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  • 1.
    Larsson, Glenn
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden; PICTA, Prehospital Innovation Arena, Lindholmen Science Park, Gothenburg, Sweden.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. PreHospen.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    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 study2024In: BMC Emergency Medicine, E-ISSN 1471-227X, Vol. 24, no 1, article id 11Article in journal (Refereed)
    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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  • 2.
    Larsson, Glenn
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    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.
    Characteristics of a trauma population in an ambulance organisation in Sweden: results from an observational study2023In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 31, no 1, article id 33Article in journal (Refereed)
    Abstract [en]

    Background

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

    Methods

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

    Results

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

    Conclusion

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

     

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  • 3.
    Kauppi, Wivica
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Emergency Medical Service (EMS), Sahlgrenska University Hospital, Gothenburg, Sweden.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Jiménez‐Herrera, Maria
    Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden; Nursing Department, Universitat Rovira i Virgili (URV), Tarragona, Spain.
    Palmér, Lina
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Lived experiences of being cared for by ambulance clinicians when experiencing breathlessness—A phenomenological study2023In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712Article in journal (Refereed)
    Abstract [en]

    Background

    Breathlessness is a serious and distressing symptom and a common reason why patients require prehospital care by ambulance clinicians. However, little is known about how patients experience this care when they are in a state of breathlessness.

     

    Aim

    The aim of this study is to describe the lived experiences of being cared for by ambulance clinicians when experiencing breathlessness.

     

    Methods

    Fourteen lifeworld interviews were conducted with patients who experienced breathlessness and were cared for by ambulance clinicians. The interviews were analysed using a qualitative phenomenological approach.

     

    Findings

    The essential meaning of being cared for by ambulance clinicians when experiencing breathlessness is described in two ways: existential humanising care, in which the experience is that of being embraced by a genuine presence or existential dehumanising care, in which feeling exposed to an objectifying presence is the main experience. This meaning has four constituents: surrendering to and trusting in the care that will come; being exposed to an objectifying presence is violating; being embraced by a genuine presence is relieving; and knowing is dwelling.

     

    Conclusion

    The findings reveal that the ability of ambulance clinicians to provide existential humanising and trustful care, which is the foundation of professional judgement, was essential in how patients responded to and handled the overall situation when breathlessness.

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  • 4.
    Olander, Agnes
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Magnusson, Carl
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Sundler, Annelie Johansson
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bremer, Anders
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Linnaeus University, Faculty of Health and Life Sciences, Växjö, Sweden.
    Andersson, Henrik
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Linnaeus University, Faculty of Health and Life Sciences, Växjö, Sweden.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Prediction of the Risk of Sepsis by Using Analysis of Plasma Glucose and Serum Lactate in Ambulance Services: A Prospective Study2023In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 38, no 2, p. 160-167Article in journal (Refereed)
    Abstract [en]

    Introduction: The early recognition of patients with sepsis is difficult and the initial assessment outside of hospitals is challenging for ambulance clinicians (ACs). Indicators that ACs can use to recognize sepsis early are beneficial for patient outcomes. Research suggests that elevated point-of-care (POC) plasma glucose and serum lactate levels may help to predict sepsis in the ambulance service (AS) setting. 

    Study Objective: The aim of this study was to test the hypothesis that the elevation of POC plasma glucose and serum lactate levels may help to predict Sepsis-3 in the AS. 

    Methods: A prospective observational study was performed in the AS setting of Gothenburg in Sweden from the beginning of March 2018 through the end of September 2019. The criteria for sampling POC plasma glucose and serum lactate levels in the AS setting were high or intermediate risk according to the Rapid Emergency Triage and Treatment System (RETTS), as red, orange, yellow, and green if the respiratory rate was >22 breaths/minutes. Sepsis-3 were identified retrospectively. A primary and secondary analyses were carried out. The primary analysis included patients cared for in the AS and emergency department (ED) and were hospitalized. In the secondary analysis, patients who were only cared for in the AS and ED without being hospitalized were also included. To evaluate the predictive ability of these biomarkers, the area under the curve (AUC), sensitivity, specificity, and predictive values were used. 

    Results: A total of 1,057 patients were included in the primary analysis and 1,841 patients were included in the secondary analysis. In total, 253 patients met the Sepsis-3 criteria (in both analyses). The AUC for POC plasma glucose and serum lactate levels showed low accuracy in predicting Sepsis-3 in both the primary and secondary analyses. Among all hospitalized patients, regardless of Sepsis-3, more than two-thirds had elevated plasma glucose and nearly one-half had elevated serum lactate when measured in the AS. 

    Conclusions: As individual biomarkers, an elevated POC plasma glucose and serum lactate were not associated with an increased likelihood of Sepsis-3 when measured in the AS in this study. However, the high rate of elevation of these biomarkers before arrival in hospital highlights that their role in clinical decision making at this early stage needs further evaluation, including other endpoints than Sepsis-3.

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  • 5.
    Herlitz, Johan
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Wireklint Sundström, Birgitta
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Lundgren, Peter
    Sahlgrenska universitetssjukhuset, Göteborg .
    Larsson, Glenn
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Magnusson, Carl
    Sahlgrenska universitetssjukhuset, Göteborg .
    Wibring, Kristoffer
    Göteborgs universitet.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Över 100 doktorsavhandlingar inom den prehospitala akutsjukvården i Sverige2023In: Läkartidningen, ISSN 1652-7518, Vol. 120Article, review/survey (Refereed)
    Abstract [sv]

    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.
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  • 6.
    Schierbeck, Sofia
    et al.
    Karolinska insitute.
    Hollenberg, Jacob
    Karolinska insitute.
    Nord, Anette
    Karolinska insitute.
    Svensson, Leif
    Karolinska insitute.
    Nordberg, Per
    Karolinska insitute.
    Ringh, Mattias
    Karolinska insitute.
    Forsberg, Sune
    Karolinska insitute.
    Lundgren, Peter
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Claesson, Andreas
    Karolinska insitute.
    Automated external defibrillators delivered by drones to patients with suspected out-of-hospital cardiac arrest2022In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, p. 1478-1487Article in journal (Refereed)
    Abstract [en]

    Aims Early defibrillation is critical for the chance of survival in out-of-hospital cardiac arrest (OHCA). Drones, used to deliver automated external defibrillators (AEDs), may shorten time to defibrillation, but this has never been evaluated in real-life emergencies. The aim of this study was to investigate the feasibility of AED delivery by drones in real-life cases of OHCA. Methods and results In this prospective clinical trial, three AED-equipped drones were placed within controlled airspace in Sweden, covering approximately 80 000 inhabitants (125 km(2)). Drones were integrated in the emergency medical services for automated deployment in beyond-visual-line-of-sight flights: (i) test flights from 1 June to 30 September 2020 and (ii) consecutive real-life suspected OHCAs. Primary outcome was the proportion of successful AED deliveries when drones were dispatched in cases of suspected OHCA. Among secondary outcomes was the proportion of cases where AED drones arrived prior to ambulance and time benefit vs. ambulance. Totally, 14 cases were eligible for dispatch during the study period in which AED drones took off in 12 alerts to suspected OHCA, with a median distance to location of 3.1 km [interquartile range (IQR) 2.8-3.4). AED delivery was feasible within 9 m (IQR 7.5-10.5) from the location and successful in 11 alerts (92%). AED drones arrived prior to ambulances in 64%, with a median time benefit of 01:52 min (IQR 01:35-04:54) when drone arrived first. In an additional 61 test flights, the AED delivery success rate was 90% (55/61). Conclusion In this pilot study, we have shown that AEDs can be carried by drones to real-life cases of OHCA with a successful AED delivery rate of 92%. There was a time benefit as compared to emergency medical services in cases where the drone arrived first. However, further improvements are needed to increase dispatch rate and time benefits.

  • 7.
    Kauppi, Wivica
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Jiménez-Herrera, Maria F.
    Nursing Department, Universitat Rovira i Virgili (URV), Tarragona, Spain.
    Palmér, Lina
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Patients' lived experiences of breathlessness prior to prehospital care – A phenomenological study2022In: Nursing Open, E-ISSN 2054-1058, Vol. 9, no 4, p. 2179-2189Article in journal (Refereed)
    Abstract [en]

    Abstract Aims and objectives The study aimed to describe how breathlessness is experienced by patients prior to prehospital care. Design A qualitative phenomenological design. Methods Lifeworld interviews were conducted with 14 participants. The analysis was carried out within the descriptive phenomenological framework. Results The essential meaning of the breathlessness phenomenon is described as an existential fear in terms of losing control over one?s body and dying, which involves a battle to try to regain control. This is further described by four constituents: being in an unknown body, striving to handle the situation, the ambiguity of having loved ones close and reaching the utmost border. Conclusions Patients describe a battling for survival. It is at the extreme limit of endurance that patients finally choose to call the emergency number. It is a challenge for the ambulance clinician (AC) to support these patients in the most optimal fashion.

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  • 8.
    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
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Norberg-Boysen, Gabriella
    Kauppi, Wivica
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Prehospital Emergency Care , Sahlgrenska University Hospital, SE-411 04, Gothenburg, Sweden.
    Packendorff, Niclas
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Larsson, Glenn
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Wibring, Kristoffer
    Suboptimal prehospital decision- making for referral to alternative levels of care – frequency, measurement, acceptance rate and room for improvement2022In: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 22, no 1, article id 89Article in journal (Refereed)
    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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  • 9.
    Azeli, Y.
    et al.
    Sistema d’Emergències Mèdiques de Catalunya, Carrer de Pablo Iglesias 101–115, L’Hospitalet de Llobregat, Barcelona, Spain.
    Bardají, A.
    Institut d’Investigació Sanitària Pere Virgili (IISPV), Reus, Spain.
    Barbería, E.
    Universitat Rovira i Virgili, Tarragona, Spain.
    Lopez-Madrid, V.
    Emergency Department, Sant Joan University Hospital, Reus, Spain.
    Bladé-Creixenti, J.
    Atenció Primaria, Institut Català de la Salut, Tarragona, Spain.
    Fernández-Sender, L.
    Llevant Clinic Unit, Santa Tecla Hospital, Tarragona, Spain.
    Bonet, G.
    Cardiology Department, Joan XXIII, University Hospital, Tarragona, Spain.
    Rica, E.
    Department de Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Tarragona, Spain.
    Álvarez, S.
    Department de Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Tarragona, Spain.
    Fernández, A.
    Departament d’Enginyeria Química, Universitat Rovira i Virgili, Tarragona, Spain.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Jiménez-Herrera, M. F.
    Department of Nursing, Universitat Rovira i Virgili, Tarragona, Spain.
    Clinical outcomes and safety of passive leg raising in out-of-hospital cardiac arrest: a randomized controlled trial2021In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 25, no 1, article id 176Article in journal (Refereed)
    Abstract [en]

    Background: There are data suggesting that passive leg raising (PLR) improves hemodynamics during cardiopulmonary resuscitation (CPR). This trial aimed to determine the effectiveness and safety of PLR during CPR in out-of-hospital cardiac arrest (OHCA).

    Methods: We conducted a randomized controlled trial with blinded assessment of the outcomes that assigned adults OHCA to be treated with PLR or in the flat position. The trial was conducted in the Camp de Tarragona region. The main end point was survival to hospital discharge with good neurological outcome defined as cerebral performance category (CPC 1–2). To study possible adverse effects, we assessed the presence of pulmonary complications on the first chest X-rays, brain edema on the computerized tomography (CT) in survivors and brain and lungs weights from autopsies in non-survivors.

    Results: In total, 588 randomized cases were included, 301 were treated with PLR and 287 were controls. Overall, 67.8% were men and the median age was 72 (IQR 60–82) years. At hospital discharge, 3.3% in the PLR group and 3.5% in the control group were alive with CPC 1–2 (OR 0.9; 95% CI 0.4–2.3, p = 0.91). No significant differences in survival at hospital admission were found in all patients (OR 1.0; 95% CI 0.7–1.6, p = 0.95) and among patients with an initial shockable rhythm (OR 1.7; 95% CI 0.8–3.4, p = 0.15). There were no differences in pulmonary complication rates in chest X-rays [7 (25.9%) vs 5 (17.9%), p = 0.47] and brain edema on CT [5 (29.4%) vs 10 (32.6%), p = 0.84]. There were no differences in lung weight [1223 mg (IQR 909–1500) vs 1239 mg (IQR 900–1507), p = 0.82] or brain weight [1352 mg (IQR 1227–1457) vs 1380 mg (IQR 1255–1470), p = 0.43] among the 106 autopsies performed.

    Conclusion: In this trial, PLR during CPR did not improve survival to hospital discharge with CPC 1–2. No evidence of adverse effects has been found.

    Clinical trial registration ClinicalTrials.gov: NCT01952197, registration date: September 27, 2013, https://clinicaltrials.gov/ct2/show/NCT01952197. [Figure not available: see fulltext.] 

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  • 10.
    Herlitz, Johan
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Magnusson, Carl
    Sahlgrenska universitetssjukhuset, Göteborg.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Lundgren, Peter
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Larsson, Glenn
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Rawshani, Araz
    Sahlgrenska universitetssjukhuset, Göteborg.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Den prehospitala akutsjukvården i Sverige har stora utmaningar2021In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, article id 21119Article, review/survey (Refereed)
  • 11.
    Abelsson, A.
    et al.
    Department of Nursing Science, Jönköping University, Jönköping, Sweden.
    Appelgren, J.
    Faculty of Arts and Social Sciences, Karlstads Universitet, Karlstad, Sweden.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Enhanced self-assessment of CPR by low-dose, high-frequency training2021In: International Journal of Emergency Services, ISSN 2047-0894, E-ISSN 2047-0908, Vol. 10, no 1, p. 93-100Article in journal (Refereed)
    Abstract [en]

    Purpose: The purpose was to investigate what effect an intervention of low-dose, high-frequency cardiopulmonary resuscitation (CPR) training with feedback for one month would have on professionals' subjective self-assessment skill of CPR.

    Design/methodology/approach: This study had a quantitative approach. In total, 38 firefighters performed CPR for two minutes on a Resusci Anne QCPR. They then self-assessed their CPR through four multiple-choice questions regarding compression rate, depth, recoil and ventilation volume. After one month of low-dose, high-frequency training with visual feedback, the firefighters once more performed CPR and self-assessed their CPR.

