Ambulance Transfer Research Articles

Enhanced Public Health Surveillance for the Sixth Worldwide Uchinanchu Festival Conducted by the Okinawa Prefectural Government, Japan

Objective: The Okinawa prefectural government conducted enhanced surveillance for the Sixth Worldwide Uchinanchu Festival, with participation of more than 5300 visitors from abroad, many of whom were Okinawan or of Okinawan descent, for early detection of Zika virus disease and other potential public health threat outbreaks. Method: Enhanced surveillance conducted from 12 October through 13 November involved four surveillance systems, (Nursery) School Absenteeism Surveillance system ((N)SASSy), Prescription Surveillance (PS), and Official Syndromic Surveillance (OSS), each of them operates routinely, in addition to case-based and sentinel surveillance under the Infectious Diseases Control Law as Official National Surveillance of Infectious Diseases (ONSID). This enhanced surveillance was conducted for analysis and evaluation, with intensive information sharing among concerned parties. Result: We performed the enhanced surveillance for 33 days from 12 October through 13 November. Information from enhanced surveillance was analyzed and evaluated, and eventually summarized as a daily report. There has been one rubella case at an elementary school in Okinawa City on 20 October and a measles case at an elementary school in Uruma City on 2 November. Those two cases were registered into (N)SASSy on a timely basis. The public health center investigated them quickly, and the measles case was denied later because symptoms did not satisfy with case definition. Discussion: We regard enhanced surveillance as useful to confirm events that might demand a public health response. Moreover, the related including public health centers or medical institutions confirmed the situation as valuable for the administrative structure. However, because almost all (nursery) schools or pharmacies are closed during successive holidays, outbreaks that occur on such days cannot be recognized on a timely basis. More sensitive surveillance for such days, with better preparations for ambulance transfer and at emergency departments in hospitals remains as a challenge for future work.

Bi-manual proximal external aortic compression after major abdominal-pelvic trauma and during ambulance transfer: A simulation study

BackgroundApplying manual pressure after hemorrhage is intuitive, cost-free, and logistically-simple. When direct abdominal-pelvic compression fails, clinicians can attempt indirect proximal-external-aortic-compression (PEAC), while expediting transfer and definitive rescue. This study quantifies the sustainability of simulated bi-manual PEAC both immediately on scene and during subsequent ambulance transfer. The goal is to understand when bi-manual PEAC might be clinically-useful, and when to prioritize compression-devices or endovascular-occlusion. MethodsWe developed a simulated central vessel compression model utilizing a digital scale and Malbrain intra-abdominal pressure monitor inside a cardiopulmonary resuscitation mannequin. Twenty prehospital health care professionals (HCPs) performed simulated bimanual PEAC i) while stationary and ii) inside an 80km/h ambulance on a closed driving-track. Participants compressed at “the maximal effort they could maintain for 20min”. Results were measured in mmHg applied-pressure and kilograms compressive-weight. The Borg scale of perceived-exertion was used to assess sustainability, with <16 regarded as acceptable. ResultsWhile stationary all participants could maintain 20min of compressive pressure/weight: within five-percent of their starting effort, and with a Borg-score <16. Participants applied 88–300mmHg compression pressure; (mean 180mmHg), 14–55kg compression-weight (mean 33kg), and 37–66% of their bodyweight (mean 43%). In contrast, participants could not apply consistent or sustained compression in a moving ambulance: Borg Score exceeded 16 in all cases. ConclusionsSurvival following major abdominal-pelvic hemorrhage requires expedited operative/interventional rescue. Firstly, however, we must temporize pre-hospital exsanguination both on scene and during transfer. Despite limitations, our work suggests PEAC is feasible while waiting for, but not during, ambulance-transfer. Accordingly, we propose a chain-of-survival that cautions against over-reliance on manual PEAC, while supporting pre-hospital devices, endovascular occlusion, and expeditious but safe hospital-transfer.

A Pathophysiological Model-Driven Communication for Dynamic Distributed Medical Best Practice Guidance Systems.

