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  • 1.
    Abelsson, Anna
    et al.
    Jönköping University, HHJ, Avdelningen för omvårdnad.
    Odestrand, Per
    Jönköping University, HHJ, Avdelningen för omvårdnad.
    Nygårdh, Annette
    Jönköping University, HHJ, Avdelningen för omvårdnad.
    To strengthen self-confidence as a step in improving prehospital youth laymen basic life support2020Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, nr 1, artikel-id 8Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND:

    A rapid emergency care intervention can prevent the cardiac arrest from resulting in death. In order for Cardio Pulmonary Resuscitation (CPR) to have any real significance for the survival of the patient, it requires an educational effort educating the large masses of people of whom the youth is an important part. The aim of this study was to investigate the effect of a two-hour education intervention for youth regarding their self-confidence in performing Adult Basic Life Support (BLS).

    METHODS:

    A quantitative approach where data consist of a pre- and post-rating of seven statements by 50 participants during an intervention by means of BLS theoretical and practical education.

    RESULTS:

    The two-hour training resulted in a significant improvement in the participants' self-confidence in identifying a cardiac arrest (pre 51, post 90), to perform compressions (pre 65, post 91) and ventilations (pre 64, post 86) and use a defibrillator (pre 61, post 81). In addition, to have the self-confidence to be able to perform, and to actually perform, first aid to a person suffering from a traumatic event was significantly improved (pre 54, post 89).

    CONCLUSION:

    By providing youth with short education sessions in CPR, their self-confidence can be improved. This can lead to an increased will and ability to identify a cardiac arrest and to begin compressions and ventilations. This also includes having the confidence using a defibrillator. Short education sessions in first aid can also lead to increased self-confidence, resulting in young people considering themselves able to perform first aid to a person suffering from a traumatic event. This, in turn, results in young people perceiveing themselves as willing to commence an intervention during a traumatic event. In summary, when the youth believe in their own knowledge, they will dare to intervene.

  • 2.
    Adielsson, Anna
    et al.
    Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Danielsson, Christian
    Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Forkman, Pontus
    Department of Adult Psychiatry, Mora Hospital, Mora, Sweden.
    Karlsson, Thomas
    Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Pettersson, Linda
    Center for Clinical Research Dalarna, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Lundin, Stefan
    Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Outcome prediction for patients assessed by the medical emergency team: a retrospective cohort study2022Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 22, nr 1, artikel-id 200Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Medical emergency teams (METs) have been implemented to reduce hospital mortality by the early recognition and treatment of potentially life-threatening conditions. The objective of this study was to establish a clinically useful association between clinical variables and mortality risk, among patients assessed by the MET, and further to design an easy-to-use risk score for the prediction of death within 30 days.

    Methods: Observational retrospective register study in a tertiary university hospital in Sweden, comprising 2,601 patients, assessed by the MET from 2010 to 2015. Patient registry data at the time of MET assessment was analysed from an epidemiological perspective, using univariable and multivariable analyses with death within 30 days as the outcome variable. Predictors of outcome were defined from age, gender, type of ward for admittance, previous medical history, acute medical condition, vital parameters and laboratory biomarkers. Identified factors independently associated with mortality were then used to develop a prognostic risk score for mortality.

    Results: The overall 30-day mortality was high (29.0%). We identified thirteen factors independently associated with 30-day mortality concerning; age, type of ward for admittance, vital parameters, laboratory biomarkers, previous medical history and acute medical condition. A MET risk score for mortality based on the impact of these individual thirteen factors in the model yielded a median (range) AUC of 0.780 (0.774-0.785) with good calibration. When corrected for optimism by internal validation, the score yielded a median (range) AUC of 0.768 (0.762-0.773).

    Conclusions: Among clinical variables available at the time of MET assessment, thirteen factors were found to be independently associated with 30-day mortality. By applying a simple risk scoring system based on these individual factors, patients at higher risk of dying within 30 days after the MET assessment may be identified and treated earlier in the process.

     

  • 3.
    Höglund, Erik
    et al.
    University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Schröder, Agneta
    University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.
    Möller, Margareta
    University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.
    Ohlsson-Nevo, Emma
    University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.
    Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden2020Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, nr 1Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

    There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data.

    Methods

    A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients’ medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test.