    Findings: With one month of low-dose, high-frequency training with visual feedback, the level of self-assessment was 87% (n = 33) correct self-assessment of compression rate, 95% (n = 36) correct self-assessment of compression depth, 68% (n = 26) correct self-assessment of recoil and 87% (n = 33) correct self-assessment of ventilations volume. The result shows a reduced number of firefighters who overestimate their ability to perform CPR.

    Originality/value: With low-dose, high-frequency CPR training with visual feedback for a month, the firefighters develop a good ability to self-assess their CPR to be performed within the guidelines. By improving their ability to self-assess their CPR quality, firefighters can self-regulate their compression and ventilation quality. © 2020, Emerald Publishing Limited.

  • 12.
    Magnusson, C.
    et al.
    Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
    Carlström, M.
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Lidman, N.
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
    Wennberg, P.
    Research and Development Centre, Skaraborg Hospital, Skövde, Sweden.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Evaluation and treatment of pain in the pre-hospital setting. A comparison between patients with a hip injury, chest pain and abdominal pain2021In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013X, Vol. 56, article id 100999Article in journal (Refereed)
    Abstract [en]

    Background: A large proportion of patients who call 112 in Sweden do so because of pain. The purpose of this study was to compare three of the most common types of pain presented by the patients: chest pain, abdominal pain and hip injury, in terms of initial assessment, intensity, treatment and effect of treatment. The overall rationale was to evaluate whether the early assessment and treatment of pain in the pre-hospital setting is optimal or whether there is room for improvement.

    Methods: Observational study during 2016 including 1234 patients triaged to chest pain, abdominal pain and hip injury by the Emergency Medical Services (EMS) in Gothenburg, Sweden.

    Results: Severe pain on the arrival of the EMS was described by 39% of patients with a hip injury, 27% with abdominal pain and 15% with chest pain. Analgesics were given to 58% of patients with a hip injury, 35% with chest pain and 34% with abdominal pain. A lower intensity of pain at re-evaluation was observed in 80% of patients with a hip injury, 57% with chest pain and 43% with abdominal pain. Administration of analgesics increased with the duration of pre-hospital care time in all three groups.

    Conclusions: Patients with a hip injury had the most severe pain and they received most pain-relieving medication. Overall, a relatively small proportion of patients with pain received pain-relieving medication and there appears to be an extensive room for improvement. 

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  • 13.
    Magnusson, Carl
    et al.
    Göteborgs universitet.
    Ryge, Helena
    Sahlgrenska universitetssjukhus.
    Scott, Filip
    Sahlgrenska universitetssjukhus.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Limited need for hospital resources among patients brought to hospital by the emergency medical services2021In: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 21, no 1, article id 156Article in journal (Refereed)
    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).

  • 14.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden..
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden..
    Höglind, Robert
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden..
    Wennberg, Pär
    Research and Development Centre, Skaraborg Hospital, Skövde, Sweden..
    Edelvik Tranberg, Anna
    Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden..
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden..
    Zelano, Johan
    Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden..
    Prehospital lactate levels in blood as a seizure biomarker: A multi-center observational study.2021In: Epilepsia, ISSN 0013-9580, E-ISSN 1528-1167, Vol. 62, no 2, p. 408-415Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The objective of this study was to assess the value of prehospital measurement of lactate level in blood for diagnosis of seizures in cases of transient loss of consciousness.

    METHODS: Between March 2018 and September 2019, prehospital lactate was measured with a point-of-care device by the emergency medical services in an area serving a population of 900 000. A total of 383 cases of transient loss of consciousness were identified and categorized as tonic-clonic seizure (TCS), other seizure, syncope, or other cause, according to the final diagnosis in the electronic medical records system. Receiver operating characteristic curve analyses were used to identify the optimal lactate cut-off.

    RESULTS: A total of 383 cases were included (135 TCS, 42 other seizure, 163 syncope, and 43 other causes). The median lactate level in TCS was 7.0 mmol/L, compared to a median of 2.0 mmol/L in all other cases (P < .001). The area under the curve (AUC) of TCS vs nonepileptic causes was 0.87 (95% confidence interval [CI] 0.83-0.91). The optimal cut-off (Youden index, 67.8%) was 4.75 mmol/L, with 79% sensitivity (95% CI 71-85) and 89% specificity (95% CI 85-93) for TCS.

    SIGNIFICANCE: Prehospital lactate can be a valuable tool for identifying seizures in transient loss of consciousness. For acceptable specificity, a higher cut-off than that previously demonstrated for hospital-based measurements must be used when values obtained close to the time of the event are interpreted.

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  • 15.
    Kauppi, Wivica
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Magnusson, Carl
    Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Palmér, Lina
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Characteristics and outcomes of patients with dyspnoea as the main symptom, assessed by prehospital emergency nurses- a retrospective observational study2020In: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, no 1, p. 1-11Article in journal (Refereed)
    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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  • 16.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
    Lövgren, E
    The Department of Emergency Care in South Älvsborg, Sweden.
    Alfredsson, J
    The Department of Emergency Care in South Älvsborg, Sweden.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Rosengren, Lars
    Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Jood, Katarina
    Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
    Difficulties in the prehospital assessment of patients with TIA/stroke2020In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404Article in journal (Refereed)
    Abstract [en]

    Background: In patients with TIA/stroke, early assessment is critical.

    Aim: To describe patients who were not directly transported to hospital by ambulance after prehospital assessment.

    Methods: Patients hospitalised with TIA/stroke in Gothenburg, Data were obtained from the EMS and hospital case record system.

    Results: There were 7,812 patients with TIA/stroke, of which 4,853 (62%) were candidates for EMS transport. Among them, 176 (3.6%) were not directly transported to hospital by ambulance. In 45% of them, delay from symptom onset to calling for EMS was ≤ 24 hours. On EMS arrival, common symptom was dizziness (28%), followed by weakness in arm or leg (21%), loss of sensibility (13%), speech disturbances (7%) and facial numbness (4%). The modified National Institute of Health Stroke Score (mNIHSS) was 0 in 80% and > 1 in two per cent. The NIHSS at the emergency department was 1-4 in 39% and 5-15 in six per cent. The EMS clinician made the decision not to transport the patient to hospital by the EMS in 84%, the dispatcher in 12% and the patient or relatives in four per cent. Patients were involved in the decision in 51%. Final diagnosis was stroke in 74% and the proportion who were independent in normal daily activities at hospital discharge decreased by 15% compared with before event.

    Conclusion: About 3-4% of patients with TIA/stroke were not directly transported to hospital by EMS after prehospital assessment. The most common symptom was dizziness. Decision-support tools for EMS to identify time-sensitive conditions are required.

  • 17.
    Jimenez-Herrera, Maria F.
    et al.
    Nursing Department, Universitat Rovira i Virgili (URV), Av/ Catalunya, 35 43002, Tarragona, Spain.
    Llaurado-Serra, Mireia
    Faculty of Medicine and Health science, Nursing Department, University Internacional of Catalonia (UIC), Barcelona, Spain.
    Acebedo-Urdiales, Sagrario
    Nursing Department, Universitat Rovira i Virgili (URV), Av/ Catalunya, 35 43002, Tarragona, Spain.
    Bazo-Hernandez, Leticia
    Nursing Department, Universitat Rovira i Virgili (URV), Av/ Catalunya, 35 43002, Tarragona, Spain.
    Font-Jimenez, Isabel
    Nursing Department, Universitat Rovira i Virgili (URV), Av/ Catalunya, 35 43002, Tarragona, Spain.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Emotions and feelings in critical and emergency caring situations: a qualitative study2020In: BMC Nursing, ISSN 1472-6955, E-ISSN 1472-6955, Vol. 19, no 1Article in journal (Refereed)
    Abstract [en]

    Background Moral emotions are a key element of our human morals. Emotions play an important role in the caring process. Decision-making and assessment in emergency situations are complex and they frequently result in different emotions and feelings among health-care professionals. Methods The study had qualitative deductive design based on content analysis. Individual interviews and focus groups were conducted with sixteen participants. Results The emerging category “emotions and feelings in caring” has been analysed according to Haidt, considering that moral emotions include the subcategories of “Condemning emotions”, “Self-conscious emotions”, “Suffering emotions” and “Praising emotions”. Within these subcategories, we found that the feelings that nurses experienced when ethical conflicts arose in emergency situations were related to caring and decisions associated with it, even when they had experienced situations in which they believed they could have helped the patient differently, but the conditions at the time did not permit it and they felt that the ethical conflicts in clinical practice created a large degree of anxiety and moral stress. The nurses felt that caring, as seen from a nursing perspective, has a sensitive dimension that goes beyond the patient’s own healing and, when this dimension is in conflict with the environment, it has a dehumanising effect. Positive feelings and satisfaction are created when nurses feel that care has met its objectives and that there has been an appropriate response to the needs. Conclusions Moral emotions can help nurses to recognise situations that allow them to promote changes in the care of patients in extreme situations. They can also be the starting point for personal and professional growth and an evolution towards person-centred care.

  • 18.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    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.2020In: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, no 1, article id 7Article in journal (Refereed)
    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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  • 19.
    Kauppi, Wivica
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsson, Thomas
    Biostatistics, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Magnusson, Carl
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Palmér, Lina
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Pre-hospital predictors of an adverse outcome among patients with dyspnoea as the main symptom assessed by prehospital emergency nurses- a retrospective observational study2020In: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 20, no 89, p. 1-12Article in journal (Refereed)
    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
  • 20.
    Wibring, Kristoffer
    et al.
    Department of Prehospital Emergency Care, Region Halland, Sweden.
    Magnusson, Carl
    Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Lundgren, Peter
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Towards definitions of time-sensitive conditions in prehospital care2020In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 28, no 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Prehospital care has changed in recent decades. Advanced assessments and decisions are made early in the care chain. Patient assessments form the basis of a decision relating to prehospital treatment and the level of care. This development imposes heavy demands on the ability of emergency medical service (EMS) clinicians properly to assess the patient. EMS clinicians have a number of assessment instruments and triage systems available to support their decisions. Many of these instruments are based on vital signs and can sometimes miss time-sensitive conditions. With this commentary, we would like to start a discussion to agree on definitions of temporal states in the prehospital setting and ways of recognising patients with time-sensitive conditions in the most optimal way.

    MAIN BODY:

    There are several articles discussing the identification and management of time-sensitive conditions. In these articles, neither definitions nor terminology have been uniform. There are a number of problems associated with the definition of time-sensitive conditions. For example, intoxication can be minor but also life threatening, depending on the type of poison and dose. Similarly, diseases like stroke and myocardial infarction can differ markedly in terms of severity and the risk of life-threatening complications. Another problem is how to support EMS clinicians in the early recognition of these conditions. It is well known that many of them can present without a deviation from normal in vital signs. It will most probably be impossible to introduce specific decision support tools for every individual time-sensitive condition. However, there may be information in the type and intensity of the symptoms patients present. In future, biochemical markers and machine learning support tools may help to identify patients with time-sensitive conditions and predict mortality at an earlier stage.

    CONCLUSION:

    It may be of great value for prehospital clinicians to be able to describe time-sensitive conditions. Today, neither definitions nor terminology are uniform. Our hope is that this commentary will initiate a discussion on the issue aiming at definitions of time-sensitive conditions in prehospital care and how they should be recognised in the most optimal fashion.

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  • 21.
    Andersson Hagiwara, Magnus
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Magnusson, Carl
    University of Gothenburg and Sahlgrenska University Hospital,.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Seffel, Elin
    Department of Ambulance Care, Södra Älvsborg Hospital.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Munters, Monica
    Department of Ambulance Care, Region of Dalarna.
    Strömsöe, Anneli
    School of Health, Care and Social Welfare, Mälardalens högskola.
    Nilsson, Lena
    Department of Anaesthesiology and Intensive Care and Department of Medical and Health Sciences, Linköping University.
    Adverse events in prehospital emergency care: a trigger tool study2019In: BMC Emergency Medicine, Vol. 19, no 1Article in journal (Refereed)
    Abstract [en]

    Prehospital emergency care has developed rapidly during the past decades. The care is given in a complex context which makes prehospital care a potential high-risk activity when it comes to patient safety. Patient safety in the prehospital setting has been only sparsely investigated. The aims of the present study were 1) To investigate the incidence of adverse events (AEs) in prehospital care and 2) To investigate the factors contributing to AEs in prehospital care.

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  • 22.
    Alsholm, Linda
    et al.
    Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Niva, My
    Department of Ambulance Care, Jönköping County Hospital.
    Claesson, Lisa
    Department of Ambulance Care, Halland County Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Magnusson, Carl
    Department of Molecular and Clinical Medicine, University of Gothenburg and Sahlgrenska University Hospital.
    Rosengren, Lars
    Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg.
    Jood, Katarina
    Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg.
    Interrupted transport by the emergency medical service in stroke/transitory ischemic attack: A consequence of changed treatment routines in prehospital emergency care.2019In: Brain and Behavior, ISSN 2162-3279, E-ISSN 2162-3279, article id e01266Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The discovery that not all patients who call for the emergency medical service (EMS) require transport to hospital has changed the structure of prehospital emergency care. Today, the EMS clinician at the scene already distinguishes patients with a time-critical condition such as stroke/transitory ischemic attack (TIA) from patients without. This highlights the importance of the early identification of stroke/TIA.

    AIM: To describe patients with a final diagnosis of stroke/TIA whose transport to hospital was interrupted either due to a lack of suspicion of the disease by the EMS crew or due to refusal by the patient or a relative/friend.

    METHODS: Data were obtained from a register in Gothenburg, covering patients hospitalised due to a final diagnosis of stroke/TIA. The inclusion criterion was that patients were assessed by the EMS but were not directly transported to hospital by the EMS.

    RESULTS: Among all the patients who were assessed by the EMS nurse and subsequently diagnosed with stroke or TIA in 2015, the transport of 34 of 1,310 patients (2.6%) was interrupted. Twenty-five of these patients, of whom 20 had a stroke and five had a TIA, are described in terms of initial symptoms and outcome. The majority had residual symptoms at discharge from hospital. Initial symptoms were vertigo/disturbed balance in 11 of 25 cases. Another three had symptoms perceived as a change in personality and three had a headache.

