Examining the Pre-Hospital Workflow of Stroke Patients Referred with Code SAMA (724) and their Outcome in the Emergency Department of Imam Reza Hospital (AS)

HintergrundDas Sachverständigengutachten zur bedarfsgerechten Steuerung der Gesundheitsversorgung 2018 empfiehlt zur Entlastung der klinischen Notfallversorgung unter anderem, dem Rettungsdienst die Option einzuräumen, geeignete Patienten direkt in eine Praxis zur fachärztlichen Versorgung zu transportieren.FragstellungQuantifizierung von Patienten, die mit dem Rettungswagen (RTW) in der Notaufnahme vorgestellt wurden und sicher und sinnvoll zur Behandlung primär in eine Praxis transportiert hätten werden können.Material und MethodenRetrospektive Auswertung prähospitaler und klinischer Daten von erwachsenen Patienten, die innerhalb von 2 Monaten mit einem RTW in die Notaufnahme eines universitären Maximalversorgers eingeliefert wurden. Anhand einer durch Rettungsassistenten durchgeführten, 5‑stufigen Dringlichkeitseinschätzung erfolgte durch die Autoren zunächst die Kategorisierung in „dringliche“ (Arztkontakt innerhalb von maximal 30 min notwendig) und „weniger dringliche“ Fälle (Arztkontakt nicht in weniger als 30 min notwendig, maximal in 120 min). In der Gruppe der „weniger dringlichen“ Fälle wurden aus den klinischen Behandlungsdaten diejenigen mit ambulanter Weiterbehandlung diskriminiert sowie folgend die Fälle, deren administrative Notaufnahme von Montag bis Freitag (Feiertage ausgeschlossen) jeweils zwischen 08.00 und 19.00 Uhr stattfand (praxistaugliche Fälle). Außerdem erfolgte eine medizinisch-inhaltliche Differenzierung dieser Fälle und ein Vergleich mit der Dringlichkeitseinschätzung in der Notaufnahme (Manchester Triage System, MTS).ErgebnisseEs wurden n = 1260 Patienten mit dem RTW in die Notaufnahme disponiert (Gesamtbehandlungszahl n = 11.506). Bei n = 894 war eine prähospitale Dringlichkeitseinschätzung dokumentiert, auf deren Grundlage n = 477 (53,4 %) als „weniger dringliche“ Fälle kategorisiert und n = 317 (66,5 %) ambulant weiterbehandelt wurden, n = 114 (23,9 %) zu üblichen Praxisöffnungszeiten. Das entspricht 1 % aller im Beobachtungszeitraum behandelten Patienten. 70 Fälle dieser praxistauglichen Gruppe (63,6 % von n = 110 mit dokumentierter MTS) wurden in der Notaufnahme dringlicher eingestuft. Die prähospital dokumentierten Beschwerdebilder und die in der Klinik erhobenen Hauptdiagnosen lassen den Einsatz relevanter diagnostischer Ressourcen bei einer Vielzahl der praxistauglichen Fälle vermuten.DiskussionDie Notaufnahmen könnten im Zeitfenster üblicher Praxisöffnungszeiten bei primärer Disposition der weniger dringlichen, ambulant behandelten Fälle in eine Praxis von ungefähr jedem zehnten mit dem RTW disponierten Patienten und 1 % ihrer Gesamtpatientenzahl entlastet werden. Unter dem Aspekt der Patientensicherheit ist dieses Vorgehen mit > 60 % möglicher Untertriage kritisch zu bewerten. Für die Diagnostik und Behandlung müssten entsprechende Ressourcen in der Praxis vorhanden und dem Rettungsdienst bekannt sein. Die primäre Disposition in eine Praxis erscheint bezogen auf die mögliche Entlastung einer großstädtischen Notaufnahme unbedeutend, ist potenziell patientengefährdend und mit einem enormen logistischen Aufwand verbunden.