There is a great divide between rural and urban areas, particularly in medical emergency care. Although medical best practice guidelines exist and are in hospital handbooks, they are often lengthy and difficult to apply clinically. The challenges are exaggerated for doctors in rural areas and emergency medical technicians (EMT) during patient transport. In this paper, we propose the concept of distributed executable medical best practice guidance systems to assist adherence to best practice from the time that a patient first presents at a rural hospital, through diagnosis and ambulance transfer to arrival and treatment at a regional tertiary hospital center. We codify complex medical knowledge in the form of simplified distributed executable disease automata, from the thin automata at rural hospitals to the rich automata in the regional center hospitals. However, a main challenge is how to efficiently and safely synchronize distributed best practice models as the communication among medical facilities, devices, and professionals generates a large number of messages. This complex problem of patient diagnosis and transport from rural to center facility is also fraught with many uncertainties and changes resulting in a high degree of dynamism. A critically ill patient's medical conditions can change abruptly in addition to changes in the wireless bandwidth during the ambulance transfer. Such dynamics have yet to be addressed in existing literature on telemedicine. To address this situation, we propose a pathophysiological model-driven message exchange communication architecture that ensures the real-time and dynamic requirements of synchronization among distributed emergency best practice models are met in a reliable and safe manner. Taking the signs, symptoms, and progress of stroke patients transported across a geographically distributed healthcare network as the motivating use case, we implement our communication system and apply it to our developed best practice automata using laboratory simulations. Our proof-of-concept experiments shows there is potential for the use of our system in a wide variety of domains.

The Role of Telemedicine in Wound Care: A Review and Analysis of a Database of 5,795 Patients from a Mobile Wound-Healing Center in Languedoc-Roussillon, France.

Telemedicine in wound care is an evolving method of information technology and telecommunication designed to provide health care at a distance. Given the visual nature of wound care, telemedicine has many potential applications within this field. The authors will review the current status of wound care and telemedicine. A comprehensive literature review of articles published on telemedicine in wound care was performed. Articles were selected for their relevance to wound healing and then reviewed for their discussion on the potential applications, benefits, and limitations to telemedicine in wound care. The CICAT network data were reviewed including 5,794 patients between January 2005 and October 2015. Clinical efficacy and medicoeconomic results were analyzed. Current literature suggests a myriad of potential benefits of telemedicine in wound care, often citing increased access to professional expertise in remote and rural settings, as well as cost savings. The CICAT wound network in France analyzed wounds, which were principally pressure ulcers (44%), leg ulcers (24%), and diabetic foot ulcers (8%). Results demonstrated 75% of wounds improved or healed, a 72% reduction in the number of hospitalizations, and 56% reduction in ambulance transfers to wound healing centers. There is an increasing demand for assistance from professionals not specialized in wound healing, facing complex wounds. The goal is to enable the spread of expertise beyond major medical centers. Several limitations and barriers to the application of telemedicine in all settings are evident, including over diagnosis, dependence on a functional telecommunication system, and various legal aspects. The CICAT network in France provides an example of a how telemedicine may be of benefit in wound care, although it is important to note that in other countries, such as the United States, legal constraints and credentialing concerns may make telemedicine extremely complicated.

Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study.

Interhospital transfer is a common strategy to provide high-quality regionalized care in rural emergency departments (EDs), but several reports have highlighted problems with selection of children for transfer. The purpose of this study is to characterize the burden of potentially avoidable transfer (PAT) and to estimate the medical and family-oriented costs associated with PAT. This study was a cohort study of all children treated in Iowa EDs between 2004 and 2013. PAT was defined as a child who was transferred and then either discharged from the receiving ED or admitted for ≤ 1day, without having any separately billed procedures performed. Costs of care were estimated from 1) medical costs, 2) ambulance transfer, and 3) family costs (travel and lodging). Over 10years, 2,117,317 children were included (1% transferred to another hospital). Only 63% were transferred to a designated children's hospital, and PATs were identified in 39% of all transfers. PAT was associated with $909 in additional cost. The conditions most strongly associated with PAT were seizure (additional cost $1,138), fracture ($814), isolated traumatic brain injury without extra-axial bleeding ($1,455), respiratory infection ($556), and wheezing ($804). Few of these charges are attributable to nonmedical family costs ($21). Potentially avoidable pediatric interhospital transfer is common and is responsible for significant healthcare-related costs. Future work should focus on improving selection of children who benefit from interhospital transfer for high-yield conditions, to reduce the costly and distressing burden that PAT places on rural patients and their families.

