care area of expertise. They were defended during 1982-2021. Productivity has successively increased with 31 theses being defended during the last five years (2017-2021). The highest number of theses were written and defended at the University of Gothenburg (n=27), the Karolinska Institute (n=22), and the University of Umeå (n=9). These theses have been written by 51 nurses, 28 physicians, one statistician, one socio economist, and one public health specialist (one thesis was written by a person who had both a nurse and physician education). Women were the authors of 48% of the theses. The theses have been divided into the following areas of expertise and in some cases associated subgroups: A. Acute disease, A1) Prognostic factors (n=255) and A2) Patient and next of kin perspective (n=8); B. Disaster (n=6); C. Ethics and values (n=3); D. Workers’ health and environment (n=2); E. Competence, learning and education, E1) Ambulance nurse (n=5) and E2) Cardiopulmonary education (n=2); F. Trauma and pain, F1) Injury and saving (n=4), F2) Pain (n=1) and F3) Hypothermia (n=4); G. Emergency care processes and priority, G1) Resource utilization (n=1) and G2) Dispatch center and cooperation (n= 8); H. Caring assessments and decisions, H1) Caring approach (n=3), H2) Diagnostic assessments and decisions (n=6) and H3) Identification of disease and level of care (n=4).

Conclusion: The number of doctoral theses in prehospital emergency care is increasing. Nurses are the majority of the authors. Theses cover a broad spectrum of areas of expertise but prognostic factors in acute disease dominate. The distribution of sex among the authors is acceptable. The patient and next of kin perspective is sparsely illuminated as well as some large patient groups, such as those with trauma and infection. Research in prehospital emergency care started with a focus on survival after out-of-hospital cardiac arrest. But over the years, the area of expertise has broadened to include broader problem areas; optimal level of care is one such example.

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: The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably. In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count. This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase. Method: A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results: In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women). With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably. In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke. Conclusion: Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

Background Many patients who suffer from acute chest pain are transported by ambulance. It is not known how often treatment prior to hospital admission is optimal and how optimal pain-relieving treatment is defined. It is often difficult to delineate pain from anxiety. Aim To describe various aspects of chest pain in the pre-hospital setting with the emphasis on a) treatment and b) presumed acute coronary syndrome. Methods In the literature search, we used PubMed and the appropriate key words. We included randomised clinical trials and observational studies. Results Four types of drug appear to be preferred: 1) narcotic analgesics, 2) nitrates, 3) beta-blockers and 4) benzodiazepines. Among narcotic analgesics, morphine has been associated with the relief of pain at the expense of side-effects. Alfentanil was reported to produce more rapid pain relief. Nitrates have been associated with the relief of pain with few side-effects. Beta-blockers have been reported to increase the relief of pain when added to morphine. The combination of beta-blockers and morphine has been reported to be as effective as beta-blockers alone in pain relief, but this combination therapy was associated with more side-effects. Experience from anxiety-relieving drugs such as benzodiazepines is limited. It is not known how these 4 drugs should be combined. The results indicate that various pain-relieving treatments might modify the disease. Conclusion Our knowledge of the optimal treatment of chest pain and associated anxiety in the pre-hospital setting is insufficient. Recommendations from existing guidelines are limited. Large randomised clinical trials are warranted.

Background: To decrease the morbidity burden of cardiovascular disease and to avoid the development ofpotentially preventable complications, early assessment and treatment of acute coronary syndrome (ACS) areimportant. The aim of this study has therefore been to explore the possible association between patients’ estimatedintensity of chest pain when first seen by the ambulance crew in suspected ACS, and the subsequent outcomebefore and after arrival in hospital.

Methods: Data was collected both prospectively and retrospectively. The inclusion criteria were chest pain raisingsuspicion of ACS and a reported intensity of pain ≥4 on the visual analogue scale.

Results: All in all, 1603 patients were included in the study. Increased intensity of chest pain was related to: 1) moreheart-related complications before hospital admission; 2) a higher proportion of heart failure, anxiety and chest painafter hospital admission; 3) a higher proportion of acute myocardial infarction and 4) a prolonged hospitalisation.However, there was no significant association with mortality neither in 30 days nor in three years. Adjustment forpossible confounders including age, a history of smoking and heart failure showed similar results.