IntroductionThe provision of efficient and integrated emergency services constitutes a vital cornerstone for reducing mortality rates and improving clinical outcomes for patients and casualties within complex healthcare systems. Effective engagement between hospital-based and pre-hospital emergency services is crucial for the delivery of higher quality and more appropriate patient care. This study was conducted with the aim of analyzing the factors affecting organizational engagement between pre-hospital and hospital emergency departments.MethodsThis was a qualitative study employing a conventional content analysis approach, conducted across pre-hospital emergency services and affiliated educational hospitals of Shahid Sadoughi University of Medical Sciences, Iran, in 2025. Participants included 38 experienced stakeholders in the field, encompassing managers, supervisors, physicians, nurses, and emergency medical technicians. These individuals were selected using purposive sampling until data saturation was achieved. Data were collected through semi-structured interviews and subsequently analyzed using MAXQDA software (Version 22). The credibility and trustworthiness of the findings were assessed according to Lincoln and Guba’s criteria.ResultsData analysis revealed that organizational interaction between pre-hospital and hospital emergency services faced significant barriers, primarily attributable to poor managerial coordination, cognitive and professional limitations, and gaps in clinical practice. Specifically, the lack of effective inter-organizational communication, weak leadership in conflict resolution, and insufficient structural and human resource support were identified as key managerial obstacles. In the domain of cognitive and professional limitations, negative attitudes, knowledge and skills gaps, and decision-making biases—often arising under conditions of high workload or limited information—were found to reduce mutual understanding and collaboration between personnel across the two sectors. Regarding clinical practice gaps, the absence of standardized patient handover protocols, inconsistencies in the implementation of care processes, and deficiencies in initial clinical assessments disrupted care continuity and diminished overall service quality.ConclusionThe findings of this study provide scientific guidance for decision-makers seeking to establish a more integrated, efficient, and safer emergency system. Enhancing organizational engagement within the emergency system necessitates a multifaceted and policy-driven approach, wherein policymakers play a pivotal role in reforming organizational structures, empowering human resources, and standardizing operational processes.

Background: Pre-hospital care plays an important role in managing patients who require emergency services and preserving human life. The aim of this study was to evaluate the cost of completed public pre-hospital emergency missions according to the activity-based costing model and to compare it with the cost of private pre-hospital emergency services in Mashhad in 2016. Methods: In this applied and descriptive cross-sectional study, the data were collected using a researcher-made form 4 major groups of costs were identified to estimate the total costs: 1- Personnel salaries, 2- Current expenses 3- Medical consumables 4- Depreciation. The cost of providing pre-hospital services was calculated based on the activity-based costing. Eventually, the cost of pre-hospital emergency services was compared between the public and private sectors. To investigate the cost-effective factors for missions, multiple regression analysis, Breusch-Pagan, Ramsey RESET, Swilk, and Linktest diagnostic tests were used by Stata 11.0 software. Results: The average cost of each mission was equal to 2114337 ± 217786 thousand Rials in 58 emergency medical centers of Mashhad in 2016. Of this cost, 78.51 %, (1660129 ± 1578445 Rials) was related to employees' salaries, 19.24 % (406842 ± 375083 Rials) was related to the current costs of each center, 0.23 % (4796 ± 4476 Rials) was related to depreciation, and 2/02 % (42761 ± 42822 Rials) was related to medical consumables in each pre-hospital emergency mission. The value of contract with an emergency pre-hospital emergency was 1104000 Rials for each mission in 2016, which is almost half of the cost related to the public pre-hospital. Results of the regression model estimation also showed that among the variables of the model, the fuel cost variable was identified as an effective variable on the cost of each mission (p = 0.0001). Conclusion: The private sector provides pre-hospital emergency services at a lower cost. Moreover, before establishing a pre-hospital pre-service center, the cost-effectiveness of establishing a center in each region should be checked.

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

Emergency care is operationally defined as time-critical acute care across pre-hospital services, emergency departments, and critical care units (excluding routine urgent care and elective admissions), demanding rapid decision-making under pressure. Digital twin technology, creating real-time virtual replicas through continuous data integration, represents a transformative shift in managing acute conditions, resource allocation, and outcome prediction in emergency medicine. This review examines the current applications, benefits, challenges, and future directions of digital twin technology in emergency care and medicine, highlighting its potential to revolutionise emergency healthcare delivery. A comprehensive narrative literature review was conducted using PubMed, IEEE Xplore, Scopus, and Web of Science databases. Studies published between January 2015 and June 2025 focusing on digital twin applications in emergency departments, trauma care, critical care, and prehospital emergency services were included. Grey literature, conference proceedings, and technical reports were also reviewed to capture emerging developments. Digital twins demonstrate significant utility across multiple emergency care domains including patient monitoring, resource allocation, workflow optimisation, predictive analytics, and training simulations. Key applications include real time patient condition prediction, emergency department capacity management, trauma response coordination, and personalised treatment planning. Despite promising outcomes, implementation challenges persist, including data integration complexities, computational requirements, and regulatory considerations. Digital twin technology holds substantial promise for enhancing emergency care delivery through improved decision support, resource optimisation, and predictive capabilities. Continued research, standardisation efforts, and interdisciplinary collaboration are essential for successful clinical integration and widespread adoption.

