Prehospital Research Articles

Road network disruptions during extreme flooding events and their impact on the access to emergency medical services: A spatiotemporal vulnerability analysis

The impact of extreme floods can be significant, affecting humans, the environment and any type of human-built infrastructure. A further consequence of flooding is restricted access to medical facilities, including constraints to access more dedicated emergency medical services (EMS). To date, there has been a lack of investigation into EMS accessibility dynamics during extreme floods. The objective of this study is to gain a deeper understanding of the spatiotemporal changes in accessibility-based vulnerability related to EMS during a representative extreme flood event, which was simulated over a period of six days. The study assesses the spatial accessibility of EMS centres to populations located within 15-, 30-, 45-, and 60-minute travel time thresholds in Canton Bern, Switzerland, and applies floating catchment area method. The dynamic aspects of EMS access vulnerability during extreme floods were assessed in two different ways. Firstly, the ratios between accessibility change and accessibility under normal conditions in 1 km grid cells were calculated at hourly moments, t. Subsequently, the resulting values were used to calculate the average vulnerability score. Secondly, percentage changes of affected populations were evaluated for different accessibility classes during the flood event and under all-time high static flood conditions. Varied spatial patterns of accessibility were generally observed with respect to the road network and population distributions in the hilly and mountainous landscape. Extending evaluations to consider temporal dynamics revealed a complex pattern of accessibility gains and losses in different regions of the study area, including those where no direct flood impacts occurred on the road network. The application of a static, all-time high flood condition resulted in an overestimation of accessibility limits to EMS centres. While this overestimation was not considered to be critical, the application of a spatiotemporal accessibility-based vulnerability analysis method to EMS is considered to be more holistic. Insights from this study can be used to evaluate the effectiveness of EMS risk management plans with respect to evolving extreme flood scenarios.

Trauma patients in the practice of medical rescue teams in Poland

Quick and effective access to professional medical assistance in emergencies has become a key element of the modern healthcare system. Emergency medical services play a vital role in immediate response to medical emergencies, in particular traumatic injury. According to estimates, emergency medical services delivered to trauma patients account for 10-20% of all services provided by paramedic units in Poland. An analysis of paramedic services delivered to trauma patients will make a significant contribution to the effectiveness and optimization of emergency medical services. The aim of this study was to analyze the emergency medical services delivered by paramedic units to trauma patients in the voivodeship of Warmia and Mazury over a period of three years. The study involved a retrospective analysis of statistical data for the above voivodeship. The patients were classified according to the 10th Revision of the International Classification of Diseases (ICD-10) [1]. Most trauma patients were assigned ICD-10 codes S (injury, poisoning, and certain other consequences of external causes) and T (injuries involving multiple body regions) categories. Results: The diagnoses made by physicians, paramedics, and emergency nurses in patient care reports were the source of data for the retrospective analysis. A total of 400,251 cases (n= 400,251) were analyzed and 11,329 cases were selected (n=11,329), including 1130 patients (n=1130) who were assigned code S and 10,199 patients (n=10,199) who were assigned to code T. The examined database is administered by the Governor of the Voivodeship of Warmia and Mazury in Olsztyn [2]. The following types of information were analyzed: area of intervention, the patients’ age and sex, type of medical emergency, location, date, and alcohol breath odor. The collected data were analyzed to determine the presence of relationships between: a life-threatening medical emergency and the patient’s age, a life-threatening medical emergency and the patient’s sex, the patient’s age and the diagnosis made by paramedics, alcohol breath odor and the patient’s sex, and the patient’s sex and the diagnosis made by paramedics. Conclusions: The results of the study suggest that the risk of a life-threatening medical emergency is higher in younger patients and decreases gradually in older patients. The above risk is somewhat higher in men than in women. The percentage of patients assigned code S (injury, poisoning, and certain other consequences of external causes) increases with age. Alcohol breath odor is more frequently detected in patients residing in areas with a population above 10,000 than in patients residing in small towns and rural areas. The patient’s sex is not significantly correlated with the type of medical emergency, and the prevalence of the diagnosed medical emergencies tends to be similar in both sexes.

Atrial fibrillation and atrial flutter in the practice of the emergency medical team in Poland