    Results

    Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women.

    Conclusions

    Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.

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  • 4.
    Jensen, Emil
    et al.
    Högskolan i Borås.
    Rentzhog, Helena
    Högskolan i Borås.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Axelsson, Christer
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Lundgren, Peter
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Changes in temperature in preheated crystalloids at ambient temperatures relevant to a prehospital setting: an experimental simulation study with the application of prehospital treatment of trauma patients suffering from accidental hypothermia2024Ingår i: BMC Emergency Medicine, E-ISSN 1471-227X, Vol. 24, artikel-id 59Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

    Accidental hypothermia is common in all trauma patients and contributes to the lethal diamond, increasing both morbidity and mortality. In hypotensive shock, fluid resuscitation is recommended using fluids with a temperature of 37–42°, as fluid temperature can decrease the patient’s body temperature. In Sweden, virtually all prehospital services use preheated fluids. The aim of the present study was to investigate how the temperature of preheated infusion fluids is affected by the ambient temperatures and flow rates relevant for prehospital emergency care.

    Methods

    In this experimental simulation study, temperature changes in crystalloids preheated to 39 °C were evaluated. The fluid temperature changes were measured both in the infusion bag and at the patient end of the infusion system. Measurements were conducted in conditions relevant to prehospital emergency care, with ambient temperatures varying between − 4 and 28 °C and flow rates of 1000 ml/h and 6000 ml/h, through an uninsulated infusion set at a length of 175 cm.

    Results

    The flow rate and ambient temperature affected the temperature in the infusion fluid both in the infusion bag and at the patient end of the system. A lower ambient temperature and lower flow rate were both associated with a greater temperature loss in the infusion fluid.

    Conclusion

    This study shows that both a high infusion rate and a high ambient temperature are needed if an infusion fluid preheated to 39 °C is to remain above 37 °C when it reaches the patient using a 175-cm-long uninsulated infusion set. It is apparent that the lower the ambient temperature, the higher the flow rate needs to be to limit temperature loss of the fluid.

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  • 5. Jimenez, Maria
    et al.
    Azeli, Youcef
    Valero Mora, Eva
    Lucas Guarquel, Isac
    Lopes Gomariz, Alfredo
    Castro Naval, E
    Axelsson, Christer
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Passive leg raise (plr) during cardiopulmonary (cpr): a method article on a randomised study of survival in out-of-hospital cardiac arrest (ohca)2014Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 14, nr 15Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background It is estimated that about 275,000 inhabitants experience an out-of-hospital cardiac arrest (OHCA) every year in Europe. Survival in out-of-hospital cardiac arrest is relatively low, generally between five per cent and 10%. Being able to explore new methods to improve the relatively low survival rate is vital for people with these conditions. Passive leg raise (PLR) during cardiopulmonary resuscitation (CPR) has been found to improve cardiac preload and blood flow during chest compressions. The aim of our study is to evaluate whether early PLR during CPR also has an impact on one-month survival in sudden and unexpected out-of-hospital cardiac arrest (OHCA). Method/Design A prospective, randomized, controlled trial in which all patients (≥18 years) receiving out-of hospital CPR are randomized by envelope to be treated with either PLR or in the flat position. The ambulance crew use a special folding stool which allows the legs to be elevated about 20 degrees. Primary end-point: survival to one month. Secondary end-point: survival to hospital admission to one month and to one year with acceptable cerebral performance classification (CPC) 1–2. Discussion PLR is a simple and fast maneuver. We believe that the greatest benefit with PLR is when performed early in the process, during the first minutes of CPR and before the first defibrillation. To reach power this study need 3000 patients, we hope that this method article will encourage other sites to contact us and take part in our study. Trial registration ClinicalTrials.gov NCT01952197.

  • 6.
    Johansson, Helena
    et al.
    Falck Ambulans Östergötland.
    Lundgren, Kristin
    Ambulanssjukvården Region Jönköpings län.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Reasons for bias in ambulance clinicians’ assessments of non-conveyed patients: a mixed-methods study2022Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 22, nr 1, artikel-id 79Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The number of ambulance assignments and the influx of patients to the emergency departments (EDs) in Sweden have increased in recent years. This is one reason the protocol for prehospital emergency care was developed around referring patients for non-conveyance, either through the see-and-convey elsewhere approach or through the see-and-treat approach. However, this protocol has led to challenges in patient assessments.