    CONCLUSION: From this pilot study, we hypothesise that a fraction of patients with stroke/TIA who call for the EMS have their direct transport to hospital interrupted due to a lack of suspicion of the disease by the EMS nurse at the scene. These patients appear to have more vague symptoms including vertigo and disturbed balance. Instruments to identify these patients at the scene are warranted.

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  • 23.
    Holmén, Johan
    et al.
    Department of Prehospital and Emergency Care, Department of Anaesthesiology and Intensive Care, Queen Silvia's Children's Hospital Sahlgrenska University Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Jimenez-Herrera, Maria
    Department of Nursing, Universitat Rovira i Virgili Spain.
    Karlsson, Thomas
    Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Passive leg raising in out-of-hospital cardiac arrest.2019In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 137, p. 94-101, article id S0300-9572(18)30888-8Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The use of passive leg raising (PLR) in cardiopulmonary resuscitation (CPR) is sometimes discussed and even recommended. The effect of this intervention has never been properly addressed. We planned to determine whether PLR in out-of-hospital cardiac arrest (OHCA) is associated with an improved survival to 30 days.

    METHODS: In eight districts in western Sweden, we introduced PLR within five minutes after the start of CPR, among patients with OHCA. Patients in whom PLR was not performed, within the same district, served as a control group. Thirty-day survival was the primary endpoint. A propensity score analysis, as well as a standard multivariate analysis, was used to assess possible differences between the two groups.

    RESULTS: We identified 3554 patients with OHCA from the eight districts. Forty-four percent were treated with PLR during CPR. Patients who received PLR differed from those who did not, by having more risk factors for an adverse outcome (fewer crew-witnessed cases, more OHCA at home, a greater need for medication and prolonged delays to treatment). The overall survival to 30 days was 7.9% among patients who received PLR versus 13.5% among those who did not. A comparison of the groups, using propensity score matching, revealed a 30 -day survival of 8.6% in the PLR group versus 8.2% in the control group (odds ratio 1.07; 95% confidence interval 0.80-1.44).

    CONCLUSION: In an observational study, we introduced PLR as an addition to standard treatment in patients with OHCA. We did not find any evidence that this treatment improves survival to 30 days.

  • 24.
    Azeli, Youcef
    et al.
    Sistema d'Emergències Mèdiques de Catalunya, L'Hospitalet de Llobregat, Barcelona, Spain.
    Barberia, E
    Institut de Medicina Legal y Forense de Catalunya, Tarragona, Spain.
    Jimenez Herrera, Maria
    Departamento de Enfermería, Universitat Rovira i Virgili, Tarragona, Spain.
    Ameijide, A
    Unidad de Bioestadística, Fundació Lliga per a la Investigació i Prevenció del Càncer, Reus, Tarragona, Spain.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bardaji, Alfredo
    Institut d'Investigació Sanitaria Pere Virgili, Tarragona, España. Universitat Rovira i Virgili, Tarragona, Spain.
    Serious injuries secondary to cardiopulmonary resuscitation: incidence and associated factors.2019In: Emergencias, Vol. 31, no 5, p. 327-334, article id 31625304Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES:

    To determine the incidence of serious rib cage damage (SRD) and serious visceral damage (SVD) secondary to cardiopulmonary resuscitation (CPR) and to explore associated factors.

    MATERIAL AND METHODS:

    We analyzed data from the prospective registry of cases of sudden death in Tarragona, Spain (the ReCaPTa study). Cases were collected from multiple surveillance sources. In this study we included the cases of autopsied nonsurvivors after attempted manual CPR between April 2014 and May 2016. A specific protocol to detect injuries secondary to CPR was used during the autopsies.

    RESULTS:

    We analyzed 109 cases. The mean age at death was 63 years and 32.1% were women. SRD were found in 63.3% and SVD in 14.7%. The group with SRD were significantly older (63 vs 59 years, P=.031) and included higher percentages of persons with a chest circumference over 101 cm (56.5 vs 30%, P=.016) and a waist circumference over 100 cm (62.3 vs 37.5%, P=.017). A multivariable analysis confirmed chest circumference over 101 cm as the only risk factor for SRD (odds ratio [OR], 2.45; 95% CI, 1.03-5.84) and female sex as the only risk factor for SVD (OR, 5.02; 95% CI, 1.18-21.25).

    CONCLUSION:

    Women and any patient with a chest circumference greater than 101 cm are at greater risk for serious injuries related to CPR.

  • 25.
    Andersson, Jan-Otto
    et al.
    Ambulance Service, Skaraborg Hospital.
    Nasic, Salmir
    Research and Development Centre, Skaraborg Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Hjertonsson, Erik
    Department of Medicine, Skövde County Hospital.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    The intensity of pain in the prehospital setting is most strongly reflected in the respiratory rate among physiological parameters.2019In: American Journal of Emergency Medicine, ISSN 0735-6757, E-ISSN 1532-8171, Vol. 37, no 12, p. 2125-2131, article id S0735-6757(19)30038-5Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In order to treat pain optimally, the Emergency Medical Service (EMS) clinician needs to be able to make a reasonable estimation of the severity of the pain. It is hypothesised that various physiological parameters will change as a response to pain.

    AIM: In a cohort of patients who were seen by EMS clinicians, to relate the patients' estimated intensity of pain to various physiological parameters.

    METHODS: Patients who called for EMS due to pain in a part of western Sweden were included. The intensity of pain was assessed according to the visual analogue scale (VAS) or the Numerical Rating Scale (NRS). The following were assessed the same time as pain on EMS arrival: heart rate, systolic and diastolic blood pressure, respiratory rate, moist skin and paleness.

    RESULTS: In all, 19,908 patients (≥18 years), were studied (51% women). There were significant associations between intensity of pain and the respiratory rate (r = 0.198; p < 0.0001), heart rate (r = 0.037; p < 0.0001), systolic blood pressure (r = -0.029; p < 0.0001), moist skin (r = 0.143; p < 0.0001) and paleness (r = 0.171; p < 0.0001). The strongest association was found with respiratory rate among patients aged 18-64 years (r = 0.258; p < 0.0001).

    CONCLUSION: In the prehospital setting, there were significant but weak correlations between intensity of pain and physiological parameters. The most clinically relevant association was found with an increased respiratory rate and presence of pale and moist skin among patients aged < 65 years. Among younger patients, respiratory rate may support in the clinical evaluation of pain.

  • 26.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsson, T
    Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg.
    Jimenez Herrera, Maria
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    The performance of EMS triage (RETTS-P) and the agreement between the field assessment and final hospital diagnosis: a prospective observational study among children <16 years.2019In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 19, no 500, article id 31842832Article in journal (Refereed)
    Abstract [en]

    Background

    The rapid triage and treatment system for paediatrics (RETTS-p) has been used by the emergency medical services (EMS) in the west of Sweden since 2014. The performance of the RETTS-p in the pre-hospital setting and the agreement between the EMS nurse’s field assessment and the hospital diagnosis is unknown. The aim of this study was to evaluate the performance of the RETTS-p in the EMS and the agreement between the EMS field assessment and the hospital diagnosis.

    Methods

    A prospective observational study was conducted among 454 patients < 16 years of age who were assessed and transported to the PED. Two instruments were used for comparison: 1) Classification of an emergent patient according to predefined criteria as compared to the RETTS-p and 2) Agreement between the EMS nurse’s field assessment and the hospital diagnosis.

    Results

    Among all children, 11% were identified as having vital signs associated with an increased risk of death and 7% were diagnosed in hospital with a potentially life-threatening condition. Of the children triaged with RETTS-p (85.9%), 149 of 390 children (38.2%) were triaged to RETTS-p red or orange (life-threatening, potentially life-threatening), of which 40 (26.8%) children were classified as emergent. The hospitalised children were triaged with the highest frequency to level yellow (can wait; 41.5%). In children with RETTS-p red or orange, the sensitivity for a defined emergent patient was 66.7%, with a corresponding specificity of 67.0%. The EMS field assessment was in agreement with the final hospital diagnosis in 80% of the cases.

    Conclusions

    The RETTS-p sensitivity in this study is considered moderate. Two thirds of the children triaged to life threatening or potentially life threatening were later identified as non-emergent. Of those, one in six was discharged from the PED without any intervention. Further, one third of the children were under triaged, the majority were found in the yellow triage level (can wait). The highest proportion of hospitalised patients was found in the yellow triage level. Our result is in agreement with previous studies using other triage instruments. A computerised decision support system might help the EMS triage to increase sensitivity and specificity.

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  • 27.
    Sjösten, Oscar
    et al.
    SÄS.
    Nilsson, Johanna
    SÄS.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Jiménez-Herrera, Maria
    Universitat Rovira i Virgili.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    The prehospital assessment of patients with a final hospital diagnosis of sepsis: Results of an observational study2019In: Australasian Emergency Care, ISSN 2588-994XArticle in journal (Refereed)
    Abstract [en]

    Background

    Sepsis is a severe condition which affects 300–800/100,000 persons each year. There are indications that the prehospital identification of patients with sepsis is difficult. The aim of the study was, among patients with a final hospital diagnosis of sepsis, to compare emergency medical service (EMS) field assessments of patients in whom there was a prehospital suspicion of sepsis with those without this suspicion.

    Methods

    The study had a retrospective, observational design. The data used in the study were retrieved from the prehospital and hospital medical records of patients with a final hospital diagnosis of sepsis, transported to hospital by the EMS within a region in the south west of Sweden during a period of one year.

    Results

    Among patients with a final diagnosis of sepsis (n = 353), the EMS identified the condition in 36% of the cases. These patients were characterised by more abnormal vital signs (a higher respiratory rate and heart rate and more frequent temperature abnormalities) and were more ambitiously assessed (more lung auscultations and more assessments of the degree of consciousness).

    Conclusion

    The EMS was already able to identify 36% of patients with a final diagnosis of sepsis in the prehospital phase. There were minor differences in the prehospital assessment between patients who were identified by the EMS nurse and those who were not.

  • 28.
    Holmén, Johan
    et al.
    Department of Anesthesiology and Intensive Care, Queen Silvia’s Children’s Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Sahlgrenska Academy, University of Gothenburg.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Immediate coronary intervention in prehospital cardiac arrest-Aiming to save lives.2018In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 202, p. 144-147, article id S0002-8703(18)30158-3Article in journal (Refereed)
  • 29.
    Holmén, Johan
    et al.
    Department of Anesthesiology and Intensive Care, Queen Silvia’s Children’s Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Sahlgrenska Academy, University of Gothenburg.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. SU Ambulansen.
    Immediatecoronary intervention in prehospital cardiac arrest-Aiming to save lives.2018In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 202, p. 144-147Article in journal (Refereed)
  • 30.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, Sahlgrenska Academy.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Department of Molecular and Clinical Medicine, Sahlgrenska Academy.
    Karlsson, Thomas
    Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. SU Ambulansen.
    Initialassessment, level of care and outcome among children who were seen by emergencymedical services: a prospective observational study.2018In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 26, no 1, p. 88-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

    METHODS:

    A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher's exact test and Spearman's rank statistics.

    RESULTS:

    The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0-15 years.

    CONCLUSIONS:

    Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

  • 31.
    Andersson, Henrik
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Larsson, Anna
    Bremer, Anders
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Gellerstedt, Martin
    Bång, Angela
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Ljungström, Lars
    The early chain of care in bacteraemia patients: Early suspicion, treatment and survivalin prehospital emergency care2018In: American Journal of Emergency Medicine, ISSN 0735-6757, E-ISSN 1532-8171Article in journal (Refereed)
    Abstract [en]

    Introduction: Bacteraemia is a first stage for patients risking conditions such as septic shock. The primary aim ofthis study is to describe factors in the early chain of care in bacteraemia, factors associated with increased chanceof survival during the subsequent 28 days after admission to hospital. Furthermore, the long-term outcome wasassessed.

    Methods: This study has a quantitative design based on data fromEmergencyMedical Services (EMS) and hospitalrecords.

    Results: In all, 961 patients were included in the study. Of these patients, 13.5% died during the first 28 days. TheEMS was more frequently used by non-survivors. Among patients who used the EMS, the suspicion of sepsis alreadyon scene was more frequent in survivors. Similarly, EMS personnel noted the ESS code “fever, infection”more frequently for survivors upon arriving on scene. The delay time fromcall to the EMS and admission to hospitaluntil start of antibiotics was similar in survivors and non-survivors. The five-year mortality rate was 50.8%.Five-year mortalitywas 62.6% among those who used the EMS and 29.5% among those who did not (p b 0.0001).

    Conclusion: This study shows that among patientswith bacteraemiawho used the EMS, an early suspicion of sepsisor fever/infection was associated with improved early survival whereas the delay time from call to the EMSand admission to hospital until start of treatment with antibiotics was not. 50.8% of all patients were deadafter five years.

  • 32.
    Magnusson, Carl
    et al.
    Department of Molecular and Clinical Medicine, University of Gothenburg .
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Nilsson, Lena
    Department of Anaesthesiology and Intensive Care and Department of Medical and Health Sciences, Linköping University.
    Strömsöe, Anneli
    School of Education, Health and Social Studies, Dalarna University .
    Munters, Monica
    Department of Ambulance Care, Region of Dalarna.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    The final assessment and its association with field assessment in patients who were transported by the emergency medical service.2018In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 26, no 1, article id 111Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In patients who call for the emergency medical service (EMS), there is a knowledge gap with regard to the final assessment after arriving at hospital and its association with field assessment.

    AIM: In a representative population of patients who call for the EMS, to describe a) the final assessment at hospital discharge and b) the association between the assessment in the field and the assessment at hospital discharge.

    METHODS: Thirty randomly selected patients reached by a dispatched ambulance each month between 1 Jan and 31 Dec 2016 in one urban, one rural and one mixed ambulance organisation in Sweden took part in the study. The exclusion criteria were age < 18 years, dead on arrival, transport between health-care facilities and secondary missions. Each patient received a unique code based on the ICD code at hospital discharge and field assessment.