Conclusion: The estimated intensity of chest pain reported by the patients on admission by the ambulance team wasassociated with the risk of complications prior to hospital admission, heart failure, anxiety and chest pain after hospitaladmission, the final diagnosis and the number of days in hospital.

BACKGROUND: Patients who call for an ambulance but only have primary care needs do not always get appropriate care. The starting point in this study is that such patients should be assigned to as basic of care as possible, while maintaining high levels of patient trust and patient safety.

AIM: To evaluate patient trust and patient safety among low-priority ambulance patients referred to care at either the Community Health Centre (CHC) or the Emergency Department (ED).

METHODS: This randomized controlled trial pilot study compared the level of patient trust and patient safety among low-priority ambulance patients who were randomized into two groups: CHC (n = 105) or ED (n = 83).

RESULTS: There was a high level of trust in the care received, regardless of whether the patient received care at CHC or ED. Overall 31% fulfilled one or more of the given criteria for potentially jeopardizing patient safety.

CONCLUSION: Patient selection for the trial indicated a potential limit in patient safety. There was a high level of trust in the care received regardless of whether the patient received care. The accuracy of patient selection for the new care model needs to be further improved with the intention to enhance patient safety even further.

Rationale aims and objectives: The objective of this study was to develop a questionnaire measuring the level of trust and its constituents in patients calling the Emergency Medicak Services (EMS) for suspected acute primary healthcare problems. The questionnaire is called the Patient Trust Questionnaire (PTQ). The following frontline service providers were involved: 1) The Dispatch Centre, 2) the Emergency Medical Services and 3) the recieving unit (the Emergency Department/Healthcare Centre)

Method: Cross-sectional data were collected repeately and redundant items were discarded using a step-by-step approach. Based on litterature review, the PTQ was developed in line with the folowing 4-step procedure: 1) item construction, 2) a face-to-face evaluation of separate items, 3) an emerical pre-evaluation targeting each separate frontline service provider and 4) an emperical full-scale evaluation. The inclusion criteria for participating were that the patient must be 18 years of age or older and suspected having a suspected acute primary care problem when calling the EMS. In the finale full-scale evaluation of the questionnaire, 427 patients were included.

Results: A set of 8 items with good phsycometric properties remained through the developing procedure. Two constituents of trust emerged (labelled credibility and accessibility), witch were robust across all fronline service providers.

Conclusion: A new measuring instrument has been developed for this particular healthcare chain, for patients with suspected acute primary care problem calling the EMS. Althought not yet validated, the PTQ is a potentially usefull tool in future healthcare research with reference to the concept of patient trust.

Purpose: Patients must be able to feel as much trust for caregivers and the healthcare system at the healthcare centre as at the emergency department. The aim of this study is to explain and understand the phenomenon of trust in the early chain of healthcare, when a patient has called an ambulance for non-urgent condition and been referred to the healthcare centre.

Method: A lifeworld hermeneutic approach from the perspective of caring science was used. Ten patient participated: seven female and three male. The setting is the early chain of healthcare in south-wetern Sweden.

Results: The findings show that the phenomenon of trust does not automatically involve medical care. However, attention to the patient's lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the "voice of lifeworld" enables the patient to feel trust.

Conclusion: Trust in the early chain of healthcare entails caregivers' ability to play attention to both medical and existentioal issues in compliance with the patient's information and questions. Thus, the patient must be invited to participate in assessment and decisions concerning his or her own healthcare, in a credible manner and using everyday language.

OBJECTIVE: To investigate patients who called the emergency medical services (EMS) for primary healthcare (PHC) problems.

DESIGN: A retrospective and exploratory patient record study from an EMS perspective, comparing two groups: those who were potential candidates for PHC and those who were not. All data were gathered from EMS and hospital records.

SETTINGS: The study was completed at the EMS and five hospital areas in the western region of Sweden.

SUBJECTS: The patients (n = 3001) who called the EMS in 2011. Data were missing for 10%.

MAIN OUTCOME MEASURES: The frequency and the clinical characteristics of the patients who called the EMS and were actually potential candidates for PHC.