Background: Atrial Fibrillation (AF) is one of the most common heart arrhythmias globally. It is characterized by irregular, chaotic contractions of the atrial muscle, leading to an irregular and often rapid heart rhythm. The prevalence of this arrhythmia increases with age, which is associated with both the aging population and cardiovascular risk factors such as hypertension, coronary artery disease, and diabetes. Atrial Flutter (AFL) represents a less common variant of atrial fibrillation, occurring significantly less frequently - in relation to atrial fibrillation (AF), it is estimated to account for less than one-tenth of cases. The aim of the study was to analyze emergency medical services delivered to patients diagnosed with atrial fibrillation (AF) and atrial flutter (AFL) in the Voivodeship of Warmia and Mazury (Poland). The patients were classified according to the 10th Revision of the International Classification of Diseases (ICD-10 )[1]. Methods: The study was based on a retrospective data analysis. From a total population of 400,251 subjects (n= 400,251), 4715 patients were selected for the study. The majority of the patients were women (n=2941; 62.38%), whereas men accounted for 37.62% of the examined sample (n=1774). The analysis relied on a database administered by the Governor of the Voivodeship of Warmia and Mazury in Olsztyn [2]. The analyzed data included the area of intervention, the patient's age and sex, and the diagnoses made by physicians, paramedics, and emergency nurses. Three research hypotheses postulating the presence of relationships between the patient's sex and the diagnosis (1), the patient's age and the diagnosis (2), and a life-threatening emergency and the patient's age (3) were formulated. Results: The results of the study suggest that the patient's sex affects the medical diagnosis. In particular, women were more frequently diagnosed with chest pain, whereas the probability of the remaining diagnoses was similar in both sexes. The patient's age does not significantly influence the diagnosis. The patient's sex is not a significant predictor of a life-threatening emergency. Conclusion: The conducted study on the dataset from the Warmian-Masurian Voivodeship revealed significant correlations between demographic variables and the diagnosis of atrial fibrillation (AF) and atrial flutter (AFL) in patients. Analyzing this data may have significant implications for emergency medical systems, enabling the adaptation of intervention strategies to different patient categories.

Working in emergency services in Germany: cross-sectional data on violence experience and perception

Abstract Background Violence in emergency medical services (EMS) continues to be a topic of concern. Experiencing violence impedes the workers’ wellbeing, thus impairing the coverage and quality of EMS. We explored employment-related factors associated with violence experience and perception. Methods We conducted an anonymous online-based survey among EMS staff in Germany (09.2023-01.2024). Participants reported on their work setting, frequency of violent experiences and perception of violence. Descriptive statistics and logistic regression were calculated. Results Of 224 participants with completed questionnaires, 86 reported to have been exposed to physical violence (PV) in the past 12 months (Median number of events=2.00) and 129 reported to have experienced non-physical violence (NPV; Median number of events=5.00) with the majority of participants reporting that all cases occurred during assignment (n(PV)=79; n(NPV)=86). Of those, 78 reported PV by patients and 5 by colleagues, while in NPV cases 113 participants experienced violence by patients and 40 by colleagues. Women had a higher probability of reporting PV experiences compared to men (OR = 2.214, p=.010). Reporting NPV experiences was negatively associated with age between 45 and 49 (compared to ≤ 24 years, OR=.291, p=.019) and having worked for the current employer for ≥16 years (OR=.339, p=.035). Participants who have experienced violence in the past year had a higher likelihood of perceiving a general increase in the prevalence of violence in EMS (PV: OR = 6.766, p<.001; NPV: OR = 1.688, p=.047). Conclusions Younger EMS workers with juniority have a higher probability of reporting experiencing NPV. Women are more likely to report experiencing PV. It remains to be explored, if these associations refer to the experiences of violence, to reporting frequency or both. Regardless, the majority of respondents perceive an increase in violence within the work setting of EMS, especially if they have been subjected to it themselves. Key messages • EMS professionals experience significant levels of physical and non-physical violence originating from patients and colleagues. • Sex, age and seniority may affect the likelihood of EMS professionals of experiencing physical or non-physical violence.

Socio-economic factors affecting spatial inequalities in pregnancy-related ambulance attendances in Greater London

Exploring inequalities in ambulance and pre-hospital demand is important to improve service equity and reduce wider health inequalities. Maternity incidents amongst ambulance demand are a key area of focus because of the specialized care that is needed for patients, as well as the impact of wider determinants of health on pregnancy outcomes. Since there are spatial inequalities amongst pregnant patients who call for an ambulance, the aim of this study is to assess the underlying factors associated with pregnancy related ambulance complaints, to determine why maternity patients utilize the ambulance service. Local indicators of spatial autocorrelation were used to identify clusters of ambulance maternity demand within Greater London (UK). A negative binomial regression model was used to explore associations between socioeconomic, environmental, accessibility and demographic variables. Our results reveal that neighborhoods with low adult skills (i.e. qualifications/English language abilities) have a higher rate of demand. Moreover, our results imply that the demand for ambulance services may not be directly tied to health outcomes; rather, it might be more closely associated with patients' reasons for calling an ambulance, irrespective of the actual necessity. The benefits of identifying factors that drive demand in ambulance services are not just linked to improving equity, but also to reducing demand, ultimately relieving pressure on services if alternative options are identified or underlying causes addressed. Doing so can improve health inequalities by firstly, improving ambulance care equity by directly supporting a better allocation of resources within ambulance systems to target patterns in demand.