    RESULTS: In all, 1080 patients took part in the study, of which 1076 (99.6%) had a field assessment code. A total of 894 patients (83%) were brought to a hospital and an ICD code (ICD-10-SE) was available in 814 patients (91% of these cases and 76% of all cases included in the study). According to these ICD codes, the most frequent conditions were infection (15%), trauma (15%) and vascular disease (9%). The most frequent body localisation of the condition was the thorax (24%), head (16%) and abdomen (13%). In 118 patients (14% of all ICD codes), the condition according to the ICD code was judged as time critical. Among these cases, field assessment was assessed as potentially appropriate in 75% and potentially inappropriate in 12%.

    CONCLUSION: Among patients reached by ambulance in Sweden, 83% were transported to hospital and, among them, 14% had a time-critical condition. In these cases, the majority were assessed in the field as potentially appropriate, but 12% had a potentially inappropriate field assessment. The consequences of these findings need to be further explored.

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  • 33.
    Djarv, T
    et al.
    Karolinska University Hospital.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Stromsoe, A
    Mälardalen University.
    Israelsson, J
    Linnaeus University.
    Claesson, A
    Linköping University.
    Traumatic cardiac arrest in Sweden 1990-2016 - a population-based national cohort study.2018In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 26, no 1, article id 30Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Trauma is a main cause of death among young adults worldwide. Patients experiencing a traumatic cardiac arrest (TCA) certainly have a poor prognosis but population-based studies are sparse. Primarily to describe characteristics and 30-day survival following a TCA as compared with a medical out-of-hospital cardiac arrest (medical CA).

    METHODS: A cohort study based on data from the nationwide, prospective population-based Swedish Registry for Cardiopulmonary Resuscitation (SRCR), a medical cardiac arrest registry, between 1990 and 2016. The definition of a TCA in the SRCR is a patient who is unresponsive with apnoea where cardiopulmonary resuscitation and/or defibrillation have been initiated and in whom the Emergency Medical Services (EMS, mainly a nurse-based system) reported trauma as the aetiology. Outcome was overall 30-day survival. Descriptive statistics as well as multivariable logistic regression models were used.

    RESULTS: In all, between 1990 and 2016, 1774 (2.4%) cases had a TCA and 72,547 had a medical CA. Overall 30-day survival gradually increased over the years, and was 3.7% for TCAs compared to 8.2% following a medical CA (p < 0.01). Among TCAs, factors associated with a higher 30-day survival were bystander witnessed and having a shockable initial rhythm (adjusted OR 2.67, 95% C.I. 1.15-6.22 and OR 8.94 95% C.I. 4.27-18.69, respectively).

    DISCUSSION: Association in registry-based studies do not imply causality but TCA had short time intervals in the chain of survival as well as high rates of bystander-CPR.

    CONCLUSION: In a medical CA registry like ours, prevalence of TCAs is low and survival is poor. Registries like ours might not capture the true incidence. However, many individuals do survive and resuscitation in TCAs should not be seen futile.

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  • 34.
    Ranta, Aarne
    et al.
    Chalmers University of Technology.
    Angelov, Krasimir
    Chalmers University of Technology.
    Höglind, Robert
    Sahlgrenska University Hospital.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Sandsjö, Leif
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    A Mobile Language Interpreter App for Prehospital/Emergency Care2017In: Medicinteknikdagarna 2017, 2017Conference paper (Other academic)
    Abstract [en]

    Lack of a shared language is a common communication situation in the globalizing world. Sometimes this can be mitigated by the use of machine translation technology, such as Google translate, but there are mission-critical tasks, like in health care, where one has to be sure about the correctness of the translation. In such situations, human interpreters are the best choice, but interpreters are scarce and in urgent situations they are not always available. This calls for improved and more reliable machine translation initiatives.

    The project to be presented is developing a mobile translator for ambulance personnel use. The translator uses a verifiable and controllable machine translation technology, which is based on semantics, grammars, and professional terminology. The technology has been developed in the international open source project Grammatical Framework (GF) and tested in numerous research projects as well as commercial applications. This project is the first one to apply GF in a healthcare setting. The aim is to develop a platform for a range of health care applications, provided this pilot project for ambulance/emergency care is successful.

    The translator works as a mobile app, in which the user can speak and write questions and other phrases, and get them translated to speech and text in other languages. The phrases cover the concepts used in the SBAR protocol (Situation-Bakgrund-Aktuellt tillstånd-Rekommendation) for ambulance use, as gathered from available documents and a questionnaire sent out to professionals at SU Ambulans. The SBAR protocol is also made available as a dynamic phrasebook, where the user can select appropriate phrases from menus. To help translate spontaneous speech and writing, the translator will also have a facility of suggesting nearest-matching phrases and ranking them by proximity to the verified standard phrases.

    The current prototype covers around 400 concepts, from which millions of phrases can be built. It will work for 7 languages and enable translation between any two of them, although the primary use case is translation from Swedish to another language and translating simple answers from the other language to Swedish. GF has potential for extending the application to over 30 languages.

  • 35.
    Claesson, A
    et al.
    Karolinska Institutet.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Svensson, L
    Karolinska Institute.
    Ottosson, L
    Sahlgrenska University Hospital.
    Bergfeldt, L
    Sahlgrenska University Hospital.
    Engdahl, J
    Karolinska Institutet.
    Ericson, C
    Sahlgrenska University Hospital.
    Sandén, P
    Sahlgrenska University Hospital.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bremer, Anders
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Defibrillation before EMS arrival in western Sweden.2017In: American Journal of Emergency Medicine, ISSN 0735-6757, E-ISSN 1532-8171, Vol. 35, no 8, p. 1043-1048, article id S0735-6757(17)30117-1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Bystanders play a vital role in public access defibrillation (PAD) in out-of-hospital cardiac arrest (OHCA). Dual dispatch of first responders (FR) alongside emergency medical services (EMS) can reduce time to first defibrillation. The aim of this study was to describe the use of automated external defibrillators (AEDs) in OHCAs before EMS arrival.

    METHODS: All OHCA cases with a shockable rhythm in which an AED was used prior to the arrival of EMS between 2008 and 2015 in western Sweden were eligible for inclusion. Data from the Swedish Register for Cardiopulmonary Resuscitation (SRCR) were used for analysis, on-site bystander and FR defibrillation were compared with EMS defibrillation in the final analysis.

    RESULTS: Of the reported 6675 cases, 24% suffered ventricular fibrillation (VF), 162 patients (15%) of all VF cases were defibrillated before EMS arrival, 46% with a public AED on site. The proportion of cases defibrillated before EMS arrival increased from 5% in 2008 to 20% in 2015 (p<0.001). During this period, 30-day survival increased in patients with VF from 22% to 28% (p=0.04) and was highest when an AED was used on site (68%), with a median delay of 6.5min from collapse to defibrillation. Adjusted odds ratio for on-site defibrillation versus dispatched defibrillation for 30-day survival was 2.45 (95% CI: 1.02-5.95).

    CONCLUSIONS: The use of AEDs before the arrival of EMS increased over time. This was associated with an increased 30-day survival among patients with VF. Thirty-day survival was highest when an AED was used on site before EMS arrival.

  • 36.
    Zhang, Yanru
    et al.
    University of Shanghai for Science and Technology.
    Jiménez-Herrera, María
    Universitat Rovira I Virgili.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Cheng, Yunzhang
    University of Shanghai for Science and Technology.
    Not Bad: Passive Leg Raising in Cardiopulmonary Resuscitation-A New Modeling Study2017In: Frontiers in Physiology, E-ISSN 1664-042X, Vol. 7, p. 665-Article in journal (Refereed)
    Abstract [en]

    Aim: To evaluate, using a simulated haemodynamic circulation model, whether passive leg raising (PLR) is able to improve the effect during cardiopulmonary resuscitation (CPR); to expose the possible reasons why PLR works or not.

    Materials and Methods: We adapted a circulatory model for CPR with PLR. First we compared cardiac output (CO), coronary perfusion pressure (CPP), blood flow to heart (Qheart), and blood flow to neck and brain (Qhead) of standard chest compression-only CPR with and without PLR; second we simulated the effects of PLR in different situations, by varying the thoracic pump factor (TPF) from 0 to 1; third we simulated the effects when the legs are lifted to the different heights. Finally, we compared our results with those obtained from a published clinical study.

    Results: According to the simulation model, (1) When TPF is in the interval (0,1), CPP, CO, Qheart, and Qhead are improved with PLR, among them with half-thoracic/half-cardiac pump effect (TPF is 0.5), CPP, CO, Qhead, and Qheart increase the most (by 14, 14, 15, and 17%). (2) When TPF is 1 (pure thoracic pump, with an emphysema or extremely thick thorax), PLR has almost no effect on CPP, CO, and Qheart (-1, 2, and 0%), whereas Qhead is increased by 9%; (3) Regardless of whether there is a cardiac or thoracic pump effect, PLR is able to increase Qhead by 9-15%. (4) When the legs are lifted to 30 degrees to the ground, the volume transferred from legs to upper body is 36% of the initial volume in legs; when the legs are lifted to 45 degrees , the volume transferred is 43%; when the legs are lifted to 60 degrees , the volume transferred is 47%; when the legs are lifted to 90 degrees , the volume transferred is 50%.

    Conclusion: Generally PLR is able to achieve improved cerebral perfusion and coronary perfusion. In some extreme situations, it has no effect on cardiac output and coronary perfusion, but still improves cerebral perfusion. PLR could be a beneficial supplement to CPR, and it is not necessary to lift the legs too high above the ground.

  • 37.
    Tärnqvist, Julia
    et al.
    The Ambulance Service in Skaraborg, Lidköping, Sweden.
    Dahlén, Erik
    The Ambulance Service in Skaraborg, Lidköping, Sweden.
    Magnusson, Carl
    Sahlgrenska Univ Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Strömsöe, Anneli
    University of Dalarna.
    Norberg, Gabriella
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. Sahlgrenska University Hospital.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    On-Scene and Final Assessments and Their Interrelationship Among Patients Who Use the EMS on Multiple Occasions2017In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 32, no 5, p. 528-535Article in journal (Refereed)
    Abstract [en]

    Introduction The use of Emergency Medical Services (EMS) is increasing. A number of patients call repeatedly for EMS. Early studies of frequent callers show that they form a heterogenous group. Problem There is a lack of research on frequent EMS callers. There is furthermore a lack of knowledge about characteristics and the prehospital assessment of the patients who call for EMS on several occasions. Finally, there is a general lack of knowledge with regard to the association between the prehospital assessment by health care providers and the final diagnosis. Method Patients in Skaraborg in Western Sweden, who used the EMS at least four times in 2014, were included, excluding transport between hospitals. Information on the prehospital assessment on-scene and the final diagnosis was collected from the EMS and hospital case records. Results In all, 339 individual patients who used the EMS on 1,855 occasions were included, accounting for five percent of all missions. Fifty percent were women. The age range was 10-98 years, but more than 50.0% were in the age range of 70-89 years. The most common emergency signs and symptoms (ESS) codes on the scene were dyspnea, chest pain, and abdominal pain. The most common final diagnosis was chronic obstructive pulmonary disease (eight percent). Thirteen percent of all cases had a final diagnosis defined as a potentially life-threatening condition. Among these, 22.0% of prehospital assessments were retrospectively judged as potentially inappropriate. Forty-nine percent had a defined final diagnosis not fulfilling the criteria for a potentially life-threatening condition. Among these cases, 30.0% of prehospital assessments were retrospectively judged as potentially inappropriate. Conclusion: Among patients who used EMS on multiple occasions, the most common symptoms on-scene were dyspnea, chest pain, and abdominal pain. The most common final diagnosis was chronic obstructive pulmonary disease. In 13.0%, the final diagnosis of a potentially life-threatening condition was indicated. In a minority of these cases, the assessment on-scene was judged as potentially inappropriate. Tärnqvist J , Dahlén E , Norberg G , Magnusson C , Herlitz J , Strömsöe A , Axelsson C , Andersson Hagiwara M . On-Scene and Final Assessments and Their Interrelationship Among Patients Who Use the EMS on Multiple Occasions. Prehosp Disaster Med. 2017;32(5):1–8.

  • 38.
    Holmén, Johan
    et al.
    Sahlgrenska University Hospital.
    Hollenberg, Jacob
    Karolinska Institutet.
    Claesson, Andreas
    Karolinska Institutet.
    Herrera, Maria Jiménez
    Sistema Emergències Mèdiques de Catalunya.
    Azeli, Youcef
    Sistema Emergències Mèdiques de Catalunya.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Survival in ventricular fibrillation with emphasis on the number of defibrillations in relation to other factors at resuscitation.2017In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 113, p. 33-38, article id S0300-9572(17)30017-5Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Mortality after out of hospital cardiac arrest (OHCA) is high and a shockable rhythm is a key predictor of survival. A concomitant need for repeated shocks appears to be associated with less favorable outcome.

    AIM: To, among patients found in ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) describe: (a) factors associated with 30-day survival with emphasis on the number of defibrillatory shocks delivered; (b) the distribution of and the characteristics of patients in relation to the number of defibrillatory shocks that were delivered.

    METHODS: Patients who were reported to The Swedish Register for Cardiopulmonary Resuscitation (SRCR) between January 1 1990 and December 31 2015 and who were found in VF/pVT took part in the survey.

    RESULTS: In all there were 19,519 patients found in VF/pVT. The 30-day survival decreased with an increasing number of shocks among all patients regardless of witnessed status and regardless of time period in the survey. In a multivariate analysis there were 12 factors that were associated with the chance of 30-day survival one of which was the number of shocks that was delivered. For each shock that was added the chance of survival decreased. Factors associated with an increased 30-day survival included CPR before arrival of EMS, female sex, cardiac etiology and year of OHCA (increasing survival over years). Factors associated with a decreased chance of 30-day survival included: increasing age, OHCA at home, the use of adrenaline and intubation and an increased delay to CPR, defibrillation and EMS arrival.

    CONCLUSION: Among patients found in VF/pVT, 7.5% required more than 10 shocks. For each shock that was added the chance of 30-day survival decreased. There was an increase in 30-day survival over time regardless of the number of shocks. On top of the number of defibrillations, eleven further factors were associated with 30-day survival.