RESULTS: Of a total of 2703 patients, a group of 426 (16%) were assessed as potential candidates for PHC and could thus be treated at a level of care other than the emergency department. Patients who were classified as suitable for PHC were found at all priority levels and within all symptom groups, but were younger and healthier than the other group.

CONCLUSION: Numerous patients seeking help from the EMS do not end up at the most appropriate level in the healthcare system.

IMPLICATIONS: In the EMS, guidelines are needed to enable pre-hospital emergency nurses to assess and triage patients to the most appropriate level of healthcare. Key points Patients calling the emergency medical services do not always end up at an appropriate level of healthcare. In total, 16% of patients were identified by the Swedish emergency medical services as potential candidates for primary healthcare. These patients were younger and healthier than those needing care at the emergency department. They were found at all priority levels and within all symptom groups.

This article examines and exemplifies how existential philosophy can provide a deeper understanding of existential issues in a caring context. Existential philosophy, including lifeworld theory, is treated both as an epistemology for the development of research methods and inspiration for analysis and discussions in caring science research. The significance of the lifeworld is also highlighted as a guide to perform and enable caring and caring didactics, along with short descriptions where existential philosophy has previously influenced the development of caring science. The concept of existential caring science is suggested as a research area for research on existential and meaning-oriented phenomena.

AIMS: The aims of this study were (a) to determine the prehospital prevalence of electrocardiographic (ECG) signs of acute myocardial ischemia in patients with suspected acute coronary syndrome and (b) to describe the relationships between the various ECG patterns and the diagnosis of acute myocardial infarction (AMI) and outcomes. METHODS: Prospective cohort study using data from an interventional trial in acute chest pain patients transported by the emergency medical services. These patients were classified into 3 groups: patients with ECG showing signs of acute myocardial ischemia, patients with ECG showing other abnormal changes (bundle-branch block, pacemaker rhythm, Q-wave or T-wave inversion) and patients without significant pathologic findings. All P values are age-adjusted. RESULTS: Among 1546 patients, 312 (20%) had ECG signs of acute myocardial ischemia. Of them, 57% had a final diagnosis of AMI versus 26% of those with other abnormal ECGs and 12% of those with ECG without significant pathologic findings (P<.0001). In all, 53% of all AMI cases involved patients without ECG signs of acute myocardial ischemia. Although ECG signs of acute myocardial ischemia predicted heart failure and ventricular tachyarrhythmias both prior to and after hospital admission, there was no significant difference in 30-day mortality between the 3 patient groups (4.3%, 3.7%, and 1.2%, respectively, P=.11). CONCLUSION: Among patients with a clinical suspicion of AMI in the prehospital setting, the prevalence of ECG signs suggesting AMI was low, as was the ability to identify AMI patients using ECG findings only. We therefore need better instruments in the prehospital triage of patients with acute chest pain.

OBJECTIVES: To identify pre-hospital predictors of a) death or the development of cardiovascular complications during hospitalisation (primary objective) and b) all-cause death during one year of follow-up (secondary objective), in chest pain patients with suspected acute coronary syndrome (ACS).

METHODS: A prospective study that comprised patients in western Sweden, who were transported to hospital by the emergency medical service (EMS) due to chest pain and suspected ACS. Multiple logistic regression was used to identify independent predictors of adverse outcomes.

RESULTS: Among all 1600 eligible patients, 21% died or had a cardiovascular complication during hospitalisation and 10% died during one year of follow-up. Nine factors were identified pre-hospitalisation as independent predictors of death or cardiovascular complications during hospitalisation. They were increasing age, a history of congestive heart failure, nausea and/or vomiting, rapid breathing rate, low oxygen saturation, high heart rate, together with ST-segment elevation, ST-segment depression and right bundle branch block on the pre-hospital electrocardiogram (ECG). For the secondary objective of death during one year of follow-up, the following five factors were identified as independent predictors: increasing age, a history of congestive heart failure, dyspnea, low oxygen saturation and left bundle branch block on the pre-hospital ECG.

CONCLUSIONS: In the pre-hospital setting of chest pain and suspected ACS, we identified nine predictors of the primary adverse outcome. They were factors representing previous history, symptoms and ECG findings. This information may contribute to the development of a decision support system for the EMS, which then needs to be clinically tested.

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).