Clinical impact of helicopter transport with a physician in cardiogenic shock complicating acute coronary syndrome

Abstract Introduction Cardiogenic shock (CS) remains the leading cause of death in patients with acute coronary syndrome (ACS). Helicopter transport with a physician may improve the prognosis through reduction of the ischemic time and an early critical care. However, the impact of transfer of a physician-staffed helicopter and outcomes of CS complicating ACS is uncertain. Purpose The aim of the present study was to evaluate compare the clinical characteristics and long-term outcome between helicopter transport with a physician and ground transport in CS complicating ACS patients. Methods We retrospectively investigated 2324 consecutive patients with ACS who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death. Results Among the 2324 eligible patients, 273 ACS patients (11.7%) were complicated by CS. Of 273 CS complicating ACS, a total of 81 (29.7%) patients were transported by helicopter, 166 (60.8%) patients were transported by ambulance, and 26 (9.5%) patients did not use emergency medical service. The mean age was 71 years, 75% of patients were male, STEMI was seen in 87%, and mechanical circulatory support was used in 64%. Kaplan-Meier analysis showed that CV mortality up to 30 days was significantly lower with helicopter transport group compared those with ground transport (P = 0.0407). The rate of long-term CV death was comparable between groups (P = 0.19). Multivariate Cox regression analysis showed helicopter transport was significantly associated with lower 30-day CV mortality (adjusted HR 0.56, 95%CI 0.32-0.99, P = 0.0447). Conclusions Helicopter transport with a physician may improve cardiovascular outcomes of CS complicating ACS.Figure 1.Figure 2.

Identifying low-risk chest pain in out-of-hours primary care: the diagnostic performance of preHEAR and preHEART scores based on two European cohorts

Abstract Background Distinguishing cardiac from non-cardiac acute chest pain presents a diagnostic challenge. Risk stratification tools, such as the HEART score, have been developed for decision support for hospital-based settings. For prehospital settings, the preHEART score was developed as an alternative to the HEART score, with refinements made to meet prehospital conditions, as illustrated in Figure 1. While promising for use by emergency medical services, the diagnostic performance in primary care is unknown. Purpose In this study, we aim to evaluate the preHEART score (with and without high-sensitivity cardiac troponin (hs-cTn)) as a risk stratification tool to rule out acute myocardial infarction (MI) in patients evaluated in out-of-hours primary care. Methods We relied on retrospective data from two cohorts, namely, the OUT-ACS study involving 1,711 consecutive patients (47.7% female, median age: 56 (25th-75th percentiles: 45-68)) evaluated at a Norwegian primary care emergency centre from 2016-2018; and the TRACE study involving 664 consecutive patients (56.9% female, median age: 48 (25th-75th percentiles: 32-67) from a Dutch primary care emergency centre in 2017. We evaluated the preHEAR (OUT-ACS & TRACE without hs-cTn) and preHEART scores (OUT-ACS). The threshold of ≤3 points was considered low-risk and previously determined as optimal for rule-out purposes. The primary outcome was the diagnostic performance for ruling out MI at the index episode, and the secondary outcome was the composite of 90-day all-cause death or MI. Results In the OUT-ACS cohort, 61 (3.6%) patients were diagnosed with an MI; for the TRACE study, MI was diagnosed in 20 (3.0%) patients. The percentage of patients deemed at low risk by preHEAR was 49.3% (n=843) and 82.7% (n=549) for OUT-ACS and TRACE, respectively. For preHEART, only 33.6% (n=575) of OUT-ACS patients were deemed low-risk. As shown in Figure 2, the corresponding sensitivity/specificity indices for index MI were 63.9%/49.8% (OUT-ACS) and 65.0%/84.2% (TRACE) for preHEAR and 93.4%/34.6% for preHEART. Positive predictive values were low (preHEAR 5.0-11.3%, preHEART 5.0%), whereas negative predictive values were high (preHEAR 97.4-98.7%, preHEART 99.3%). For the secondary outcome, similar diagnostic performance metrics were found. All missed MI cases (n=4) in the low-risk preHEART group were female. Conclusion The preHEAR and preHEART scores did not result in adequate rule-out safety for an emergency primary care setting despite a low a priori MI risk. Moreover, the score appears to underestimate the risk for MI in females.preHEAR(T) risk scoresPerformance of the risk scores

Prehospital point of care ultrasound in Helicopter Emergency Medical Services: a 5-year experience study in Belgium

IntroductionThe utilization of Clinical Ultrasound (CUS) in Helicopter Emergency Medical Services (HEMS) has become increasingly prevalent, reflecting its significant role in emergency care.MethodsThis descriptive, monocentric study, conducted at the Helicopter Medical Center (CMH) of Bra-sur-Lienne, Belgium, aimed to describe the use of CUS within HEMS and evaluate its potential impact on diagnostic accuracy, therapeutic interventions, and hospital destination decisions.ResultsOver a 5-year period, from January 2018 to December 2022, our retrospective analysis included 6,126 HEMS interventions, with CUS performed in 29.55% of cases. The study demonstrated that CUS led to therapeutic changes in 30.88% of instances and affected the hospital destination in 9% of cases, despite a potential bias toward directing patients to the University Hospital Center of Liège (CHU of Liège) due to operational constraints. The agreement between prehospital CUS findings and hospital imaging was substantial, with an 80.39% concordance rate, underscoring CUS's utility in enhancing prehospital diagnostic accuracy. We found no significant increase in on-scene time due to CUS usage, with most exams completed in <5 min.DiscussionOur findings highlight the interesting role of CUS in HEMS, facilitating more informed and confident medical decision-making in prehospital emergency care. However, variability in CUS application emphasize the need for standardized guidelines to optimize its use. The study's limitations include its retrospective, monocentric design and the focus on on-scene ultrasound evaluations. Future research should aim at a more extensive, prospective analysis to further validate the benefits of CUS in emergency medical services.