  • 39.
    Schmidbauer, Simon
    et al.
    Lund University.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsson, Thomas
    Sahlgrenska University Hospital.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Friberg, Hans
    Lund University.
    Use of automated chest compression devices after out-of-hospital cardiac arrest in Sweden.2017In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 120, p. 95-102, article id S0300-9572(17)30603-2Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate the implementation of automated chest compression cardiopulmonary resuscitation (ACC-CPR) after out-of-hospital cardiac arrest (OHCA) in Sweden during the years 2011 through 2015. The association between ACC-CPR and 30-day survival was studied as a secondary objective.

    METHODS: The Swedish cardiopulmonary resuscitation registry is a prospectively recorded nationwide registry of modified Utstein parameters including all patients with attempted resuscitation after OHCA. Propensity score matching (PSM) was used to adjust for known confounders in the secondary analysis.

    RESULTS: Of the 24,316 patients included in the study population, 32.4% received ACC-CPR, with substantial regional variation ranging from 0.8% to 78.8%. Male gender and an initial shockable rhythm were associated with ACC-CPR, whereas crew witnessed status was associated with manual CPR. Potential markers of prolonged resuscitation attempts (drug administration and endotracheal intubation) were more prevalent in the ACC-CPR group. The unadjusted 30-day survival rate was 6.3% for ACC-CPR patients. The adjusted odds ratio for 30-day survival regarding use of an ACC device was 0.72 (95% CI 0.62-0.84, p<0.001, n=13922).

    CONCLUSION: The use of ACC devices varied significantly between Swedish regions and overall survival to 30days was low among patients receiving ACC-CPR. Although measured and unmeasured confounding might explain our finding of lower survival rates for patients exposed to ACC-CPR, specific guidelines recommending when and how ACC-CPR should be used are warranted as there might be circumstances where these devices do more harm than good.

  • 40. Claesson, Andreas
    et al.
    Djärv, Therese
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Nordberg, Pär
    Ring, Mattias
    Hollenberg, Jacob
    Ravn-Fischer, Annika
    Strömsöe, Annelie
    Medical versus non medical etiology in out-of-hospital cardiac arrest-Changes in outcome in relation to the revised Utstein template.2016In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 110, p. 48-55Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION:

    The Utstein-style recommendations for reporting etiology and outcome in out-of-hospital cardiac arrest (OHCA) from 2004 have recently been revised. Among other etiologies a medical category is now introduced, replacing the cardiac category from Utstein template 2004.

    AIM:

    The aim of this study is to describe characteristics and temporal trends from reporting OHCA etiology according to the revised Utstein template 2014 in regards to patient characteristics and 30-day survival rates.

    METHODS:

    This registry study is based on consecutive OHCA cases reported from the Emergency medical services (EMS) to the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) 1992-2014. Characteristics, including a presumed cardiac etiology in Utstein template 2004, were transcribed to a medical etiology in Utstein template 2014.

    RESULTS:

    Of a total of n=70,846 cases, 92% were categorized as having a medical etiology and 8% as having a non-medical cause. Using the new classifications, the 30-day survival rate has significantly increased over a 20-year period from 4.7% to 11.0% in the medical group and from 3% to 9.9% in the non-medical group (p≤0.001). Trauma was the most common cause in OHCA of a non-medical etiology (26%) with a 30-day survival rate of 3.4% whilst drowning and drug overdose had the highest survival rates (14% and 10% respectively).

    CONCLUSION:

    Based on Utstein 2014 categories of etiology, overall survival after OHCA with a medical etiology has more than doubled in a 20-year period and tripled for non-medical cases. Patients with a medical etiology found in a shockable rhythm have the highest chance of survival. There is great variability in characteristics among non-medical cases.

  • 41. Claesson, Andreas
    et al.
    Djärv, Therese
    Norberg, Per
    Ring, Mattias
    Hollenberg, Jacob
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Ravn-Fisher, Annica
    Stromsoe, Annelie
    Medicalversus non medical etiology in out-of-hospital cardiac arrest-Changes inoutcome in relation to the revised Utstein template2016In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 110, p. 48-55Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The Utstein-style recommendations for reporting etiology and outcome in out-of-hospital cardiac arrest (OHCA) from 2004 have recently been revised. Among other etiologies a medical category is now introduced, replacing the cardiac category from Utstein template 2004. AIM: The aim of this study is to describe characteristics and temporal trends from reporting OHCA etiology according to the revised Utstein template 2014 in regards to patient characteristics and 30-day survival rates. METHODS: This registry study is based on consecutive OHCA cases reported from the Emergency medical services (EMS) to the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) 1992-2014. Characteristics, including a presumed cardiac etiology in Utstein template 2004, were transcribed to a medical etiology in Utstein template 2014. RESULTS: Of a total of n=70,846 cases, 92% were categorized as having a medical etiology and 8% as having a non-medical cause. Using the new classifications, the 30-day survival rate has significantly increased over a 20-year period from 4.7% to 11.0% in the medical group and from 3% to 9.9% in the non-medical group (p</=0.001). Trauma was the most common cause in OHCA of a non-medical etiology (26%) with a 30-day survival rate of 3.4% whilst drowning and drug overdose had the highest survival rates (14% and 10% respectively). CONCLUSION: Based on Utstein 2014 categories of etiology, overall survival after OHCA with a medical etiology has more than doubled in a 20-year period and tripled for non-medical cases. Patients with a medical etiology found in a shockable rhythm have the highest chance of survival. There is great variability in characteristics among non-medical cases.

  • 42.
    Andersson Hagiwara, Magnus
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Nilsson, Lena
    Linköping University.
    Strömsöe, Anneli
    Mälardalens högskola.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Kängström, Anna
    University of Borås, Faculty of Librarianship, Information, Education and IT.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Patient safety and patient assessment in pre-hospital care: a study protocol2016In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 24, no 1, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Background: Patient safety issues in pre-hospital care are poorly investigated. The aim of the planned study is to

    survey patient safety problems in pre-hospital care in Sweden.

    Methods/Design: The study is a retro-perspective structured medical record review based on the use of 11 screening

    criteria. Two instruments for structured medical record review are used: a trigger tool instrument designed for

    pre-hospital care and a newly development instrument designed to compare the pre-hospital assessment with

    the final hospital assessment. Three different ambulance organisations are participating in the study. Every month,

    one rater in each organisation randomly collects 30 medical records for review. With guidance from the review

    instrument, he/she independently reviews the record. Every month, the review team meet for a discussion of

    problematic reviews. The results will be analysed with descriptive statistics and logistic regression.

    Discussion: The findings will make an important contribution to knowledge about patient safety issues in prehospital

    care.

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  • 43.
    Axelsson, Christer
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Holmen, Johan
    Herreira, Maria
    Canardo, Guillermo
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    PCI De Lucs.: A clinical pathway directly to the PCI lab in out of hospital cardiac arrest2016In: American Heart Association, 2016Conference paper (Refereed)
    Abstract [en]

    Purpose: In Sweden, the ambulance response time from call to arrival is 11 minutes in patients with an out-of-hospital cardiac arrest (OHCA). However, there is a small group of OHCA patients (20%) in whom this delay is minimized, namely those that occur minutes before or after the arrival of the ambulance. Despite CPR and/or defibrillation within one minute, only 20% survive to hospital discharge. The objective was therefore to determine whether a pathway with direct transportation to the cath lab, using mechanical chest compression (LUCAS), could improve survival in this selected group.

    Aim: To describe characteristics, feasibility and outcome among a selected group of OHCA patients transported directly to the cath lab by the ambulance in a new pathway

    Method: A prospective observational study from November 2013 to November 2015

    Inclusion criteria: 1. Crew-witnessed cardiac arrest (CA) of cardiac origin or CA immediately defibrillated to return of spontaneous circulation (ROSC) by public access. 2. CA occurring two to three minutes before ambulance arrival where the patient had immediate bystander CPR of high quality. 4. CA occurring two to three minutes before ambulance arrival where the patient was still breathing at ambulance arrival.

    Exclusion criteria: Non-cardiac origin CA or high physiologic age (hospice patients)

    Result: Sixty-four patients fulfilled the inclusion criteria and 14 were excluded. Of the remaining 50 patients, 25 were transported with mechanical CPR to the cath lab. The time from CA to hospital was a median of 38 minutes. Survival to 30 days was 38% among all patients, 47% among VF (N=34) and 12% (N=25) among those who were transported with mechanical CPR.

    Conclusion: The pathway appears safe and feasible, but the inclusion criteria need to be less complex. The vast majority of survivors were found in the VF population. There were survivors (12%) among patients transported with ongoing CPR (N=25) directly to the cath lab by the ambulance.

  • 44.
    Axelsson, Christer
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsson, Anders
    Sjöberg, Henrik
    Jiménez-Herrera, Maria
    Bång, Angela
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Jonsson, Anders
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bremer, Anders
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Andersson, Henrik
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Gellerstedt, Martin
    Ljungström, Lars
    The Early Chain of Care in Patients with Bacteraemia with the Emphasis on the Prehospital Setting2016In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 31, no 3, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Purpose:  There is a lack of knowledge  about the early phase of severe infection. This reportdescribes the early chain of care in bacteraemia as follows:  (a) compare patients who were and were not transported by the Emergency Medical Services (EMS); (b) describe various aspects of the EMS chain; and (c) describe factors of importance for the delay to the start ofintravenous antibiotics. It was hypothesized that, for patients with suspected sepsis judged by the EMS clinician, the delay until the onset of antibiotic treatment would be shorter.

    Basic Procedures: All  patients  in the Municipality of Gothenburg  (Sweden) with apositive blood culture, when assessed at the Laboratory of Bacteriology in the Municipality of Gothenburg, from February 1 through April 30, 2012 took part in the survey.

    Main Findings/Results:  In all, 696 patients fulfilled the inclusion criteria. Their mean agewas 76 years and 52% were men. Of all patients, 308 (44%) had been in contact with the EMS and/or the emergency department (ED). Of these 308 patients, 232 (75%) were transported by the EMS and 188 (61%) had “true pathogens” in blood cultures. Patients who were transported by the EMS were older, included more men, and suffered from more severe symptoms  and signs.The EMS nurse  suspected sepsis in only six percent of the cases. These patients had a delay from arrival at hospital until the start of antibiotics of one hour and 19 minutes  versus three hours and 21 minutes among the remaining patients (P = .0006). The corresponding figures for cases with “true pathogens” were one hour and19 minutes  versus three hours and 15 minutes  (P = .009).

    Conclusion:  Among patients with bacteraemia, 75% used the EMS, and these patients were older, included more men, and suffered from more severe symptoms  and signs. The EMS nurse  suspected sepsis in six percent of cases. Regardless  of whether or not patients with true pathogens  were isolated,  a suspicion of sepsis by the EMS clinician at thescene was associated with a shorter delay to the start of antibiotic treatment.

  • 45. Azeli, Youcef
    et al.
    Barberia, E
    Jimenez Herrera, Maria
    Bonet, G
    Valero-Mora, Eva
    Lopez-Gomariz, A
    Lucas-Guarque, Isac
    Guillen-Lopez, A
    Alonso-Villaverde, C
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bardaji, Alfredo
    The ReCaPTa study - a prospective out of hospital cardiac arrest registry including multiple sources of surveillance for the study of sudden cardiac death in the Mediterranean area2016In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, ISSN ISSN 1757-7241, Vol. 24, no 1, article id 127Article in journal (Refereed)
    Abstract [en]

    Background: Cardiovascular diseases are one of the leading causes of death in the industrialized world. Sudden cardiac death is very often the first manifestation of the disease and it occurs in the prehospital setting. The determination of the sudden cardiac death phenotype is challenging. It requires prospective studies in the community including multiple sources of case ascertainment that help to identify the cause and circumstances of death. The aim of the Clinical and Pathological Registry of Tarragona (ReCaPTa) is to study incidence and etiology of Sudden Cardiac Death in the Tarragona region (Catalonia, Spain). Methods: ReCaPTa is a population-based registry of OHCA using multiple sources of surveillance. The population base is 511,662. This registry is compiled chronologically in a relational database and it prospectively contains data on all the OHCA attended by the EMS from April 2014 to April 2017. ReCaPTa collects data after each emergency medical assistance using an online application including variables of the onset of symptoms. A quality control is performed and it permits monitoring the percentage of cases included by the emergency crew. Simultaneously, data from the medico-legal autopsies is taken from the Pathology Center of the area. All the examination findings following a specific protocol for the sudden death study are entered into the ReCaPTa database by one trained person. Survivors admitted to hospital are followed up and their clinical variables are collected in each hospital. The primary care researchers analyze the digital clinical records in order to obtain medical background. All the available data will be reviewed after an adjudication process with the aim of identifying all cases of sudden cardiac death. Discussion: There is a lack of population-based registries including multiple source of surveillance in the Mediterranean area. The ReCaPTa study could provide valuable information to prevent sudden cardiac death and develop new strategies to improve its survival.

  • 46. Lindblad, Pär
    et al.
    Åström Victorén, Annika
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Madsen Härdig, Bjarne
    A Chest Compression Quality Evaluation Using Mechanical Chest Compressions under Different Working Situations in the Ambulance2015In: International Journal of Clinical Medicine, ISSN 2158-284X, E-ISSN 2158-2882, Vol. 6, p. 530-537Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of this study was to analyze the quality of chest compressions in different working situations pertaining to ambulance crews using either standard chest compressions (S-CC) or LUCAS mechanical chest compressions (L-CC) in a manikin setting. Participants and Methods: Cardiopulmonary resuscitation (CPR) was performed using a compression to ventilation ratio of 30:2 with both S-CC and L-CC. Quality parameters were collected using a modified manikin enabling impedance measurements. The evaluation was performed in two manikin scenarios: Scenario 1 evaluated ten minutes of CPR on the ground and Scenario 2 assessed six minutes of CPR in different settings relevant to work in the ambulance. Quality parameters compared were: time to apply LUCAS, hands-off fraction, number of correct chest compressions and the rate of compressions. Results: In Scenario 1 the hands-off fraction was higher when S-CC was performed (S-CC group 29% vs. L-CC 16%, P = 0.003). We found a higher number of chest compressions (S-CC = 913 vs. L-CC = 831, P = 0.0049) and a higher rate of chest compressions (S-CC = 118 vs. L-CC = 99, P < 0.0001) in the S-CC group. In Scenario 2 we noted a higher hands-off fraction for S-CC (39% vs. L-CC = 19%, P = 0.003), but a higher number of compressions given during S-CC ((n = 504) vs. L-CC (n = 396) P = 0.0002). Conclusion: Mechanical chest compression with the LUCAS 2TM device enables ambulance personnel to provide high quality chest compression even while transporting the patient.