The lived experiences of healthcare professionals working in pre-hospital emergency services in Jordan: A qualitative exploratory study

This systematic review examined the efficacy and safety of intranasal fentanyl (INF) for acute pain treatment in children, adults, and the elderly in prehospital emergency services (PHES) and emergency departments (ED). ClinicalTrials.gov, LILACS, PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane databases were consulted until 31 December 2022. A total of 23 studies were included: 18 in children (1 PHES, 17 ED), 5 in adults (1 PHES, 4 ED) and 1 in older people (1 PHES subgroup analysis). In children, INF was effective in both settings and as effective as the comparator drugs, with no differences in adverse events (AEs); one randomised controlled trial (RCT) showed that INF was more effective than the comparator drugs. In adults, one study demonstrated the efficacy of INF in the PHES setting, one study demonstrated the efficacy of INF in the ED setting, two RCTs showed INF to be less effective than the comparator drugs and one RCT showed INF to be as effective as the comparator, with no difference in AEs reported. In older people, one study showed effective pain relief and no AEs. In summary, INF appears to be effective and safe in children and adults in PHES and ED. More high-quality studies are needed, especially in PHES and older people.

Objective To understand the ethics conflict situations between the pre-hospital patients and ambulance staff's determinations. Methods Taking a survey among the pre-hospital emergency physicians(80 people)and nurses(248 people)by Questionnaire of ethics conflicts during pre-hospital emergeney service,to investigate the ethics conflict situations between the pre-hospital patients and ambulance staff's determinations. Resulls (8.046±6.990)%of the patients who needed treatments refused to be treated completely,and(14.544±10.558)%of them refused partially.(14.451±14.747)% of the patients who needed ambulance transport refused to be delivered.In the patients who refused treatments and transportation.payment problem accounted for(23.52±19.79)%,(22.22±20.84)%of them did not believe they needed.(5.77±4.47)%of them wished to die,(19.44.4±18.65)%of them were hard to be idenfified.Other reasons accounted for(30.08±25.78)%.(20.31.4±16.66)% of the patients refused the ambulance crews' judge for some state.(29.66.4±24.02)%of the patients who got the pre-hospital emergency service were not necessary to call an ambulance.(22.1 l±19.52)%of the patients' demand conflicted with pre-hospital emergency services network management system.Conclusions There exists some conflicts between the pre-hospital patients and ambulance crews' determinations. Key words: Pre-hospital emergency service; Ethics; Conflict

Emergency Department Physician Computed Tomography Utilization and Admission Rates

Objective To explore the variations in category of internal diseases in order to plan out strategies to deal with during pre-hospital period in Chongqing urban area.Methods The category of internal diseases of pre-hospital emergency service in Chongqing urban area from January 2004 to December 2013 was studied and the data were analyzed retrospectively.Results Firstly,the number of patients in pre-hospital emergency service continued to mount up year by year,from 6031 patients in 2004 to 12 264 patients in 2013.The ration of male to femal was 1.24∶1 to 1.68∶ 1,and the cases of female increased year after year,from 2246 to 5486.Secondly,cardiovascular disease was the leading illness in the wide varieties of internal disease (15.35％-19.36％).The number of cerebrovascular accident (9.72％-13.11％),respiratory diseases (7.48％-10.20％) and digestive diseases (8.36％-10.58％) were escalating.However,the acute poisoning cases (2.36％-6.18％) showed a tendency of decline.The peak time of the pre-hospital emergency service was stable in past ten years.Thirdly,there were seasonal variation in incidence of cardiovascular,cerebrovascular and respiratory disease,more cases occurred in January and December than in other months.Alcoholism commonly peaked before Spring Festival.Fourthly,the peak time of internal disease occurred in the past 10 years was stable,peaked during 20:00-24:00,and the trough time was during 0:00-4:00,the ratio of trough to peak ranged from 30.7％ to 43.5％.Conclusion The variation of the internal disease category was associated more or less with seasonal rotation,the improved living standards,and stress of modern life,and the incidence of emergency illness were escalating year by year,thus the corresponding measures should be instituted to deal with those major changes.Improving pre-hospital emergency response capacity and efficacy of treatment is of great significance.Strengthening the prophylaxis and healthcare,and establishing a professional capability for triage classification of diseases during emergency service are great essential for promoting the swiftness of prehospital emergency response. Key words: Pre-hospital care; Prevention; Spectrum of diseases ; Internal medicine; Retrospective study; Response strategies