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  • 7.
    Kauppi, Wivica
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Karlsson, Thomas
    Biostatistics, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Magnusson, Carl
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Palmér, Lina
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Axelsson, Christer
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Pre-hospital predictors of an adverse outcome among patients with dyspnoea as the main symptom assessed by prehospital emergency nurses- a retrospective observational study2020Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, nr 89, s. 1-12Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Dyspnoea is one of the most common reasons for patients contacting emergency medical services (EMS). Pre-hospital Emergency Nurses (PENs) are independently responsible for advanced care and to meet thesepatients individual needs. Patients with dyspnoea constitute a complex group, with multiple different final diagnoses and with a high risk of death. This study aimed to describe on-scene factors associated with an increased risk of a time-sensitive final diagnosis and the risk of death.

    Methods: A retrospective observational study including patients aged ≥16 years, presenting mainly with dyspnoea was conducted. Patients were identified thorough an EMS database, and were assessed by PENs in the southwestern part of Sweden during January to December 2017. Of 7260 missions (9% of all primary missions), 6354 were included. Among those, 4587 patients were randomly selected in conjunction with adjusting for uniquepatients with single occasions. Data were manually collected through both EMS- and hospital records and final diagnoses were determined through the final diagnoses verified in hospital records. Analysis was performed usingmultiple logistic regression and multiple imputations.

    Results: Among all unique patients with dyspnoea as the main symptom, 13% had a time-sensitive final diagnosis. The three most frequent final time-sensitive diagnoses were cardiac diseases (4.1% of all diagnoses), infectious/inflammatory diseases (2.6%), and vascular diseases (2.4%). A history of hypertension, renal disease, symptoms of pain, abnormal respiratory rate, impaired consciousness, a pathologic ECG and a short delay until call for EMS were associated with an increased risk of a time-sensitive final diagnosis. Among patients with time-sensitive diagnoses, approximately 27% died within 30 days. Increasing age, a history of renal disease, cancer, low systolic bloodpressures, impaired consciousness and abnormal body temperature were associated with an increased risk of death.

    Conclusions: Among patients with dyspnoea as the main symptom, age, previous medical history, deviating vital signs, ECG pattern, symptoms of pain, and a short delay until call for EMS are important factors to consider in the prehospital assessment of the combined risk of either having a time-sensitive diagnosis or death.

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    Pre-hospital predictors of an adverse outcome
  • 8.
    Kauppi, Wivica
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Magnusson, Carl
    Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Palmér, Lina
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Axelsson, Christer
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Characteristics and outcomes of patients with dyspnoea as the main symptom, assessed by prehospital emergency nurses- a retrospective observational study2020Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, nr 1, s. 1-11Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Dyspnoea (breathing difficulty) is among the most commonly cited reasons for contacting emergency medical services (EMSs). Dyspnoea is caused by several serious underlying medical conditions and, based on patients individual needs and complex illnesses or injuries, ambulance staff are independently responsible for advanced care provision. Few large-scale prehospital studies have reviewed patients with dyspnoea. This study aimed to describe the characteristics and final outcomes of patients whose main symptom was classified as dyspnoea by the prehospital emergency nurse (PEN).

    Methods: This retrospective observational study included patients aged >16 years whose main symptom was dyspnoea. All the enrolled patients were assessed in the south-western part of Sweden by PENs during January and December, 2017. Of 7,260 assignments (9% of all primary missions), 6,354 fulfilled the inclusion criteria. Analysis was performed using descriptive statistics, and the tests used were odds ratios and Kaplan-Meier analysis.

    Results: The patients mean age was 73 years, and approximately 56% were women. More than 400 different final diagnostic codes (International Statistical Classification of Diseases and Related Health Problems [ICD]-10th edition) were observed, and 11% of the ICD-10 codes denoted time-critical conditions. The three most commonly observed aetiologies were chronic obstructive pulmonary disease (20.4%), pulmonary infection (17.1%), and heart failure (15%). The comorbidity values were high, with 84.4% having previously experienced dyspnoea. The overall 30-day mortality was 11.1%. More than half called EMSs more than 50 hours after symptom onset.