Improving prehospital risk stratification using deep learning ECG interpretation in suspected acute coronary syndrome

Abstract Introduction Most patients presenting with chest pain in the Emergency Medical Services (EMS) setting are suspected of non-ST-elevation acute coronary syndrome (NSTE-ACS). Distinguishing true NSTE-ACS from non-cardiac chest pain based solely on the electrocardiogram (ECG) is challenging. Recent advances in artificial intelligence (AI) models for ECG interpretation show promising results. Purpose The aim of this study is to develop and validate a Convolutional Neural Network (CNN)-based model to diagnose NSTE-ACS within the prehospital ECG and to compare it to current prehospital available diagnostic tools. Methods For this study, a training/internal validation cohort (n= 4891) and external validation cohort (n= 754) were used, both consisting of suspected NSTE-ACS patients, and the first prehospital standard 12-lead ECG at presentation was extracted. A CNN (ECG-AI) was trained and validated to detect NSTE-ACS. The training/internal validation cohort was extracted from suspected NSTE-ACS patients presenting to the emergency department. The external validation cohort was extracted from a prehospital, prospective cohort study in which subjects were assessed by EMS paramedics. A validated prehospital clinical risk score (preHEART) was calculated, which includes manual on-site ECG analyses by EMS paramedic (ECG-EMS) and a point-of-care (POC) troponin assessment, and compared to ECG-AI in diagnosing NSTE-ACS. Results In the external validation cohort, 202 (27%) subjects were diagnosed with NSTE-ACS. ECG-AI had a better diagnostic performance than ECG-EMS (AUC 0.70 (0.66–0.74) vs. AUC 0.65 (0.61–0.70), p=0.045) for diagnosing NSTE-ACS. The overall diagnostic accuracy of preHEART was AUC 0.78 (0.74–0.82) and superior compared to ECG-AI (p= 0.001). Incorporating ECG-AI instead of ECG-EMS into preHEART led to a significant improvement in diagnostic performance (AUC 0.83 (0.79–0.86,p < 0.001)). Conclusion Integrating AI in prehospital ECG interpretation improves NSTE-ACS diagnosis. However, clinical risk scores still yield the best diagnostic performance in the prehospital setting and their accuracy could be further enhanced through AI.ROC prehospital diagnostic toolsROC preheart and preheart-AI

Post-ROsc ecG pREdictS Survival after out-of hospital cardiac arrest: validation of the PROGRESS score

Abstract Background Prognostication is crucial for patients with an out-of-hospital cardiac arrest (OHCA) both during resuscitation and after return of spontaneous circulation (ROSC) and early prognostication is still a challenge. At this regard, we proposed the PROGRESS score: a post-ROSC 12-lead ECG features’-based score to predict 30-day survival. Purpose The aim of the present study is to validate the PROGRESS score on a larger population of post-OHCA patients and to test its performance even after correction for patients’ and events’ characteristics, contained in the UB-ROSC score, could increase its discrimination ability. Methods Cardiac arrest cases were retrieved from the Lombardy Cardiac Arrest Registry (LombardiaCARe) from January 2015 to December 2022. We considered only patients with a post-ROSC 12-lead ECG and all the variables for UB-ROSC calculation available. The PROGRESS score considers age, sex, number of segments with ST elevation, QRS width, and Brugada pattern and from 0 to 26 identifies three categories of risk of death at 30 days (low: 0-4; intermediate: 5-7; high: 8-26). The UB-ROSC score considers age, aetiology, location, witnessed OHCA, bystander cardiopulmonary resuscitation (CPR), emergency medical service (EMS) arrival time and type of presenting rhythm. The performance of the PROGRESS score, in terms of discriminatory power of calibration, was tested both alone and after correction for UB-ROSC score. Results We considered 940 OHCAs of whom 63.9% were males with a median age of 70 [59.5-79]. 30-day survival was 37.9%, 63.1% and 64.5% in high, intermediate, and low risk groups respectively. PROGRESS score was shown to discriminate high-risk patients from low-risk ones [HR 1.97 (95% CI 1.42-2.73), p-value <0.001], (Harrel-C= 0.58). After correction for UB-ROSC score both calibration and discrimination improved (Harrel-C = 0.70). Conclusions The PROGRESS score was confirmed to predict the risk of death at 30 days in patients resuscitated from an OHCA and its discriminatory power was increased by correction for the UB-ROSC score. The use of this two scores in the field allows risk stratification during resuscitation manoeuvres and in post-ROSC care, which is essential to guide resource allocation.