Prehospital emergency care is a vital pillar of the health system and serves as the first point of contact for patients. It plays an important role in providing timely care to emergency patients. The expectations of patients and their companions from these services, especially in critical situations, have the capacity to exert a significant influence on their experience and the quality of services. The aim of this study is to identify and investigate the needs and expectations of patients and their companions regarding prehospital emergency services. In this descriptive-cross-sectional study, 1100 patients and their companions were selected. The collection of data was facilitated by means of a questionnaire on expectations of pre-hospital emergency services, which was administered via telephone interviews following the determination of validity and reliability. The collected data were then analyzed using SPSS21 statistical software, and the results were interpreted through the use of descriptive and inferential statistics. In this study, the average score of interviewees’ expectations was high (80.01 ± 8.9) and the level of expectations was reported to be higher in women than in men. The results showed that the highest expectations of patients and their companions were related to the presence of a doctor in the ambulance, sufficient skills of medical personnel, respectful treatment combined with gaining trust and providing rapid emergency services. A significant relationship was observed between expectations and marital status, age, occupation and level of education (P < 0.001). The conclusion drawn from this study indicates that patients and their companions, particularly female members, hold elevated expectations of pre-hospital emergency services. The findings of this study indicate that patients and their companions, especially women, have elevated expectations of pre-hospital emergency services. These expectations encompass the presence of a medical professional in the ambulance, competent staff, respectful treatment, and expeditious service delivery. A notable correlation was identified between these expectations and socio-economic variables. These results underscore the importance of addressing patients’ needs and expectations to enhance the quality of emergency services. Specifically, enhancing staff skills and improving service delivery processes have the potential to increase patient and companion satisfaction.

Risk model of seizure cluster or status epilepticus and intervention in the emergency department

Pain, as a complex neurophysiological and neuropsychological mechanism, is one of the most common experiences among patients in prehospital emergency service. Although, there is no accurate data regarding the prevalence of pain in prehospital settings like there is for hospital emergency departments, in developed countries, despite the contradictions in the results of the numerous studies, the evidence indicate the high prevalence of acute pain in prehospital emergency service ranging from 20% to 53%. Yet, unfortunately, in Iran there is no statistics available in this regard. The physiological (affecting cardiovascular, respiratory, endocrine and other systems) and psychological (anxiety, anger, aggression, and …) complications due to uncontrolled acute pain have many adverse effects on the clinical outcomes of medical and traumatic patients and impose immense direct and indirect financial burdens on the limited resources of healthcare systems. Therefore, effective pain management using various pharmaceutical and non-pharmaceutical methods both on the scene and during transportation has become a potentially indispensable necessity and considered as a potential key performance indicator according to the National Association of EMS Physicians. An extensive literature review also revealed remarkable improvements in the use of analgesics in prehospital emergency service of many developed countries and opioid analgesics (e.g., morphine sulfate, fentanyl and ketamine); nonsteroidal anti-inflammatory drugs (e.g., Ketorolac and ibuprofen); and Paracetamol and Nitric Oxide (inhalation gas) have been put on the list of prehospital emergency service for relieving patients’ pain, which can be used based on qualification/competencies, roles, responsibilities, and degrees (EMR, EMT, AEMT, paramedic) of the providers of prehospital care with approval of the consultant physician or through use of a combination of off-line and on-line medical protocols in this regard. The majority of recent studies in this field focus on the inadequacy of prehospital pain management as well as the comparison and combination of various analgesic drugs to enhance efficacy, effectiveness and quality of healthcare provision.

Modelo de riesgo de crisis en acúmulos o estado epiléptico e intervención en servicios de urgencias

Background/Objectives: Patients with multimorbidity frequently rely on emergency services when continuity of care is weak. Strengthening communication between emergency and primary care can prevent unnecessary hospitalizations, yet this relationship remains underexplored. The aim of this study was to analyze the relationship between primary health care utilization in patients with multimorbidity and their demand for prehospital emergency services. Methods: An observational, longitudinal, analytical, and retrospective study was conducted in Málaga (Spain) between 2013 and 2017. Adults (>18 years) with multimorbidity who requested prehospital emergency care services at home were included; those with cancer, rare diseases, severe mental disorders, or incomplete electronic records were excluded. Variables encompassed sociodemographic, clinical, and behavioral characteristics, comorbidities, functional status, polypharmacy, resource type, and outcomes (on-site resolution or hospital referral). Primary health care visits before and after prehospital emergency use were extracted from electronic records. Descriptive, bivariate, and multivariate analyses were performed. Results: Among 532 patients, prior primary health care attendance predicted subsequent utilization (β = 0.57; p < 0.001), along with caregiver availability (β = 0.12; p = 0.001) and prehospital emergency services hyper-demand (β = 0.08; p = 0.022). Super-utilizers were younger, had ≥4 comorbidities, polypharmacy, prior family medicine visits, home oxygen therapy, and lower substance or alcohol use. Conclusions: In multimorbid adults, prehospital emergencies demand is influenced by factors beyond severity, including comorbidities, polypharmacy, the use of home medical devices, caregiver availability, and primary health care utilization patterns. Strengthening coordination between prehospital emergencies and primary health care, promoting patient–caregiver education, and implementing early notification pathways may improve care continuity and reduce avoidable emergencies.