21. Safety and feasibility of returning patients immediately back to their parent hospitals after transfer for primary percutaneous coronary intervention

Primary PCI is the preferred treatment for acute myocardial infarction but some time due to non availability of the beds in the CCU of PCI capable Hospitals a good number of patients who are eligible for primary PCI are deprived from this treatment. To provide this important treatment for the eligible patients in community hospitals without primary PCI capability to accept the patients for primary PCI and then transfer back to the parent hospital after primary PCI. The study were involved STEMI patients eligible for primary PCI from the other Hospitals in case of non availability of beds in Prince Sultan Cardiac Center Qassim were accepted in Cardiac center for Primary PCI and then were return back to their parent hospital after Primary PCI. Patients transfer back were with the agreement of the parent hospitals which were capable to take care of the Acute STEMI patients. Transfer back patients were selected in the inclusion criteria, stable patients and without complication during primary PCI. Adverse cardiovascular events occurring during Ambulance Transfer back, during parent Hospital stay and within 30 days were recorded. The study were involved STEMI patients eligible for primary PCI from other Hospitals in case of non availability of beds in Prince Sultan cardiac Center Qassim, were accepted for primary PCI in cardiac center and then return back to their parent Hospitals after Primary PCI. Patients transfer back were with the agreement of the parent hospitals which are capable to take care of Acute Myocardial Infarction patients. Patient transfer back were selected in the inclusion criteria, stable and without complications during primary PCI. Adverse cardiovascular events occurring during ambulance transfer back, during hospital stay in the parent hospital and within 30 days were recorded. Major and minor adverse events mortality, stroke, re infarction, bleeding, arrhythmia, vascular complications, length of hospital stay and re- admission were analyzed. During this time period 124 patients were transfer back to their parent hospitals immediately post primary PCI. There were no adverse events during transfer back in the ambulance. During hospital stay only one patient had hematoma in the right arm which was treated conservatively. Average hospital stay in parent hospital was 5 days. Only one patient was re transferred to our cardiac center due to AV block. During one month follow up no adverse events were happened. The return of patients transferred for primary PCI to their referral Hospitals in case of non availability of beds in PCI capable hospital is a safe and feasible strategy when it is applied in selected group of patients. More studies are needed to confirm this first experience in GULF and surrounding region.

Post-Policy Implementation Review of Rapid Fetal Fibronectin (fFN) Testing for Preterm Labour in Alberta.

In 2006, the Alberta Ministry of Health issued a policy to implement fetal fibronectin (fFN) testing as a publicly funded service for pregnant women. The goals were to reduce maternity health care utilization and unnecessary treatment, which would result in cost-savings for the health system by more accurately diagnosing false preterm labour. We conducted a post-policy implementation review to determine whether the policy implementation achieved its goals. We assessed the impacts of fFN testing on clinical decision-making for ambulance transfer, hospital admission, and length of hospital stay by comparing these variables between the tested and untested patients. This post-implementation analysis was conducted separately for inpatients and outpatients and for true and false preterm labour, using multilevel regressions with episodes or visits being nested within patients. We then assessed the impact of fFN testing on costs to the health system by using decision-tree models populated with actual data and results from the regressions. The additional information, provided by fFN testing, influenced clinical decision-making. However, physicians placed a greater significance on positive test results than on negative results, which resulted in an inadvertent increase in health care utilization. After including the costs of fFN testing, the total cost to the system increased by $4.2 million (in 2014 Canadian dollars) between 2008 and 2013, with contributions of $700 000 for false labour and $3.5 million for true preterm labour. The policy to adopt fFN testing in Alberta did not achieve the intended aims of reducing unnecessary health care utilization to achieve cost-savings for the health system. There was an inherent tendency to err on the side of caution, and physicians were influenced more by positive test results.