Mobile Stroke Unit Management in Patients With Acute Ischemic Stroke Eligible for Intravenous Thrombolysis

Clinical trials have suggested that prehospital management in a mobile stroke unit (MSU) improves functional outcomes in patients with acute ischemic stroke who are potentially eligible for intravenous thrombolysis, but there is a paucity of real-world evidence from routine clinical practice on this topic. To determine the association between prehospital management in an MSU vs standard emergency medical services (EMS) management and the level of global disability at hospital discharge. This was a retrospective, observational, cohort study that included consecutive patients with a final diagnosis of ischemic stroke who received either prehospital management in an MSU or standard EMS management between August 1, 2018, and January 31, 2023. Follow-up ended at hospital discharge. The primary analytic cohort included those who were potentially eligible for IV thrombolysis. A separate, overlapping cohort including all patients regardless of diagnosis was also analyzed. Patient data were obtained from the American Heart Association's Get With The Guidelines-Stroke (GWTG-Stroke) Program, a nationwide, multicenter quality assurance registry. This analysis was completed in May 2024. Prehospital management in an MSU (vs standard EMS management). The primary efficacy end point was the utility-weighted modified Rankin Scale (UW-mRS) score. The secondary efficacy end point was independent ambulation status. The coprimary safety end points were symptomatic intracranial hemorrhage (sICH) and in-hospital mortality. Of 19 433 patients (median [IQR] age, 73 [62-83] years; 9867 female [50.8%]) treated at 106 hospitals, 1237 (6.4%) received prehospital management in an MSU. Prehospital management in an MSU was associated with a better score on the UW-mRS at discharge (adjusted mean difference, 0.03; 95% CI, 0.01-0.05) and a higher likelihood of independent ambulation at discharge (53.3% [468 of 878 patients] vs 48.3% [5868 of 12 148 patients]; adjusted risk ratio [aRR], 1.08; 95% CI, 1.03-1.13). There was no statistically significant difference in sICH (5.2% [57 of 1094] vs 4.2% [545 of 13 014]; aRR, 1.30; 95% CI, 0.94-1.75]) or in-hospital mortality (5.7% [70 of 1237] vs 6.2% [1121 of 18 196]; aRR, 1.03; 95% CI, 0.78-1.27) between the 2 groups. Among patients with acute ischemic stroke potentially eligible for intravenous thrombolysis, prehospital management in an MSU compared with standard EMS management was associated with a significantly lower level of global disability at hospital discharge. These findings support policy efforts to expand access to prehospital MSU management.

Enhancing stroke awareness in schools: efficacy of the HOBIT program in Czechia’s disadvantaged areas

Abstract Background For stroke treatment to be effective, it must be given as soon as possible. Delays are often caused by stroke bystanders failing to recognize symptoms and activate emergency medical services (EMS). This is especially a problem in socially excluded localities. This study evaluated the efficacy of a school-based intervention (HOBIT) in improving determinants and behavior intentions of EMS activation for suspected stroke in Czech socially excluded localities. Methods The quasi-experiment was conducted from May to June 2023 in the Moravian-Silesian region, Czechia. Schools were allocated to the intervention or control group (1:1). The HOBIT is a school-based intervention used to change health-seeking behavior when stroke is suspected. The primary outcome was the percentage change from the pretest to the follow-up test in the intervention group compared to the control group. The primary outcome was assessed in 4 domains: 1) knowledge, 2) behavioral intentions, 3) self-efficacy, and 4) outcome expectations. The intervention and control groups were compared using an unpaired t-test. Results We recruited 138 students aged 10-16 from 4 schools. The absolute differences in improvement between the control and intervention groups were 18% (95% CI 9-26, P < 0.001) for knowledge, 15% (95% CI 2-26, P = 0.01) for behavioral intentions, 6% (95% CI -4-15, P = 0.24) for self-efficacy, and 13% (95% CI 5-21, P < 0.001) for outcome expectations. The subgroup analysis showed that the intervention effect on self-efficacy, outcome expectations, and stroke behavior intentions was significant only in females. Conclusions The HOBIT improved stroke determinants and behavior intentions of EMS activation at schools in socially excluded areas. This study presents a health promotion practice that has the potential to improve stroke outcomes on a community level. It underscores the potential of school settings as an appropriate way to reduce health inequalities in socially excluded communities. Key messages • The HOBIT intervention improved determinants and behavior intentions of EMS activation for suspected stroke among students in socially excluded localities. • The study underscores the potential of school settings in reducing health inequalities and improving stroke-related outcomes in socially excluded localities.