  • 47.
    Axelsson, Christer
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsson, Thomas
    Pande, Katarina
    Wigertz, Kristin
    Örtenwall, Per
    Nordanstig, Joakim
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    A description of the prehospital phase of aortic dissection in terms of early suspicion and treatment.2015In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 30, no 2Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Aortic dissection is difficult to detect in the early phase due to a variety of symptoms. This report describes the prehospital setting of aortic dissection in terms of symptoms, treatment, and suspicion by the Emergency Medical Service (EMS) staff.

    BASIC PROCEDURES: All patients in the Municipality of Gothenburg, Sweden, who, in 2010 and 2011, had a hospital discharge diagnosis of aortic dissection (international classification of disease (ICD) I 71,0) were included. The exclusion criteria were: age<18 years of age and having a planned operation. This was a retrospective, descriptive study based on patient records. In the statistical analyses, Fisher's exact test and the Mann-Whitney U test were used for analyses of dichotomous and continuous/ordered variables.

    MAIN FINDINGS: Of 92 patients, 78% were transported to the hospital by the EMS. The most common symptom was pain (94%). Pain was intensive or very intensive in 89% of patients, with no significant difference in relation to the use of the EMS. Only 47% of those using the EMS were given pain relief with narcotic analgesics. Only 12% were free from pain on admission to the hospital. A suspicion of aortic dissection was reported by the EMS staff in only 17% of cases. The most common preliminary diagnosis at the dispatch center (31%) and by EMS clinicians (52%) was chest pain or angina pectoris. In all, 79% of patients were discharged alive from the hospital (75% of those that used the EMS and 95% of those that did not).

    CONCLUSION: Among patients who were hospitalized due to aortic dissection in Gothenburg, 78% used the EMS. Despite severe pain in the majority of patients, fewer than half received narcotic analgesics, and only 12% were free from pain on admission to the hospital. In fewer than one-in-five patients was a suspicion of aortic dissection reported by the EMS staff.

  • 48. Strandmark, Rasmus
    et al.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Claesson, Andreas
    Bremer, Anders
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsson, Thomas
    Jimenez-Herrera, Maria
    Ravn-Fischer, Annica
    Determinants of pre-hospital pharmacological intervention and its association with outcome in acute myocardial infarction2015In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 15, no 1Article in journal (Refereed)
  • 49. Strandmark, Rasmus
    et al.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Claesson, Andreas
    Bremer, Anders
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsson, Thomas
    Jimenez-Herrera, Maria
    Ravn-Fischer, Annica
    Determinants of pre-hospitalpharmacological intervention and its association with outcome in acutemyocardial infarction2015In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 23, no 105Article in journal (Refereed)
  • 50. Hasselqvist-Ax, Ingela
    et al.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Svensson, Leif
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Early CPR in Out-of-Hospital Cardiac Arrest.2015In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 373, no 16Article in journal (Refereed)
  • 51.
    Bremer, Anders
    et al.
    University of Borås, School of Health Science.
    Jiménez Herrera, María
    Axelsson, Christer
    University of Borås, School of Health Science.
    Burjalés Martí, Dolors
    Sandman, Lars
    University of Borås, School of Health Science.
    Casali, Gian Luca
    Ethical values in emergency medical services: A pilot study2015In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 22, no 8, p. 928-942Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Ambulance professionals often address conflicts between ethical values. As individuals' values represent basic convictions of what is right or good and motivate behaviour, research is needed to understand their value profiles. OBJECTIVES: To translate and adapt the Managerial Values Profile to Spanish and Swedish, and measure the presence of utilitarianism, moral rights and/or social justice in ambulance professionals' value profiles in Spain and Sweden. METHODS: The instrument was translated and culturally adapted. A content validity index was calculated. Pilot tests were carried out with 46 participants. ETHICAL CONSIDERATIONS: This study conforms to the ethical principles for research involving human subjects and adheres to national laws and regulations concerning informed consent and confidentiality. FINDINGS: Spanish professionals favoured justice and Swedish professionals' rights in their ambulance organizations. Both countries favoured utilitarianism least. Gender differences across countries showed that males favoured rights. Spanish female professionals favoured justice most strongly of all. DISCUSSION: Swedes favour rights while Spaniards favour justice. Both contexts scored low on utilitarianism focusing on total population effect, preferring the opposite, individualized approach of the rights and justice perspectives. Organizational investment in a utilitarian perspective might jeopardize ambulance professionals' moral right to make individual assessments based on the needs of the patient at hand. Utilitarianism and a caring ethos appear as stark opposites. However, a caring ethos in its turn might well involve unreasonable demands on the individual carer's professional role. Since both the justice and rights perspectives portrayed in the survey mainly concern relationship to the organization and peers within the organization, this relationship might at worst be given priority over the equal treatment and moral rights of the patient. CONCLUSION: A balanced view on ethical perspectives is needed to make professionals observant and ready to act optimally - especially if these perspectives are used in patient care. Research is needed to clarify how justice and rights are prioritized by ambulance services and whether or not these organization-related values are also implemented in patient care.

  • 52.
    Bremer, Anders
    et al.
    University of Borås, School of Health Science.
    Jimenéz-Herrera, Maria
    Axelsson, Christer
    University of Borås, School of Health Science.
    Burjalés Martí, D
    Sandman, Lars
    University of Borås, School of Health Science.
    Casali, Luca
    Ethical values in emergency medical services: A pilot study.2015In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 22, no 8, p. 928-942Article in journal (Refereed)
    Abstract [en]

    Background: Ambulance professionals often address conflicts between ethical values. As individuals’ values represent basic convictions of what is right or good and motivate behaviour, research is needed to understand their value profiles. Objectives: To translate and adapt the Managerial Values Profile to Spanish and Swedish, and measure the presence of utilitarianism, moral rights and/or social justice in ambulance professionals’ value profiles in Spain and Sweden. Methods: The instrument was translated and culturally adapted. A content validity index was calculated. Pilot tests were carried out with 46 participants. Ethical considerations: This study conforms to the ethical principles for research involving human subjects and adheres to national laws and regulations concerning informed consent and confidentiality. Findings: Spanish professionals favoured justice and Swedish professionals’ rights in their ambulance organizations. Both countries favoured utilitarianism least. Gender differences across countries showed that males favoured rights. Spanish female professionals favoured justice most strongly of all. Discussion: Swedes favour rights while Spaniards favour justice. Both contexts scored low on utilitarianism focusing on total population effect, preferring the opposite, individualized approach of the rights and justice perspectives. Organizational investment in a utilitarian perspective might jeopardize ambulance professionals’ moral right to make individual assessments based on the needs of the patient at hand. Utilitarianism and a caring ethos appear as stark opposites. However, a caring ethos in its turn might well involve unreasonable demands on the individual carer’s professional role. Since both the justice and rights perspectives portrayed in the survey mainly concern relationship to the organization and peers within the organization, this relationship might at worst be given priority over the equal treatment and moral rights of the patient. Conclusion: A balanced view on ethical perspectives is needed to make professionals observant and ready to act optimally – especially if these perspectives are used in patient care. Research is needed to clarify how justice and rights are prioritized by ambulance services and whether or not these organization-related values are also implemented in patient care.

  • 53.
    Axelsson, Christer
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Herrera, Maria Jimenez
    Bång, Angela
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    How the context of ambulance care influences learning to become a specialist ambulance nurse a Swedish perspective.2015In: Nurse Education Today, ISSN 0260-6917, E-ISSN 1532-2793Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Ambulance emergency care is multifaceted with extraordinary challenges to implement accurate assessment and care. A clinical learning environment providing opportunities for mastering these essential skills is a key component in ensuring that prehospital emergency nurse (PEN) students acquire the necessary clinical competence.

    AIM: The aim is to understand how PEN students experience their clinically based training, focusing on their learning process.

    METHOD: We applied content analysis with its qualitative method to our material that consisted of three reflections each by 28 PEN students over their learning process during their 8weeks of clinical ambulance practice. The research was carried out at the Center for Prehospital Care, University of Borås, Sweden.

    RESULTS: The broad spectrum of ambulance assignments seems to awaken great uncertainty and excessive respect in the students. Student vulnerability appears to decrease when the clinical supervisor behaves calmly, knowledgeably, confidently and reflectively. Early traumatic incidents on the other hand may increase the students' anxiety. Each student is offered a unique opportunity to learn how to approach patients and relatives in their own environments, and likewise an opportunity to gather information for assessment. Infrequency of missions seems to make PEN students less active in their student role, thereby preventing them from availing themselves of potential learning situations. Fatigue and hunger due to lack of breaks or long periods of transportation also inhibit learning mode.

    CONCLUSION: Our findings suggest the need for appraisal of the significance of the clinical supervisor, the ambulance environment, and student vulnerability. The broad spectrum of conditions in combination with infrequent assignments make simulation necessary. However, the unique possibilities provided for meeting patients and relatives in their own environments offer the PEN student excellent opportunities for learning how to make assessments.

  • 54. Magnusson, Carl
    et al.
    Källenius, Christofer
    Knutsson, Susanne
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Pre-hospital assessment by a single responder: The Swedish ambulance nurse in a new role2015In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013XArticle in journal (Refereed)
    Abstract [en]

    When a person with vague symptoms calls 112, the dispatchers often have difficulty prioritising the severity of the call. Their only alternative has been to send an ambulance. In Gothenburg, Sweden, a nurse-manned single responder (SR) was initiated to assess this patient group. The study aims to describe patient characteristics and assessment level made by the SR nurse among patients assessed by the dispatcher as low priority and/or vague symptoms. A consecutive journal review was conducted. During six months, 529 patients were assessed; 329 (62%) attended the emergency department (ED) or inpatient care (IC). Of these, 85 patients (26%) were assessed as high priority. Only 108 were assessed as being in need of ambulance transport. ED/IC patients were significantly older. Two hundred (38%) stayed at the scene (SS) (n = 142) or were referred to primary care (PC) (n = 58). Of the 200 SS/PC patients, 38 (19%) attended the ED within 72 hrs with residual symptoms, 20 of whom were admitted to a ward. Nine patients (4% of 200 SS/PC patients) required inpatient treatment and 11 patients stayed overnight for observation. These results suggest a relatively high level of patient safety and the usefulness of an SR among patients assessed by the dispatcher as low priority.

  • 55. Lindblad, Pär
    et al.
    Åström Victorén, Annika
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bjarne Madsen, Härdig
    Quality of Chest Compressions Differs over Time between Advanced and Basic Life Support2015In: International Journal of Clinical Medicine, ISSN 2158-284X, E-ISSN 2158-2882, Vol. 6, no 12, p. 944-953Article in journal (Refereed)
    Abstract [en]

    Purpose: According to guideline recommendations, chest compressions (CC) during cardiopulmonary resuscitation (CPR) should be performed at a rate of 100 - 120 per minute, with a CC fraction (CCF) of ≥80%. The aim of this work is to explore whether CC quality differs between advanced life support (ALS) and basic life support (BLS) performed by two rescuers. Method: Cardiopulmonary resuscitation was performed by two ambulance personnel in ten ALS and ten BLS manikin scenarios. Data from these scenarios were then compared with data on ten ALS cases from the clinical setting, all with non-shockable rhythms. Data from the first two 5-minute periods of CC were evaluated from impedance data (LIFEPAK 12 defibrillator monitors) using a modified Laerdal Skillmaster manikin. Quality parameters compared were: number of CC pauses (CCPs), total time of CC (%), number of CC given and CC rate/min. Results: During the first 5 minutes, the BLS manikin scenarios had the highest number of CCPs, 15 (14 - 16), compared with the ALS manikin scenario, 14 (13 - 15), and the clinical ALS cases, 12 (10 - 15). The BLS scenario also had the highest CCFs, 81% (77% - 85%), and number of CC, 450 (435 - 495), compared with the ALS manikin scenario, 75% (64% - 81%) and 400 (365 - 444) respectively, and the clinical ALS cases, 63% (50% - 74%) and 408 (306 - 489). The median rate of CC/min in the BLS scenario was 115 (110 - 120) compared with the ALS manikin scenario, 110 (106 - 115), and the clinical ALS cases, 130 (118 - 146). During the second 5-minute period, the BLS scenario had the highest number of CCPs, 16 (15 - 17), compared with 15 (14 - 16) for the ALS manikin scenario and 11 (11 - 12) for the clinical ALS cases. The CCF in the BLS setting was 79% (75% - 83%), and the number of CC 455 (430 - 480), compared with the ALS manikin scenario, 79% (74% - 84%) and 435 (395 - 480) respectively, and the clinical ALS cases, 71% (57% - 77%) and 388 (321 - 469) respectively. The median CC rate was 118 (113 - 124) for BLS, 111 (105 - 120) for ALS manikins and 123 (103 - 128) CC/min for clinical ALS cases. Conclusion: None of the groups being studied could deliver CC at a rate of 100 - 120 CC/min or a CCF of ≥80% over the whole 10-minute period in any of the resuscitation scenarios analyzed. However, BLS had the best compliance with CC quality recommendations according to the 2010 guidelines.