    Conclusions:  Among patients assessed by PENs due to dyspnoea as the main symptom there were more than 400 different final diagnoses, of which 11% were regarded as time-critical. These patients had a severe comorbidity and 11% died within the first 30 days.

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  • 9.
    Larsson, Glenn
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden; PICTA, Prehospital Innovation Arena, Lindholmen Science Park, Gothenburg, Sweden.
    Axelsson, Christer
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. PreHospen.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Klementsson, Håkan
    Register Centre South, Karlskrona, Sweden.
    Troëng, Thomas
    Register Centre South, Karlskrona, Sweden.
    Magnusson, Carl
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Epidemiology of patients assessed for trauma by Swedish ambulance services: a retrospective registry study2024Ingår i: BMC Emergency Medicine, E-ISSN 1471-227X, Vol. 24, nr 1, artikel-id 11Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

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

    Aim

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

    Methods

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

    Results

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

    Conclusion

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

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  • 10.
    Larsson, Glenn
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Dagerhem, Alma
    Emergency Department, Halland Hospital, Halmstad, Sweden.
    Wihlborg, Jonas
    School of Health and Welfare, Dalarna University, Falun, Sweden.
    Rantala, Andreas
    Emergency Department, Helsingborg General Hospital, Helsingborg, Sweden; Department of Health Sciences, Lund University, P.O. Box 157, SE-221 00, Lund, Sweden; Centre of Interprofessional Cooperation within Emergency Care (CICE), Linnaeus University, Växjö, Sweden.
    Satisfaction among non-conveyed patients and significant others when discharged at the scene by the ambulance service: an exploratory cross-sectional survey2022Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 22, nr 1, artikel-id 100Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

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

    Methods

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

    Results

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

    Conclusions

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

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  • 11.
    Larsson, Glenn
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden; PICTA, Prehospital Innovation arena, Lindholmen Science Park, Gothenburg, Sweden.
    Eldh, Jana
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås.
    Hagman, Elisabeth
    Faculty of Health and Society, Department of Care Science, Malmö University.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    The non-conveyance of trauma patients in Swedish emergency medical services: a retrospective observational study of the trauma population not transported to an emergency department2024Ingår i: BMC Emergency Medicine, E-ISSN 1471-227X, Vol. 34Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction

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

    Methods

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

    Results

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

    Conclusion

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

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  • 12.
    Larsson, Glenn
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Hansson, Peter
    NU Hospital Group (NU), Department of Ambulance Care, SE- 461 85, Trollhättan, Sweden.
    Olsson, Emelie
    NU Hospital Group (NU), Department of Ambulance Care, SE- 461 85, Trollhättan, Sweden.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Prehospital assessment of patients with abdominal pain triaged to self-care at home: an observation study2022Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 22, nr 1, artikel-id 92Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

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

    Aim

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

    Methods

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

    Results

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

    Conclusion

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

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  • 13.
    Magnusson, C
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Gärskog, J
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Lökholm, E
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Stenström, J
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Wetter, R
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Axelsson, C
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Packendorff, N
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Jood, K
    Department of Clinical Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Karlsson, T
    Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Prediction of a time-sensitive condition among patients with dizziness assessed by the emergency medical services2021Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 21, nr 1, artikel-id 38Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Dizziness is a relatively common symptom among patients who call for the emergency medical services (EMS).

    AIM: To identify factors of importance for the early identification of a time-sensitive condition behind the symptom of dizziness among patients assessed by the EMS.

    METHODS: All patients assessed by the EMS and triaged using Rapid Emergency Triage and Treatment (RETTS) for adults code 11 (=dizziness) in the 660,000 inhabitants in the Municipality of Gothenburg, Sweden, in 2016, were considered for inclusion. The patients were divided into two groups according to the final diagnosis (a time-sensitive condition, yes or no).

    RESULTS: There were 1536 patients who fulfilled the inclusion criteria, of which 96 (6.2%) had a time-sensitive condition. The majority of these had a stroke/transitory ischaemic attack (TIA). Eight predictors of a time-sensitive condition were identified. Three were associated with a reduced risk: 1) the dizziness was of a rotatory type, 2) the dizziness had a sudden onset and 3) increasing body temperature. Five were associated with an increased risk: 1) sudden onset of headache, 2) a history of head trauma, 3) symptoms of nausea or vomiting, 4) on treatment with anticoagulants and 5) increasing systolic blood pressure.