Impact of a prehospital mobile cloud ECG transmission system on door-to-balloon time, myocardial damage and mid-term all-cause mortality in patients with ST-elevation myocardial infarction

Abstract Background Guidelines recommend to establish a regional reperfusion strategy to maximize the efficiency of care for patients diagnosed with ST-elevation myocardial infarction (STEMI). In Addition, the recently developed mobile cloud-based 12-lead electrocardiogram (ECG) transmission system enables the transmission of prehospital ECGs at a low cost. Medical staff can use electronic devices to access and review ECGs from anywhere. However, the effectiveness of the prehospital mobile cloud ECG system has not yet been clearly established. Objective This single-center study aims to evaluate the impact of the prehospital mobile cloud ECG system on reducing Door-to-Balloon Time (DTBT), myocardial damage, and mid-term all-cause mortality in patients with STEMI. Methods In June 2018, eight prehospital Mobile Cloud ECG Transmission systems were integrated into the regional Emergency Medical Service (EMS) in our region. This study examined and compared Door-to-Catheterization Laboratory Time (DTCT), DTBT, Onset-to-Reperfusion Time (OTRT), peak creatine kinase-MB (CK-MB) levels, and one-year mortality rates of STEMI patients in the five years before and after introducing the prehospital mobile cloud ECG system. From June 2013 to May 2023, our institute received a total of 426 STEMI patients via ambulances from these two EMS departments. After excluding 23 patients with OTRT exceeding 24 hours and 76 patients who were transferred without the system post-introduction, 327 consecutive STEMI patients who underwent emergency percutaneous coronary intervention (PCI) were included in the study. The patients were divided into two groups: 169 patients before the prehospital mobile cloud ECG system introduction and 158 patients after that. Results There were no significant differences in age, gender, past medical history, and Killip Class IV between the two groups, except for the proportion of left main trunk (LMT) lesions, which was significantly higher in the ECG group. Significant reductions were observed in both DTCT and DTBT in the group after introduction, with differences noted as (DTCT: 42 min vs. 26 min; p < 0. 001, and DTBT: 74 min vs. 56 min; p < 0.001, respectively). However, the OTRT did not show a significant difference. Peak creatine kinase-MB (CK-MB) levels did not differ between the two groups, and Kaplan-Meier analysis revealed no significant difference in one-year mortality between them. Multivariate Cox regression analysis, which included variables such as age, peak CK-MB levels, Killip Class IV, LMT lesions, OTRT and the prehospital mobile cloud ECG transmission system usage, revealed that only Killip Class IV was significantly associated with one-year mortality (hazard ratio of 2.82 and a 95% confidence interval of 1.61-4.94; p=0.0003). Conclusion The prehospital mobile cloud ECG transmission system significantly reduced DTBT, but did not lead to a reduction in myocardial damage or an improvement in mid-term prognosis.Effect of the ECG Transmission SystemKaplan-Meier analysis

Emergency department frequent users in the paediatric population: a retrospective analysis in Rome

Abstract Background Recent studies have reported the increasing utilisation of the Emergency Departments (EDs) for non-urgent attendances by people aged <18 years. The aim of this study is to describe the characteristic of the paediatric frequent user (FU) population, highlighting the differences between FUs and non-FUs, and to identify factors linked to appropriate ED attendance, comparing the level of variability attributed to the geographical and family physician components. Methods A retrospective cohort study was carried out of the ED attendances in 2022 in the 8 EDs of the Local Health Authority Roma 1 geographical area, in Rome. The cohort was enrolled from the regional Healthcare Emergency Information System. Records included information on number of attendance, age and gender, usage of emergency medical service (EMS), triage code, appropriateness of attendance. Multivariable nested logistic regression was performed to identify the characteristics of FU and non-FU attendances and the predictors for appropriateness of attendances. Results In 2022, the total number of children with at least 1 ED attendance is 24.824 and a total of 35.691 attendances were recorded. The regression analysis highlights that the appropriateness of attendances is associated to the female gender (OR male: 0.84), age <1 year (OR: 2.06), the usage of EMS (OR: 2.00), high triage code and being a FU (OR FU: 1.53). The family physician group have a greater influence of District group but lower influence of single patient characteristics group to determine the appropriateness of paediatric ED attendances (MOR District: 1.73; MOR PCP: 1.84; MOR single patient characteristics: 2.75). Conclusions Frequent use of the ED is partially associated with an inappropriate use of EDs, mostly due to the specific patients’ characteristics. It is therefore necessary to adopt strategies to improve the appropriate use of health service resources in order to provide quality health solutions to real health needs. Key messages • This is the first study that defines an ED paediatric FU profile in Italy. • It compares the level of variability attributed to the geographical component and family physician components.

Variations in access to acute care services by immigrant background and sociodemographic factors

Abstract Background The Emergency Medical Communication Center (EMCC) plays a vital role in the medical emergency response system by triaging contacts, notifying local physicians, and providing medical advice. The utilization of acute care services and the subsequent care pathway by individuals with immigrant background remains unclear in the Norwegian context. This study aims to investigate whether disparities exist in the acute care pathway for patients with different sociodemographic background who use ambulance services. Methods We examined all code red ambulance dispatches for life-threatening emergencies in 2021 in Norway. These ambulance dispatches were linked to primary health care and specialist health care contacts to trace patient pathways and outcomes. Statistical analyses were conducted using linear regression models, adjusted for patient characteristics, such as immigrant background, age, sex, municipality of residence, living condition, socioeconomic status, comorbidity and cause of emergency contact. Results Preliminary crude findings indicate that patients with immigrant background are overrepresented in the groups receiving acute primary care only and underrepresented in the groups transferred directly to specialist health care, within 8 hours after ambulance arrival at the patients’ location. Conclusions The preliminary results suggest challenges for the EMCC in triaging patients with immigrant background, but further research is needed to explore potential systematic differences. This study aims to improve understanding of disparities in access to acute care and inform targeted interventions to optimize resource allocation in emergency departments. Key messages • This study may improve understanding of disparities in access to acute care in Norway. • This study can inform targeted interventions to improve resource allocation in emergency departments.