LO020: Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE)

Introduction: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on first responders, Emergency Medical Services (EMS) and local Emergency Departments. Literature concerning these events is minimal and mostly consists of media reports. Recognizing the lack of epidemiologic data, we sought to accurately determine the patterns and frequency of injuries and illnesses that occur at OCRs, the treatments required, and what proportion require further medical care or transfer to hospital. Methods: Data were extracted from medical charts completed for all patients presenting to the on-site medical team at OCR events across Canada from May to August, 2015. Frequency and patterns of injuries and illnesses were determined as well as treatments and disposition. There were 45 285 OCR participants in 8 events. There were 572 total patient contacts and 557 patients were included in the study. 15 patients were excluded because they were not race participants. Results: Less than 2% of participants at any event required on-site medical care. 11 patients (1.97%) required transfer to hospital by EMS. The majority of injuries were musculoskeletal in nature (74.71%). 495 patients (88.87%) returned to the event with no need for further medical care. The majority of treatments could be provided with first aid training and basic medical equipment. Conclusion: Injury and illness rates at this series of OCRs was similar to other mass gathering events. Injuries were mostly musculoskeletal in nature and required minor treatment. Having a medical team on site likely reduced local hospital and EMS volume from these events. This study raises the question of whether having a physician on site at OCRs could significantly reduce the number of patients advised to seek further medical care or the number of ambulance transfers. Prospective research is needed in order to develop plans for more appropriate resources, safety protocols, and medical staffing, thereby improving patient care and reducing the burden on local EMS and rural hospitals.

Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes.

BackgroundAlthough advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme.MethodsThe LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed.ResultsThe uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally.ConclusionsImplementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.

Evaluating the cost of iatrogenic urethral catheterisation injuries.

Technique is vital to prevent urethral trauma during urethral catheterisation (UC). Education programmes are helpful but are not compulsory and safe UC remains operator dependent. Traumatic UC is associated with increased morbidity, length of stay, resource utilisation and surgical intervention. To determine the cost of iatrogenic urethral injuries managed in a tertiary referral centre over a 6-month period. A 6-month prospective study monitored iatrogenic urethral injuries secondary to traumatic UC. Included were referrals from district hospitals and inpatient consultations relating to urethral injury caused by traumatic UC. The added cost of management was estimated. Thirteen iatrogenic urethral injuries were recorded in 6months. Management included open surgery for a ruptured bladder (n=1), flexible cystourethroscopy (n=10), suprapubic catherisation (n=4), 3-way catheterisation (n=4) and catheter re-insertion under direct vision (n=6). The cost of acute management of these injuries was approximately €50,000 including theatre costs, ambulance transfer, hospital stay, procedural and equipment costs and short-term follow-up care. Iatrogenic injuries during UC represent a significant cost burden to the healthcare system. Training programmes should be compulsory for all healthcare professionals routinely involved in catheterisation procedures.

Caregivers' Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation.

PurposeUnderstanding caregivers’ experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers’ experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement.MethodsSemi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers’ experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison.ResultsOf the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed ‘tactics’ to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism.ConclusionsInterventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers’ use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.

転落による鈍的喉頭気管完全断裂の1救命例(A successfully treated case of blunt laryngotracheal disruption due to an accidental fall)

要旨喉頭気管損傷（laryngo–tracheal injury: LTI）の，鈍的外傷における頻度は1%以下と稀であるが，損傷形態によっては致死的であり，診断と治療は時に緊急性を要する。症例は，83歳の全盲女性。車いすで移動中，施設2階の階段より転落し，階段踊り場に臥床状態で発見された。前額部裂傷を認めたが，意識は清明で発語も可能であり，全身状態は安定していた。隣接する医療機関で診察後，創処置目的に施設車で搬送された。当院到着直前に反応がなくなり，救急外来到着時には心肺停止状態であった。一連の蘇生処置の中で経口挿管を試みたが，口腔からの出血と凝血塊で視野の確保が得られず，頸部の皮下気腫も出現し，緊急の気管切開術を行った。頸部を切開し，気管の断裂を確認した為，断端部より気管挿管チューブを挿入し気道確保に成功した。心拍は再開し，集中治療室入院となった。蘇生後脳症により意識の回復は認めなかったが，創感染を合併することなく第30病日定型的気管切開術を施行し，第45病日転院となった。LTIは特異的症状や徴候がなく診断が困難なことがある。その重症型である鈍的喉頭気管断裂（laryngotracheal disruption: LTD）であっても受傷初期には，呼吸を含む全身状態が安定している事例があることを知らなければならない。

Observed Benefits to On-site Medical Services during an Annual 5-day Electronic Dance Music Event with Harm Reduction Services.