    CONCLUSION: Among 1536 patients who were triaged by the EMS for dizziness, 6.2% had a time-sensitive condition. On the arrival of the EMS, eight factors were associated with the risk of having a time-sensitive condition. All these factors were linked to the type of symptoms or to clinical findings on the arrival of the EMS or to the recent clinical history.

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  • 14.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-405 30, Gothenburg, Sweden; Department of Prehospital Emergency Care , Sahlgrenska University Hospital, SE-411 04, Gothenburg, Sweden.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Norberg-Boysen, Gabriella
    Kauppi, Wivica
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Axelsson, Christer
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. Department of Prehospital Emergency Care , Sahlgrenska University Hospital, SE-411 04, Gothenburg, Sweden.
    Packendorff, Niclas
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Larsson, Glenn
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Wibring, Kristoffer
    Suboptimal prehospital decision- making for referral to alternative levels of care – frequency, measurement, acceptance rate and room for improvement2022Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 22, nr 1, artikel-id 89Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

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

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

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

    3) What is acceptable?

    4) How to increase patient safety?

    Main text

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

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

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

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

    Conclusion

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

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  • 15.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Axelsson, Christer
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Patient characteristics, triage utilisation, level of care, and outcomes in an unselected adult patient population seen by the emergency medical services: a prospective observational study.2020Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, nr 1, artikel-id 7Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Crowding in the emergency department (ED) is a safety concern, and pathways to bypass the ED have been introduced to reduce the time to definitive care. Conversely, a number of low-acuity patients in the ED could be assessed by the emergency medical services (EMS) as requiring a lower level of care. The limited access to primary care in Sweden leaves the EMS nurse to either assess the patient as requiring the ED or to stay at the scene. This study aimed to assess patient characteristics and evaluate the initial assessment by and utilisation of the ambulance triage system and the appropriateness of non-transport decisions.

    METHODS: A prospective observational study including 6712 patients aged ≥16 years was conducted. The patient records with 72 h of follow-up for non-transported patients were reviewed. Outcomes of death, time-critical conditions, complications within 48 h and final hospital assessment were evaluated. The Mann-Whitney U test, Fisher's exact test, and Spearman's rank correlation were used for statistical analysis.

    RESULTS: The median patient age was 66 years, and the most common medical history was a circulatory diagnosis. Males received a higher priority from dispatchers and were more frequently assessed at the scene as requiring hospital care. A total of 1312 patients (19.7%) were non-transported; a history of psychiatric disorders or no medical history was more commonly noted among these patients. Twelve (0.9%) of the 1312 patients not transported were later admitted with time-critical conditions. Full triage was applied in 77.4% of the cases, and older patients were triaged at the scene as an 'unspecific condition' more frequently than younger patients. Overall, the 30-day mortality was 4.1% (n = 274).

    CONCLUSIONS: Age, sex, medical history, and presentation all appear to influence the initial assessment. A number of patients transported to ED could be managed at a lower level of care. A small proportion of the non-transported patients were later diagnosed with a time-critical condition, warranting improved assessment tools at the scene and education of the personnel focusing on the elderly population. These results may be useful in addressing resource allocation issues aiming at increasing patient safety.

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  • 16.
    Magnusson, Carl
    et al.
    Göteborgs universitet.
    Ryge, Helena
    Sahlgrenska universitetssjukhus.
    Scott, Filip
    Sahlgrenska universitetssjukhus.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Axelsson, Christer
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Limited need for hospital resources among patients brought to hospital by the emergency medical services2021Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 21, nr 1, artikel-id 156Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: In Sweden, the majority of patients who are transported to hospital by the emergency medical services (EMS) are relatively old and the majority suffer from comorbidity. About half these patients are admitted to a hospital ward and will stay in hospital. However, the other half will only make a visit to the emergency department (ED). The burden on the ED is extensive and many elderly patients have to stay for many hours in the ED. Aim: To describe the patients who are brought to hospital by the EMS, with particular emphasis on those that were discharged from the ED, and to assess the proportion of these patients who did not require hospital resources, which could mean that they were candidates for primary care (PC). Methods: An observational analysis of a cohort of patients who were transported to hospital by the EMS in 2016 in the Municipality of Gothenburg. Results: In all, 5,326 patients were transported to hospital by the EMS of which 52% were discharged directly from the ED. These patients included 37% assessed as not requiring hospital resources. The three most common causes of contact with the EMS in this subset were abdominal pain (15%), back pain (8%) and non-specified disease (7%). Of these patients, 77% had contact with a physician in the ED, whereas 6% had contact with a nurse and 17% left the ED without any contact. Twenty-six per cent were given advice on follow-up in PC. Conclusions: Among patients who were brought to hospital by the EMS, more than half were discharged directly from the ED. Among these patients, 37% were assessed as not requiring hospital resources. These patients comprised 15% of the overall study cohort and may be candidates for primary care. © 2021, The Author(s).