Effect of nutritional guidance on mortality and composite endpoints in patients with acute myocardial infarction: a single center retrospective cohort study

Abstract Background/Introduction Acute myocardial infarction (AMI) stands as a major global cause of mortality. Various intervention strategies, such as pre-hospital care, reperfusion therapies, pharmacological interventions, dietary modifications, and exercise therapies, have been researched to improve patient prognosis (1,2). While reports suggest the efficacy of the Mediterranean diet, there remains a lack of evidence regarding the impact of nutritionist-led dietary guidance on the prognosis of AMI patients. Purpose This study aimed to elucidate whether nutritional guidance by nutritionists who have national qualifications would improve the mortality and the primary composite endpoint (including acute decompensated heart failure, stroke, and acute coronary syndrome) of patients following an acute myocardial infarction. Methods A retrospective cohort study was conducted, enrolling 446 consecutive AMI patients who underwent emergency coronary angiography and percutaneous coronary interventions between September 1, 2015, and October 31, 2023. Patients meeting the universal definition of myocardial infarction were included (3). After excluding 37 in-hospital deaths, evaluations for all-cause mortality, cardiovascular mortality, and composite endpoints were performed during follow-up in 409 patients. Nutritionists guided 223 patients (54.5%) during hospitalization in this study. The nutritional guidance used in our study was also based on the definition of adequate caloric intake of 25–30 kcal per ideal body weight (kg). Under an appropriate total energy intake, a fat energy ratio of 20–25% and a carbohydrate energy ratio of 50–60% are recommended, with protein and lipid restrictions depending on the disease state. Results During a median follow-up of 39 months, 24 cases of all-cause mortality (5.9%) and 6 cases of cardiovascular mortality (1.5%) were recorded. Additionally, 15 cases of nonfatal stroke (3.7%), 17 cases of nonfatal acute coronary syndrome (4.2%), and 20 cases of hospitalizations for acute decompensated heart failure (4.9%) were observed. Kaplan–Meier curves demonstrated significantly higher incidence rates of death and primary composite endpoints among patients without nutritional guidance. The multivariate Cox regression model incorporated all variables exhibiting statistically significant associations with long-term mortality, and the primary composite endpoints. The multivariate Cox regression model revealed nutritional guidance as a significant predictor for long-term mortality but not for primary composite endpoints. Conclusion Nutritional guidance for AMI patients may improve overall mortality. Further research is warranted to explore the physiological impacts of improved diets resulting from such guidance and their effects on enhancing prognosis.

Review of the application of drones for smart cities

AbstractIn an area of increasing digitalisation and rapid technological development, information management is becoming essential for the effective functioning of modern organisations and cities. One of the new trends is the gradual expansion and use of drones in parts of the smart cities concept. In security, drones are used to protect public order, monitor traffic in cities and municipalities, and control sub‐activities falling under the competence of police forces. In rescue work, drones allow us to efficiently and quickly manage accidental emergencies in hard‐to‐reach areas. At the same time, in the transport sector, drones have become an important component for the efficient delivery of parcels, reducing overall costs and time savings. This paper systematically overviews the importance of drones in various fields such as security, transportation, rescue operations or parcel delivery. Drones are becoming key elements for public order, crisis management and enhancing the quality of life of citizens in smart cities due to their capabilities of rapid response, monitoring hard‐to‐reach locations and autonomous data collection. Particular attention is then paid to comparing the use of drones in the Czech Republic and abroad and their benefits in the field of innovative technologies that help improve the safety and efficiency of urban services. The article also analyses the technical specifications of drones and their role in the public and private sectors, considering the legislative framework for their use. Overall, the article offers an overview of how drones contribute to integrating modern technologies into the daily functioning of smart cities and improving residents' quality of life.

Beyond Injuries: February 6th Kahramanmaras Earthquakes and Other Patients Transported by Ambulance.

This study evaluates the Emergency Medical Service system and overall emergency preparedness by analyzing ambulance-transported patients during the February 6, 2023 earthquakes, focusing on those without earthquake-related injuries (medical emergencies and traumas not caused by earthquakes). A retrospective, observational case series was conducted, involving patients aged 18 and above transported by ambulance between February 6 and March 6, 2023. Patient demographic characteristics, vital signs, diagnoses, treatments, and outcomes were recorded. Predisposing factors for ambulance transportation including post-earthquake health facility issues, housing problems, hygiene, heating, and smoke exposure were meticulously analyzed. The study included 1872 patients, with a 55.4% hospitalization rate and a 13.7% mortality rate. Cardiovascular emergencies were the primary reason for admission (28.9%). Patients from the hospital in the study's location form Group 1, whereas those from other earthquake-affected provinces constitute Group 2. Significant predisposing factors for ambulance transportation included post-earthquake health facilities (P < 0.001), housing problems (P < 0.001), hygiene (P < 0.001), heating (P = 0.001), and smoke exposure (P < 0.001). In Group 2, pneumonia (P = 0.001), soft tissue infection (P = 0.002), sepsis (P = 0.004), carbon monoxide poisoning (P < 0.001), and diabetic emergencies (P = 0.013) were statistically significantly more frequent. Analyzing post-earthquake ambulance-transported patients is vital to comprehend the demand for emergency health care and address post-disaster health care challenges.