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

OBJECTIVES: Evaluate the safety and feasibility of a prehospital system (“system”) and a support tool (“tool”) that allow the ambulance nurse to transport geriatric patients, depending on their medical needs, directly to a geriatric ward (GW), to a community emergency care centre (CECC) at a community-based hospital (CH) or to an emergency department (ED). DESIGN: Randomised controlled trial. SETTING: The Emergency Medical Services in Stockholm, Sweden. PARTICIPANTS: 806 geriatric patients who had rung the emergency telephone number 112 were randomised into an intervention group [n=410] and a control group [n=396]. INTERVENTION: The patients were randomised by the dispatcher either to an ambulance that could steer geriatric patients to alternative destinations instead of the ED, depending on the patient’s medical needs (intervention), or to an ambulance that transported all patients to the ED (control). MEASUREMENTS: The primary endpoint; number of patients steered directly to the community-based hospital [effect] i.e. the GW or CECC. The secondary endpoint; number of subsequent transfers [safety] from the CH to the ED within 24 hours after initial admittance. RESULTS: Twenty percent, 90 patients out of 449, [Confidence interval (Cl) 16.6-24.0] could be steered directly to the CH with the help of the prehospital “system” and 6.7%, 6 patients out of 90, [Cl 3.1-13.8] requested subsequent transfer from the GW or CECC to the ED. CONCLUSION: Ambulance nurses could safely and effectively steer geriatric patients to an alternative healthcare facility with the help of a prehospital decision support system and an associated decision support tool. This new system in Stockholm is a better and more effective way of using the under-dimensioned emergency care resources. It is also better for the geriatric patients. Key words: Emergency medical service; Triage; Geriatric patients.

As organizational changes in the healthcare system are in progress, to enhance care quality and reduce costs, it is important to investigate how these changes affect elderly patients’ experiences and their rights to participate in the choice of healthcare. The aim of this study is to describe elderly patients’ lived experience of participating in the choice of healthcare when being offered an alternative care pathway by the emergency medical services, when the individual patient’s medical needs made this choice possible. This study was carried out from the perspective of caring science, and a phenomenological approach was applied, where data were analysed for meaning. Data consist of 11 semi-structured interviews with elderly patients who chose a healthcare pathway to a community-based hospital when they were offered an alternative level of healthcare. The findings show that the essence of the phenomenon is described as ‘‘There was a ray of hope about a caring encounter and about being treated like a unique human being’’. Five meaningful constituents emerged in the descriptions: endurable waiting, speedy transference, a concerned encounter, trust in competence, and a choice based on memories of suffering from care. The conclusion is that patient participation in the choice of a healthcare alternative instead of the emergency department is an opportunity of avoiding suffering from care and being objectified.

Att kunna utföra vårdande bedömningar är något som sjuksköterskor ständigt ställs inför oavsett inom vilket vårdområde de är verksamma. Alla vårdmöten med patienter är mer eller mindre oförberedda och det är därför viktigt att med öppenhet kunna möta patientens behov så att inte rutinmässiga och oreflekterade bedömningar av patientens tillstånd och situation görs. Utmaningen i varje vårdmöte är att med hjälp av reflexion och vårdvetenskaplig kunskap kunna göra en bedömning med patientperspektivet som utgångspunkt. Detta kapitel syftar till att ge förståelse för vad vårdande bedömning innebär, hur du kan lära den under utbildningen och vad som begränsar sådant lärande. Exempel på denna lärandeprocesse ges från studenter i ambulanssjuksköterskeutbildningen.