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  • 56. Rubertsson, Sten
    et al.
    Axelsson, Christer
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Blomberg, Hans
    Hollenberg, Jacob
    Riva, Gabriel
    Smekal, David
    [Question mark of ventilations and chest compressions].2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112Article in journal (Refereed)
  • 57. Jiminez Herrera, Maria F
    et al.
    Axelsson, Christer
    University of Borås, School of Health Science.
    Some ethical conflicts in emergency care2015In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 22, no 8, p. 928-942Article in journal (Refereed)
    Abstract [en]

    Abstract Background: Decision-making and assessment in emergency situations are complex and result many times in ethical conflicts between different healthcare professionals. Aim: To analyse and describe situations that can generate ethical conflict among nurses working in emergency situations. Methods: Qualitative analysis. A total of 16 emergency nurses took part in interviews and a focus group. Ethical considerations: Organisational approval by the University Hospital, and informed consent and confidentiality were ensured before conducting the research. Result/conclusion: Two categories emerged: one in ‘ethical issues’ and one in ‘emotions and feelings in caring’. The four ethical subcategories are presented: Autonomy, the first sub category: first, the nurse’s ability to practise care on an emergency ward and, second, to support the patient and/or relatives in terms of care and medical treatment. The conflicts arise when the nurse ends up in the middle between the patient and the physician responsible for the diagnosis and treatment from a nature scientific perspective. Reification of injured body: patient was often reified and fragmented, becoming just a leg or arm. Different factors contributed in this perspective. Pain: pain relief was often inadequate but more effectively treated in the emergency medical services than at the emergency department. The nurses highlighted the phenomenon of suffering because they felt that pain was only an object, forgetting the patients’ care need, like separating mind from body. Death: the nurses felt that the emergency services are only prepared to save lives and not to take care of the needs of patients with ‘end-of-life’ care. Another issue was the lack of ethical guidelines during a cardiac arrest. Resuscitation often continues without asking about the patient’s ‘previous wishes’ in terms of resuscitation or not. In these situations, the nurses describe an ethical conflict with the physician in performing their role as the patient’s advocate. The nurses express feelings of distress, suffering, anger and helplessness.

  • 58.
    Wireklint-Sundström, B
    et al.
    University of Borås, School of Health Science.
    Petersson, E
    University of Borås, School of Health Science.
    Sjöholm, M
    University of Borås, School of Health Science.
    Gelang, C
    University of Borås, School of Health Science.
    Axelsson, C
    University of Borås, School of Health Science.
    Herlitz, J
    University of Borås, School of Health Science.
    A pathway care model allowing low-risk patients to gain direct admissionto a hospital medical ward a pilot study on ambulance nurses and Emergency Department phycisians2014In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 22, no 1, p. 72-Article in journal (Refereed)
    Abstract [en]

    A pathway care model allowing low-risk patients to gain rapid admission to a hospital medical ward¿¿¿a pilot study on ambulance nurses and Emergency Department physicians.BackgroundPatients with non-urgent medical symptoms who nonetheless require inpatient hospital treatment often have to wait for an unacceptably long time at the Emergency Department (ED). The purpose of this study is to evaluate the feasibility and effect on length of delay of a pathway care model for low-risk patients who have undergone prehospital assessment by an ambulance nurse and ED assessment by a physician within 10 minutes of arrival at the ED.MethodsThe pilot study comparing two low-risk groups took place in western Sweden from October 2011 until January 2012. The pathway model for low-risk patients was used prospectively in the rapid admission group (N¿=¿51), who were admitted rapidly after being assessed by the nurse on scene and then assessed by the ED physician on ED admission. A retrospectively assembled control group (N¿=¿51) received traditional care at the ED. All p-values are age-adjusted.ResultsPatients in the rapid admission group were older (mean age 80 years old) than patients in the control group (mean age 73 years old) (p¿=¿0.02). The median delay from arrival at the patient¿s side until arrival in a hospital medical ward was 57 minutes for the rapid admission group versus 4 hours 13 minutes for the control group (p¿<¿0.0001). However, the median delay time from the ambulance¿s arrival at the patient¿s side until the nurse was free for a new assignment was 77 minutes for the rapid admission group versus 49 minutes for the control group (p¿<¿0.0001). The 30-day mortality rate was 20% for the rapid admission group and only 4% for the control group (p¿=¿0.16).ConclusionThe pathway care model for low-risk patients gaining rapid admission to a hospital medical ward shortened length of delay from the first assessment until arrival at the ward. However, the result was achieved at the cost of an increased workload for the ambulance nurse. Furthermore patients who were rapidly admitted to a hospital ward had a high age level and a high early mortality rate. Patient safety in this new model of fast-track assessment needs to be further evaluated.

  • 59. Youcel, A
    et al.
    Bardaji Ruiz, A
    Axelsson, C
    University of Borås, School of Health Science.
    Chest Injuries during resuscitation following the current guidelines: First results of the Recapta Study2014Conference paper (Refereed)
  • 60. Werner, Kristoffer
    et al.
    Kander, Kristofer
    Axelsson, Christer
    University of Borås, School of Health Science.
    Electrocardiogram interpretation skills among ambulance nurces2014In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953, Vol. 15, no 4, p. 262-268Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To describe ambulance nurses' practical electrocardiogram (ECG) interpretation skills and to measure the correlation between these skills and factors that may impact on the level of knowledge. METHODS: This study was conducted using a prospective quantitative survey with questionnaires and a knowledge test. A convenience sample collection was conducted among ambulance nurses in three different districts in western Sweden. The knowledge test consisted of nine different ECGs. The score of the ECG test were correlated against the questions in the questionnaire regarding both general ECG interpretation skill and ability to identify acute myocardial infarction using Mann-Whitney U test, Kruskal-Wallis test and Spearman's rank correlation. RESULTS: On average, the respondents had 54% correct answers on the test and identified 46% of the ECGs indicating acute myocardial infarction. The median total score was 9 of 16 (interquartile range 7-11) and 1 of 3 (IQR 1-2) in infarction points. No correlation between ECG interpretation skill and factors such as education and professional experience was found, except that coronary care unit experience was associated with better results on the ECG test. CONCLUSIONS: Ambulance nurses have deficiencies in their ECG interpretation skills. This also applies to conditions where the ambulance crew has great potential to improve the outcome of the patient's health, such as myocardial infarction and cardiac arrest. Neither education, extensive experience in ambulance service nor in nursing contributed to an improved result. The only factor of importance for higher ECG interpretation knowledge was prior experience of working in a coronary care unit.

  • 61.
    Axelsson, Christer
    et al.
    University of Borås, School of Health Science.
    Azeli, Youcef
    Jiminez, Maria
    Ordonez Campana, A
    Might the bainbridge reflex have a role in resuscitation when chest compression is combined with passive leg raising?2014In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 85, no 1, p. e21-Article in journal (Refereed)
    Abstract [en]

    The effect of passive leg raising (PLR) in cardiac arrest is not clearly established but PLR has been associated with increased coronary perfusion pressure and increase in End tidal carbon dioxide (EtCO2) during cardiopulmonary resuscitation (CPR).1 A case in which PLR was used successfully has recently been published.

  • 62. Jimenez, Maria
    et al.
    Azeli, Youcef
    Valero Mora, Eva
    Lucas Guarquel, Isac
    Lopes Gomariz, Alfredo
    Castro Naval, E
    Axelsson, Christer
    University of Borås, School of Health Science.
    Passive leg raise (plr) during cardiopulmonary (cpr): a method article on a randomised study of survival in out-of-hospital cardiac arrest (ohca)2014In: BMC Emergency Medicine, ISSN 1471-227X, E-ISSN 1471-227X, Vol. 14, no 15Article in journal (Refereed)
    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.

  • 63.
    Axelsson, C
    et al.
    University of Borås, School of Health Science.
    Jimenez, M
    Herlitz, J
    University of Borås, School of Health Science.
    PCI de Lucs. A safety and feasibility study on a pathway to the cath lab for patients with OHCA2014Conference paper (Refereed)
  • 64.
    Hagiwara, M
    et al.
    University of Borås, School of Health Science.
    Bremer, A
    University of Borås, School of Health Science.
    Claesson, A
    University of Borås, School of Health Science.
    Axelsson, C
    University of Borås, School of Health Science.
    Norberg, Gabriella
    University of Borås, School of Health Science.
    Herlitz, J
    University of Borås, School of Health Science.
    The impact of direct admission to a catheterisation lab/CCU in patients with ST-elevation myocardial infarction on the delay to reperfusion and early risk of death: results of a systematic review including meta-analysis2014In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 22, no 67Article in journal (Refereed)
    Abstract [en]

    Background For each hour of delay from fist medical contact until reperfusion in ST-elevation myocardial infarction (STEMI) there is a 10% increase in risk of death and heart failure. The aim of this review is to describe the impact of the direct admission of patients with STEMI to a Catheterisation laboratory (cath lab) as compared with transport to the emergency department (ED) with regard to delays and outcome. Methods Databases were searched for from April-June 2012 and updated January 2014: 1) Pubmed; 2) Embase; 3) Cochrane Library; 4) ProQuest Nursing and 5) Allied Health Sources. The search was restricted to studies in English, Swedish, Danish and Norwegian languages. The intervention was a protocol-based clinical pre-hospital pathway and main outcome measurements were the delay to balloon inflation and hospital mortality. Results Median delay from door to balloon was significantly shorter in the intervention group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes. In all 7 included studies the time from symptom onset or first medical contact to balloon time was significantly shorter in the intervention group. The difference in median delay varied between 15 minutes and 1 hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death was reduced by 37%. Conclusion An overview of available studies of the impact of a protocol-based pre-hospital clinical pathway with direct admission to a cath lab as compared with the standard transport to the ED in ST-elevation AMI suggests the following. The delay to the start of revascularisation will be reduced. The clinical benefit is not clearly evidence based. However, the documented association between system delay and outcome defends the use of the pathway.

  • 65.
    Axelsson, C
    et al.
    University of Borås, School of Health Science.
    Herrera, MJ
    Fredriksson, M
    Lindqvist, J
    Herlitz, J
    University of Borås, School of Health Science.
    Implementation of mechanical chest compression in out-of-hospital carfdiac arrest in an emergency medical service system2013In: American Journal of Emergency Medicine, ISSN 0735-6757, E-ISSN 1532-8171, Vol. 31, no 8, p. 1196-1200Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study is to describe the outcome changes after out-of-hospital cardiac arrest (OHCA) in Gothenburg, Sweden, after introduction of mechanical chest compression (MCC). METHODS: Following introduction of MCC, 1183 OHCA patients were treated from November 1, 2007, to December 31, 2011 (period 2). They were compared with 1218 OHCA patients before MCC was introduced from January 1, 1998, to May 30, 2003 (period 1). Patients in period 2 were evaluated for survival in relation to MCC use. RESULTS: The percentage of patients admitted to hospital alive increased from 25.4% to 31.9% (P < .0001). Survival to 1 month increased from 7.1% to 10.7% (P = .002) from period 1 to period 2. The proportion of ventricular fibrillation/ventricular tachycardia decreased in period 2 (P = .002). However, bystander cardiopulmonary resuscitation (P < .0001), crew-witnessed cases (P = .04), percutaneous coronary intervention (P < .0001), therapeutic hypothermia (P < .0001), and implantable cardioverter-defibrillator use (P = .01) increased, as did time from call to emergency medicine service arrival (P < .0001) and to defibrillation (P = .006). In period 2, 60% of OHCA patients were treated with MCC. The percentages admitted alive to hospital (MCC vs no MCC) were 28.6% and 36.1% (P = .008). Corresponding figures for survival to 1 month were 5.6% and 17.6% (P < .0001). In the MCC group, we found increase in the delay from collapse to defibrillation (P < .0001), greater use of adrenaline (P < .0001), and fewer crew-witnessed cases (P < .0001). CONCLUSION: Survival to 1 month after implementation of MCC was higher than before introduction. However, patients receiving MCC had low survival. Although case selection might play a role, results do not support a widespread use of MCC after OHCA.

  • 66. Strömsöe, A
    et al.
    Afzelius, S
    Axelsson, C
    University of Borås, School of Health Science.
    Södersved Kallestedt, ML
    Enlund, M
    Svensson, L
    Herlitz, J
    University of Borås, School of Health Science.
    Improvements in logistics could increase survival after out-of-hospital cardiac arrest in Sweden.2013In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 273, no 6, p. 622-7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: In a review based on estimations and assumptions, to report the estimated number of survivors after out-of-hospital cardiac arrest (OHCA) in whom cardiopulmonary resuscitation (CPR) was started and to speculate about possible future improvements in Sweden. DESIGN: An observational study. SETTING: All ambulance organisations in Sweden. SUBJECTS: Patients included in the Swedish Cardiac Arrest Registry who suffered an OHCA between January 1, 2008 and December 31, 2010. Approximately 80% of OHCA cases in Sweden in which CPR was started are included. INTERVENTIONS: None RESULTS: In 11 005 patients, the 1-month survival rate was 9.4%. There are approximately 5000 OHCA cases annually in which CPR is started and 30-day survival is achieved in up to 500 patients yearly (6 per 100 000 inhabitants). Based on findings on survival in relation to the time to calling for the Emergency Medical Service (EMS) and the start of CPR and defibrillation, it was estimated that, if the delay from collapse to (i) calling EMS, (ii) the start of CPR, and (iii) the time to defibrillation were reduced to <2 min, <2 min, and <8 min, respectively, 300-400 additional lives could be saved. CONCLUSION: Based on findings relating to the delay to calling for the EMS and the start of CPR and defibrillation, we speculate that 300-400 additional OHCA patients yearly (4 per 100 000 inhabitants) could be saved in Sweden.

  • 67.
    Axelsson, Christer
    et al.
    University of Borås, School of Health Science.
    Claesson, Andreas
    University of Borås, School of Health Science.
    Engdahl, J
    Herlitz, Johan
    University of Borås, School of Health Science.
    Hollenberg, J
    Lindqvist, J
    Rosenqvist, M
    Svensson, L
    Outcome after out-of-hospital cardiac arrest witnessed by EMS: changes over time and factors of importance for outcome in Sweden.2012In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 83, no 10, p. 1253-1258Article in journal (Refereed)
    Abstract [en]

    Background Among patients who survive after out-of-hospital cardiac arrest (OHCA), a large proportion are recruited from cases witnessed by the Emergency Medical Service (EMS), since the conditions for success are most optimal in this subset. Aim To evaluate outcome after EMS-witnessed OHCA in a 20-year perspective in Sweden, with the emphasis on changes over time and factors of importance. Methods All patients included in the Swedish Cardiac Arrest Register from 1990 to 2009 were included. Results There were 48,349 patients and 13.5% of them were EMS witnessed. There was a successive increase in EMS-witnessed OHCA from 8.5% in 1992 to 16.9% in 2009 (p for trend < 0.0001). Among EMS-witnessed OHCA, the survival to one month increased from 13.9% in 1992 to 21.8% in 2009 (p for trend < 0.0001). Among EMS-witnessed OHCA, 51% were found in ventricular fibrillation, which was higher than in bystander-witnessed OHCA, despite a lower proportion with a presumed cardiac aetiology in the EMS-witnessed group. Among EMS-witnessed OHCA overall, 16.0% survived to one month, which was significantly higher than among bystander-witnessed OHCA. Independent predictors of a favourable outcome were: (1) initial rhythm ventricular fibrillation; (2) cardiac aetiology; (3) OHCA outside home and (4) decreasing age. Conclusion In Sweden, in a 20-year perspective, there was a successive increase in the proportion of EMS-witnessed OHCA. Among these patients, survival to one month increased over time. EMS-witnessed OHCA had a higher survival than bystander-witnessed OHCA. Independent predictors of an increased chance of survival were initial rhythm, aetiology, place and age.