An Artificial Intelligence approach to monitor infectious diseases: lessons learned from COVID-19

Abstract Background The World Health Organization declared the start (March 11th 2020) and the end (May 5th 2023) of COVID19 pandemic, while in Italy it has been present since February 2020. Indicators such as number of new positive cases, deaths and hospitalizations are used to monitor epidemiological trends, but they suffer from biases limiting their effectiveness. Methods We used data from the Emergency Medical Services Activities as an alternative and studied three types of contributions: COVID19, flu and baseline during three time frames: -period 1 (July 1st-Oct 11th 2016; Feb 10th-May 20th 2017) used to model the baseline, when flu contribution should be negligible. -Period 2: (Dec 15th-Feb 14th 2017), when flu in 2017 is very evident. -Period 3: (March 11th-31st 2020), when the first COVID19 wave is dominant. To extract the pure contribution from flu and COVID19, the baseline contribution was properly subtracted. Results From these data we developed a machine learning approach (MLA) that offers a simple and powerful tool to monitor COVID19 or future infectious diseases. To maximize the identification power of COVID19, we used the Toolkit for multivariate analysis package. An artificial neural network, multilayer perceptron, deep neural network and boosted decision tree methods have been trained, considering the events in period 3 as signal and period 1 as background. To avoid overtraining, the samples were divided in two: one half to train the algorithm, and the other to check the performance. The results are stable over time and able to efficiently discriminate COVID19. With 50% efficiency of accepting COVID19 patients, roughly 95% of baseline patients can be rejected. Conclusions MLA can be used to early assign a probability of COVID19 without specific test, only relying on standard triage and emergency call details. This tool could be very useful to early detect the presence of new pandemics and tag positive patients before the official healthcare reporting system. Key messages • AI model using data from Emergency Medical Services Activities can be a useful tool to early detect new pandemics and tag positive patients before the official healthcare reporting system. • Covid19 pandemic gave us the possibility to develop new digital tools to use in the analysis of epidemiological trends.

A new prehospital cardiac risk assessment index derived from vital signs by first contact emergency medical service, including prehospital oxygen saturation, for accurate prehospital triage of acute m

Abstract Background: Rapid and accurate triage is essential to improve the prognosis of patients with severe acute myocardial infarction (AMI). However, prehospital triage using vital signs, including prehospital oxygen saturation (SpO2), by first medical contact has not been evaluated. Purpose: The purpose of this study was to develop a new risk stratification index for AMI using vital signs including SpO2 for rapid and accurate prehospital triage. Methods: From January 2013 to June 2022, 3006 AMI patients who were directly transported by ambulance were enrolled from the Mie ACS registry. Based on observed risk relationships in 3,006 AMI patients, we developed and evaluated a prehospital cardiac risk assessment index (P-CRAI) using age, heart rate, and systolic blood pressure (SBP) and SpO2 to predict 30-day mortality: (heart rate×[age/10]2)/SBP＋1.1(100-SpO2). We also analyzed whether P-CRAI predicted the need for mechanical circulatory support (MCS) or ventilator use. Results: In the receiver operating characteristic (ROC) curve analysis, P-CRAI 38.1 has a sensitivity of 84.4%, specificity of 72.7%, and accuracy of 84.3% for predicting 30-day mortality, and P-CRAI was a strong predictor of 30-day mortality compared with the other indices and variables (Figure 1A). When divided into two groups with P-CRAI 38, Kaplan-Meier survival curves showed significant differences in 30-day survival between the high and low groups (83.7% vs. 98.7%, P&amp;lt;0.001, Figure 1B). P-CRAI≥38 was the strongest independent predictor of 30-day mortality with a hazard ratio of 7.64 compared to the other factors by multivariate Cox regression analysis. The spline curve of 30-day mortality by P-CRAI shows a correlation with prognosis (Figure 2A). In this study, we then used the bootstrap method to generate a calibration curve and validate P-CRAI. The results showed an excellent fit and that P-CRAI accurately estimated patient prognosis (Figure 2B). In addition, P-CRAI was a robust predictor of the very early events of death at 24 hours and MCS or ventilator use by ROC curve analysis. (c-statistic 0.835 and 0.726, respectively, P&amp;lt;0.01). Conclusion: The P-CRAI was found to be a useful tool for prehospital triage of AMI patients, accurately predicting 30-day mortality and the need for MCS.Figure 1.Figure 2.