Historiskt sett har ambulanssjukvård till största del utförts av icke legitimerad personal1. Under 1960-talet påtalades behov av vårdutbildad ambulanspersonal för första gången men först år 1982 skrevs ambulanssjukvård in i Hälso- och sjukvårdslagen (SFS, 1982:763). Under 1980- och 1990-talen gjordes betydande framsteg inom akutsjukvård och medicinsk behandling vilket ökade efterfrågan på en utbildning som kunde ge kunskaper både inom omvårdnadsvetenskap och medicinsk vetenskap (Suserud, 2005; Suserud & Svensson, 2009). År 1997 fastslog Socialstyrelsen att sjuksköterskors yrkesutövning inom ambulanssjukvård utgör ett specialområde och utarbetade därefter den första kompetensbeskrivningen för sjuksköterska inom ambulanssjukvård. Samma år färdigställdes en vidareutbildning inom akutsjukvård med inriktning mot ambulanssjukvård omfattande 40–45 poäng, som år 2001 övergick i Specialistsjuksköterskeutbildning med inriktning mot ambulanssjukvård omfattande 60 högskolepoäng (hp). Det är en reglerad utbildning som ger yrkesexamen på avancerad nivå, samt en skyddad yrkesbeteckning. Utbildningen kan även, efter examensarbete på avancerad nivå (15 hp), leda till en magisterexamen i omvårdnad/vårdvetenskap. Den specialistutbildade ambulanssjuksköterskan behöver utveckla en handlingsberedskap inför oförutsedda och varierande uppdrag, ofta med bristfällig information, i skiftande vårdmiljöer och under omgivande förhållanden som ibland är ogynnsamma. Kompetensen omfattar vård av patienter med akuta vårdbehov. Det innebär både att snabbt bedöma och prioritera vårdåtgärder för patienter med livshotande tillstånd och vårda i situationer som traditionellt sett inte betraktas som akuta. Kompetensen inbegriper kunskap om sjuka och/eller skadade patienter i alla åldrar, med hälsoproblem, liksom barnafödande. Vårdarbetet präglas av ett etiskt förhållningssätt, vilket innebär att möta patienten som en unik individ med individuella behov och egna erfarenheter av akut sjukdom, skada och ohälsa. Att visa omsorg och respekt för patientens integritet och värdighet är alltid viktigt men speciellt viktigt i vårdsituationer på offentliga platser och i samband med flera skadade. Vårdmötet baseras på närhet och en strävan att försöka förstå vad som hänt samt hur en plötsligt inträffad förändring påverkar patientens och närståendes liv. Ett etiskt förhållningssätt förutsätter ett personligt ansvar och förmåga att kunna åsidosätta ett slentrianmässigt omhändertagande. Reflektion och handledning utgör viktiga redskap för att vidhålla ett medvetet förhållningssätt i mötet med patienter. Den specialistutbildade ambulanssjuksköterskan skall medverka till att patienten erhåller rätt vårdnivå2 via samverkan med specialistvård, primärvård och kommunal vård. Ambulanssjukvård utövas även i tvärprofessionella vård- och räddningsteam som samverkar för att i en trygg och säker miljö uppnå största möjliga patientnytta. Det inbegriper att den specialistutbildade ambulanssjuksköterskan har den kompetens som en personcentrerad, evidensbaserad, jämlik och tillgänglig ambulanssjukvård fordrar. 4 1 Det skulle dröja till år 2005 innan Socialstyrelsen föreskrev att minst en av vårdarna i en ambulans ska vara legitimerad sjuksköterska för att möjliggöra läkemedelsbehandling inom ambulanssjukvård. 2 Inledningsvis prioriteras patientens vårdbehov av larmcentralen, som även dirigerar ambulansen till patienten.

Background:The early chain of care is critical for stroke patients. The most important part is the so-called 'system delay' i.e. the delay time from call to the emergency medical services until a diagnosis is established (computer tomography).Aim:The purpose of this study was to relate the initial priority level given by the dispatch centre to the early chain of care in acute stroke and to short-term and long-term mortality.Methods:All patients hospitalised with the first and the final diagnosis of acute stroke, 15 December 2010?15 April 2011, were recruited across nine hospitals, each hospital with a stroke care unit.Results:In all, 897 stroke patients were included. Priority at the dispatch centre: 54% received highest priority 1, 41% priority 2 and 5% priority 3. Median system delay from call to emergency medical services until diagnosis by computer tomography was 2 h and 52 min, 4 h and 49 min and 6 h and 33 min respectively in the three priority groups (p<0.0001). There was a similarly strong association between priority level at the dispatch centre and system delay to arrival in a hospital ward, suspicion of stroke by the emergency medical services nurse as well as the physician on hospital admission and the proportion of patients given thrombolysis. Mortality during the subsequent 30 days was 22% among patients with priority 1 and 14% among patients with priority 2.Conclusion:Patients given a lower priority level at the dispatch centre had the longest system delay. Although many of these patients died, the risk of death was highest among those given the highest priority.