  • 17.
    Olander, Agnes
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Andersson, Henrik
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Sundler, Annelie Johansson
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Bremer, Anders
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd. Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden.
    Ljungström, Lars
    Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Prehospital characteristics among patientswith sepsis: a comparison between patients with or without adverse outcome2019Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, artikel-id 19:43Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The prehospital care of patients with sepsis are commonly performed by the emergency medical services. These patients may be critically ill and have high in-hospital mortality rates. Unfortunately, few patients with sepsis are identified by the emergency medical services, which can lead to delayed treatment and a worse prognosis. Therefore, early identification of patients with sepsis is important, and more information about the prehospital characteristics that can be used to identify these patients is needed. Based on this lack of information, the objectives of this study were to investigate the prehospital characteristics that are identified while patients withseps is are being transported to the hospital by the emergency medical services, and to compare these values to those of the patients with and without adverse outcomes during their hospital stays.

    Methods: This was a retrospective observational study. The patients’ electronic health records were reviewed and selected consecutively based on the following: retrospectively diagnosed with sepsis and transported to an emergency department by the emergency medical services. Data were collected on demographics, prehospital characteristics and adverse outcomes, defined as the in-hospital mortality or treatment in the intensive care unit, and analysed by independent sample t-test and chi-square. Sensitivity, specificity and likelihood ratio, of prehospital characteristics for predicting or development of adverse outcome were analysed.

    Results: In total, 327 patients were included. Of these, 50 patients had adverse outcomes. When comparing patients with or without an adverse outcome, decreased oxygen saturation and body temperature, increased serumglucose level and altered mental status during prehospital care were found to be associated with an adverse outcome.

    Conclusions: The findings suggests that patients having a decreased oxygen saturation and body temperature, increased serum glucose level and altered mental status during prehospital care are at risk of a poorer patient prognosis and adverse outcome. Recognizing these prehospital characteristics may help to identify patients with sepsis early and improve their long-term outcomes. However further research is required to predict limit values of saturation and serum glucose and to validate the use of prehospital characteristics for adverse outcome in patients with sepsis.

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  • 18.
    Olander, Agnes
    et al.
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Bremer, Anders
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Sundler, Annelie Johansson
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Andersson Hagiwara, Magnus
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Andersson, Henrik
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Assessment of patients with suspected sepsis in ambulance services: a qualitative interview study2021Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 21, nr 45Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The initial care of patients with sepsis is commonly performed by ambulance clinicians (ACs). Earlyidentification, care and treatment are vital for patients with sepsis to avoid adverse outcomes. However, knowledgeabout how patients with sepsis are assessed in ambulance services (AS) by AC is limited. Therefore, the aim of thisstudy was to explore the meaning of ACs’ lived experiences in assessing patients suspected of having sepsis.

    Methods: A descriptive design with a qualitative approach was used. Fourteen ACs from three Swedish ambulanceorganizations participated in dyadic and individual semistructured interviews. A thematic analysis based ondescriptive phenomenology was performed.

    Results: AC experiences were grouped into four themes: (1) being influenced by previous experience; (2) searchingfor clues to the severity of the patient’s condition; (3) feeling confident when signs and symptoms were obvious;and (4) needing health-care professionals for support and consultation.

    Conclusions: This study indicates that several factors are important to assessments. ACs needed to engage in anongoing search for information, discuss the cases with colleagues and reconsider the assessment throughout theentire ambulance mission. A reflective and open stance based on professional knowledge could contribute torecognizing patients with sepsis.