  • 68.
    Herlitz, Johan
    et al.
    University of Borås, School of Health Science.
    Bång, Angela
    University of Borås, School of Health Science.
    Wireklint-Sundström, Birgitta
    University of Borås, School of Health Science.
    Axelsson, Christer
    University of Borås, School of Health Science.
    Bremer, Anders
    University of Borås, School of Health Science.
    Hagiwara, Magnus
    University of Borås, School of Health Science.
    Jonsson, Anders
    University of Borås, School of Health Science.
    Lundberg, Lars
    University of Borås, School of Health Science.
    Suserud, Björn-Ove
    University of Borås, School of Health Science.
    Ljungström, Lars
    Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care.2012In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 20, no 42Article in journal (Refereed)
    Abstract [en]

    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.

  • 69.
    Axelsson, Christer
    et al.
    University of Borås, School of Health Science.
    Bremer, Anders
    University of Borås, School of Health Science.
    Hagiwara, Magnus
    University of Borås, School of Health Science.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Nationella regler krävs för ambulanssjukvård2011In: Svenska Dagbladet, ISSN 1101-2412Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Ambulanssjukvården i Sverige saknar nationella riktlinjer. En konsekvens av detta är brister i tillgängligheten vilket fått allvarliga konsekvenser för flera personer under den senaste tiden. En av dem är Maximilian och hans mamma som blev påkörda på trottoaren av en 23-årig förare som hade tappat kontrollen över sin bil. Det tog nästan en timme innan pojken flögs till sjukhus med helikopter från olycksplatsen på Tjörn utanför Stenungsund. Maximilian blev bara tio veckor.

  • 70.
    Axelsson, Christer
    et al.
    University of Borås, School of Health Science.
    Bremer, Anders
    University of Borås, School of Health Science.
    Hagiwara, Magnus
    University of Borås, School of Health Science.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Englund, Lotta
    University of Borås, School of Health Science.
    Så skapas världens bästa ambulanssjukvård2011In: Göteborgsposten, ISSN 1103-9345Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Tiden från larm till dess att ambulans kommer har ökat dramatiskt de senaste tio åren i Västra Götaland. Samtidigt bedöms allt fler i behov av snabb utryckning. Kompetens finns att råda bot på detta – om den tillåts styra utvecklingen, skriver bland andra professor Johan Herlitz.

  • 71.
    Axelsson, C
    et al.
    University of Borås, School of Health Science.
    Borgström, J
    Karlsson, T
    Axelsson, Å
    Herlitz, Johan
    University of Borås, School of Health Science.
    Dispatch codes of out-of-hospital cardiac arrest should be diagnosis related rather than symptom related2010In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 17, no 5, p. 265-269Article in journal (Refereed)
    Abstract [en]

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

  • 72.
    Axelsson, Christer
    University of Borås, School of Health Science.
    Evaluation of various strategies to improve outcome after out-of-hospital cardiac arrest with particular focus on mechanical chest compressions2010Doctoral thesis, monograph (Other academic)
    Abstract [en]

    Cardiopulmonary resuscitation (CPR) skills vary among health care professionals. A previous study revealed that chest compressions were only performed half the time in out-of-hospital cardiac arrest (OHCA). Field conditions and fatigue could be possible explanations. The aim of this thesis was to study the impact of the introduction of mechanical chest compression in OHCA according to survival and its usability and b) passive leg raising (PLR), to augment the artificial circulation, during CPR. ... mer Methods: This thesis is based on a pilot study conducted in the Gothenburg/Mölndal and Södertälje Emergency Medical Service systems in 2003-2005. Witnessed OHCA (adult >18 years) received either mechanical (n=159) or manual (n=169) chest compressions. The pressure of end-tidal carbon dioxide (PETCO2) has been shown to correlate with cardiac output (CO) during CPR. To compare the effect of the different strategies, the PETCO2 was measured, during CPR, with standardised ventilation. Result: PLR during CPR increased the PETCO2 value within 30 seconds. Mechanical active compression-decompression (ACD) CPR, compared with manual compressions, produced the highest mean of initial, minimum and average values of PETCO2. However, mechanical chest compressions did not appear to result in improved survival. Clinical circumstances such as unidentified cardiac arrests (CAs) resulted in a large drop-out in the intervention group or a late start to the intervention in relation to CA. The late start meant that the intervention targeted a high-risk population with a low chance of survival. The majority of identified CAs were coded by the Rescue Co-ordination Centre (RCC) according to symptoms (usually unconsciousness), while the minority were coded according to the diagnosis of CA. Patients coded according to the diagnosis of CA had an earlier start of CPR, a higher rate of bystander CPR and a tendency toward higher survival rates. Conclusion: Since PLR during CPR appears to improve circulation after OHCA, larger studies are needed to evaluate its potential effects on survival. Compared with manual compressions, mechanical ACD CPR produces probably the most effective CPR. However, different clinical circumstances make the device difficult to study outside hospital. Coding a CA according to diagnosis rather than symptoms appears to improve the out-of-hospital care.

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  • 73.
    Axelsson, C
    et al.
    University of Borås, School of Health Science.
    Holmberg, S
    Axelsson, ÅB
    Herlitz, Johan
    University of Borås, School of Health Science.
    Passive leg raising during cardiopulmonary resuscitation in out-of-hospital cardiac arrest: Does it improve circulation and outcome?2010In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 81, no 12, p. 1615-1620Article in journal (Refereed)
    Abstract [en]

    Background Passive leg raising (PLR), to augment the artificial circulation, was deleted from cardiopulmonary resuscitation (CPR) guidelines in 1992. Increases in end-tidal carbon dioxide (PETCO2) during CPR have been associated with increased pulmonary blood flow reflecting cardiac output. Measurements of PETCO2 after PLR might therefore increase our understanding of its potential value in CPR. We also observed the alteration in PETCO2 in relation to the return of spontaneous circulation (ROSC) and no ROSC. Methods and results The PETCO2 was measured, subsequent to intubation, in 126 patients suffering an out-of-hospital cardiac arrest (OHCA), during 15min or until ROSC. Forty-four patients were selected by the study protocol to PLR 35cm; 21 patients received manual chest compressions and 23 mechanical compressions. The PLR was initiated during uninterrupted CPR, 5min from the start of PETCO2 measurements. During PLR, an increase in PETCO2 was found in all 44 patients within 15s (p=0.003), 45s (p=0.002) and 75s (p=0.0001). Survival to hospital discharge was 7% among patients with PLR and 1% among those without PLR (p=0.12). Among patients experiencing ROSC (60 of 126), we found a marked increase in PETCO2 1min before the detection of a palpable pulse. Conclusion Since PLR during CPR appears to increase PETCO2 after OHCA, larger studies are needed to evaluate its potential effects on survival. Further, the measurement of PETCO2 could help to minimise the hands-off periods and pulse checks.

  • 74.
    Axelsson, C
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    Karlsson, T
    Axelsson, ÅB
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    Mechanical active compression-decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (P(ET)CO2) during CPR in out-of-hospital cardiac arrest (OHCA).2009In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 80, no 10, p. 1099-1103Article in journal (Refereed)
    Abstract [en]

    AIM: In animal and human studies, measuring the pressure of end tidal carbon dioxide (P(ET)CO2) has been shown to be a practical non-invasive method that correlates well with the pulmonary blood flow and cardiac output (CO) generated during cardiopulmonary resuscitation (CPR). This study aims to compare mechanical active compression-decompression (ACD) CPR with standard CPR according to P(ET)CO2 among patients with out-of-hospital cardiac arrest (OHCA), during CPR and with standardised ventilation. METHODS: This prospective, on a cluster level, pseudo-randomised pilot trial took place in the Municipality of Göteborg. During a 2-year period, all patients aged >18 years suffering an out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology were enrolled. The present analysis included only tracheally intubated patients in whom P(ET)CO2 was measured for 15 min or until the detection of a pulse-giving rhythm. RESULTS: In all, 126 patients participated in the evaluation, 64 patients in the mechanical chest compression group and 62 patients in the control group. The group receiving mechanical ACD-CPR obtained the significantly highest P(ET)CO2 values according to the average (p=0.04), initial (p=0.01) and minimum (p=0.01) values. We found no significant difference according to the maximum value between groups. CONCLUSION: In this hypothesis generating study mechanical ACD-CPR compared with manual CPR generated the highest initial, minimum and average value of P(ET)CO2. Whether these data can be repeated and furthermore be associated with an improved outcome after OHCA need to be confirmed in a large prospective randomised trial.

  • 75.
    Axelsson, C
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    Axelsson, Å
    Svensson, L
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    Characteristics and outcome among patients suffering from out-of-hospital cardiac arrest with the emphasis on availability for intervention trials.2007In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 75, no 3, p. 460-468Article in journal (Refereed)
    Abstract [en]

    AIM: To describe all patients treated for out-of-hospital cardiac arrest (OHCA) according to the Utstein criteria and their characteristics and outcome with emphasis on whether they were available for early intervention trials. DESIGN: Retrospective analysis of a study where data were collected prospectively. SETTING: The Municipality of Göteborg/Mölndal in Sweden. PATIENTS: All patients suffering from out-of-hospital cardiac arrest in the Municipality of Göteborg/Mölndal in whom cardiopulmonary resuscitation (CPR) was attempted between May 2003 and May 2005. INTERVENTIONS: Part of the study cohort, i.e. patients with a witnessed, non-traumatic, out-of-hospital cardiac arrest were distributed (cluster) to mechanical (LUCAS) or manual chest compression. RESULTS: The overall survival to discharge from hospital among the 508 patients was 8.5%. The corresponding value for non-cardiac cases was 5.1% and for cardiac cases if crew witnessed 16.1%, bystander witnessed 12.7% and non-witnessed 1.4%. Fifty-nine percent of the patients fulfilled the inclusion criteria for the trial and had no exclusion criteria and 9.7% of these survived to discharge. Ten percent of patients fulfilled the inclusion criteria but were excluded and 20.4% survived to discharge. Thirty-one percent of patients did not fulfil the inclusion criteria and 2.5% survived. Among patients included in the LUCAS group, many of the survivors, 10/13 (77%), experienced a rapid return of spontaneous circulation (ROSC) before the application of the device. CONCLUSION: Among patients with OHCA in whom CPR was started 8.5% survived to hospital discharge and 59% were theoretically available for an early intervention trial. These patients have a different outcome compared with patients not available. However, among those available, the majority of survivors had a rapid ROSC before the application of the intervention (LUCAS). This raises concerns about the potential for early intervention trials to improve outcome after OHCA.

  • 76. Werling, M
    et al.
    Thorén, A-B
    Axelsson, C
    [external].
    Herlitz, Johan
    [external].
    Treatment and outcome in post-resuscitation care after out-of-hospital cardiac arrest when a modern therapeutic approach was introduced.2007In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 73, no 1, p. 40-45Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The outcome among patients who are hospitalised alive after out-of-hospital cardiac arrest is still relatively poor. At present, there are no clear guidelines specifying how they should be treated. The aim of this survey was to describe the outcome for initial survivors of out-of-hospital cardiac arrest when a more aggressive approach was applied. PATIENTS: All patients hospitalised alive after out-of-hospital cardiac arrest in the Municipality of Göteborg, Sweden, during a period of 20 months. RESULTS: Of all the patients in the municipality suffering an out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted (n=375), 85 patients (23%) were hospitalised alive and admitted to a hospital ward. Of them, 65% had a cardiac aetiology and 50% were found in ventricular fibrillation. In 32% of the patients, hypothermia was attempted, 28% underwent a coronary angiography and 21% had a mechanical revascularisation. In overall terms, 27 of the 85 patients who were brought alive to a hospital ward (32%) survived to 30 days after cardiac arrest. Survival was only moderately higher among patients treated with hypothermia versus not (37% versus 29%; NS), and it was markedly higher among those who had early coronary angiography versus not (67% versus 18%; p<0.0001). CONCLUSION: In an era in which a more aggressive attitude was applied in post-resuscitation care, we found that the survival (32%) was similar to that in previous surveys. However, early coronary angiography was associated with a marked increase in survival and might be of benefit to many of these patients. Larger registries are important to further confirm the value of hypothermia in representative patient populations

  • 77. Svensson, L
    et al.
    Nordlander, E
    Axelsson, C
    [external].
    Herlitz, Johan
    [external].
    Are predictors for myocardial infarction the same for women and men when evaluated prior to hospital admission?2006In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 109, no 2, p. 241-247Article in journal (Refereed)
    Abstract [en]

    AIM: To describe predictors of myocardial infarction prior to hospital admission in women and men among patients with a suspected acute coronary syndrome without ST-elevation. DESIGN: Prospective observational study in Stockholm and Göteborg, Sweden. RESULTS: Of 433 patients who did fulfill the inclusion criteria 45% were women. Fewer women (17%) than men (26%) developed acute myocardial infarction (AMI) (p=0.054), particularly among patients with initial ST-depression, in whom AMI was developed in 22% of women and 54% of men (p = 0.001). Predictors for infarct development in women were: a history of AMI and advanced age. Among men they were: initial ST-depression or a Q-wave on ECG and elevation of biochemical markers (both recorded on admission of the ambulance crew). There was a significant interaction between gender and the influence of ST-depression on the risk for development of myocardial infarction (p < 0.05). CONCLUSION: Among patients transported with ambulance due to a suspected acute coronary syndrome and no ST-elevation fewer women than men seem to develop AMI particularly among patients with ST-depression. These results suggest that early prediction of myocardial infarction might differ between women and men with acute chest pain.