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  • 19.
    Olsson, H
    et al.
    Department of Cardiology, NU Hospital Group, Trollhättan, Sweden.
    Karlson, B W
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; AstraZeneca Gothenburg, Mölndal, Sweden.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Karlsson, T
    Biostatistics, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Hellberg, J
    Department of Cardiology, NU Hospital Group, Trollhättan, Sweden.
    Prytz, M
    Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden.
    Sernert, N
    Department of Orthopaedics Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.
    Ekerstad, N
    Department of Gothenburg Health, Medicine and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden.
    Predictors of short- and long-term mortality in critically ill, older adults admitted to the emergency department: an observational study2022Ingår i: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 22, nr 1, artikel-id 15Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background In the future, we can expect an increase in older patients in emergency departments (ED) and acute wards. The main purpose of this study was to identify predictors of short- and long-term mortality in the ED and at hospital discharge. Methods This is a retrospective, observational, single-center, cohort study, involving critically ill older adults, recruited consecutively in an ED. The primary outcome was mortality. All patients were followed for 6.5-7.5 years. The Cox proportional hazards model was used. Results Regarding all critically ill patients aged >= 70 years and identified in the ED (n = 402), there was a significant association between mortality at 30 days after ED admission and unconsciousness on admission (HR 3.14, 95% CI 2.09-4.74), hypoxia on admission (HR 2.51, 95% CI 1.69-3.74) and age (HR 1.06 per year, 95% CI 1.03-1.09), (all p < 0.001). Of 402 critically ill patients aged >= 70 years and identified in the ED, 303 were discharged alive from hospital. There was a significant association between long-term mortality and the Charlson Comorbidity Index (CCI) > 2 (HR 1.90, 95% CI 1.46-2.48), length of stay (LOS) > 7 days (HR 1.72, 95% CI 1.32-2.23), discharge diagnosis of pneumonia (HR 1.65, 95% CI 1.24-2.21) and age (HR 1.08 per year, 95% CI 1.05-1.10), (all p < 0.001). The only symptom or vital sign associated with long-term mortality was hypoxia on admission (HR 1.70, 05% CI 1.30-2.22). Conclusions Among critically ill older adults admitted to an ED and discharged alive the following factors were predictive of long-term mortality: CCI > 2, LOS > 7 days, hypoxia on admission, discharge diagnosis of pneumonia and age. The following factors were predictive of mortality at 30 days after ED admission: unconsciousness on admission, hypoxia and age. These data might be clinically relevant when it comes to individualized care planning, which should take account of risk prediction and estimated prognosis.

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  • 20.
    Tikkanen, Viivi
    et al.
    School of Health, Care and Social Welfare, Mälardalens University, Eskilstuna, Sweden.
    Arsic, Marija
    Emergency Department, North Älvsborg County Hospital, Trollhättan, Sweden.
    Henricson, Maria
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    The general attributes and competence for nurses in a single responder unit: A modified Delphi study2023Ingår i: BMC Emergency Medicine, E-ISSN 1471-227X, Vol. 23, artikel-id 93Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Abstract

    Aim The aim of this study was to describe the general attributes and competence that nurses in the ambulance’ssingle responder units are considered to need.

    Background

    The development of ambulance care has led to an increased need for new units and working methods. Single responder unit is a single crewed unit that often uses for the patient assessments, to refer patients to the rightlevel of care and to release regular ambulances. There is a lack of description of the needed competence for thenurses within single responder unit.

    Methods

    Modified Delphi with three rounds was used. The first round was conducted with focus group interviewsand analysed with content analysis. Five competence categories and 19 subcategories were identified. The secondand third rounds were conducted through surveys using a 4-point Likert scale and analysed with descriptive statistics.

    Results

    The ability to communicate with other healthcare providers to achieve one’s goal, the ability to create a goodencounter alone and to have appropriate professional experience were identified as the most important generalattributes and competencies.

    Conclusions

    A central competence in prehospital emergency care is the ability to independently assess and treatpatients with varying care needs in complex environments. To be able to work in SRU requires good communicationand collaborations skills with other healthcare providers but it is also a prerequisite for creating a good patientrelationship. Work experience of taking care of varying patients and situations is also needed in SRU.

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