With increasing attendance and media attention, large-scale electronic dance music events (EDMEs) are a subset of mass gatherings that have a unique risk profile for attendees and promoters. Shambhala Music Festival (Canada) is a multi-day event in a rural setting with a recognized history of providing harm reduction (HR) services alongside medical care. Study/Objective This manuscript describes the medical response at a multi-day electronic music festival where on-site HR interventions and dedicated medical care are delivered as parallel public health measures. This study was a descriptive case report. Medical encounters and event-related data were documented prospectively using an established event registry database. In 2014, Shambhala Music Festival had 67,120 cumulative attendees over a 7-day period, with a peak daily attendance of 15,380 people. There were 1,393 patient encounters and the patient presentation rate (PPR) was 20.8 per one thousand. The majority of these (90.9%) were for non-urgent complaints. The ambulance transfer rate (ATR) was 0.194 per one thousand and 0.93% of patient encounters were transferred by ambulance. No patients required intubation and there were no fatalities. Harm reduction services included mobile outreach teams, distribution of educational materials, pill checking facilities, a dedicated women's space, and a "Sanctuary" area that provided non-medical peer support for overwhelmed guests. More than 10,000 encounters were recorded by mobile and booth-based preventive and educational services, and 2,786 pills were checked on-site with a seven percent discard rate. Dedicated medical and HR services represent two complementary public health strategies to minimize risk at a multi-day electronic music festival. The specific extent to which HR strategies reduce the need for medical care is not well understood. Incorporation of HR practices when planning on-site medical care has the potential to inform patient management, reduce presentation rates and acuity, and decrease utilization and cost for local, community-based health services.

Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to Emergency Departments

The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear. Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010. Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%). Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.

Development of a prehospital vital signs chart sharing system

ObjectivePhysiological parameters are crucial for the caring of trauma patients. There is a significant loss of prehospital vital signs data of patients during handover between prehospital and in-hospital teams. Effective strategies for reducing the loss remain a challenging research area. We tested whether the newly developed electronic automated prehospital vital signs chart sharing system would increase the amount of prehospital vital signs data shared with a remote trauma center prior to hospital arrival. MethodsFifty trauma patients, transferred to a level I trauma center in Japan, were studied. The primary outcome variable was the number of prehospital vital signs shared with the trauma center prior to hospital arrival. ResultsThe prehospital vital signs chart sharing system significantly increased the number of prehospital vital signs, including blood pressure, heart rate, and oxygen saturation, shared with the in-hospital team at a remote trauma center prior to patient arrival at the hospital (P < .0001). There were significant differences in prehospital vital signs during ambulance transfer between patients who had severe bleeding and non–severe bleeding within 24 hours after injury onset. ConclusionsVital signs data collected during ambulance transfer via patient monitors could be automatically converted to easily visible patient charts and effectively shared with the remote trauma center prior to hospital arrival. The prehospital vital signs chart sharing system increased the number of precise vital signs shared prior to patient arrival at the hospital, which can potentially contribute to better trauma care without increasing labor and reduce information loss during clinical handover.

Ambulance Transfer in Case of Postpartum Hemorrhage after Birth in Primary Midwifery Care in The Netherlands: A Prospective Cohort Study.

The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage (PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met. Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions. Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found (RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met. We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings.

Mass-gathering Medicine: Risks and Patient Presentations at a 2-Day Electronic Dance Music Event.

Music festivals, including electronic dance music events (EDMEs), increasingly are common in Canada and internationally. Part of a US $4.5 billion industry annually, the target audience is youth and young adults aged 15-25 years. Little is known about the impact of these events on local emergency departments (EDs). Drawing on prospective data over a 2-day EDME, the authors of this study employed mixed methods to describe the case mix and prospectively compared patient presentation rate (PPR) and ambulance transfer rate (ATR) between a first aid (FA) only and a higher level of care (HLC) model. There were 20,301 ticketed attendees. Seventy patient encounters were recorded over two days. The average age was 19.1 years. Roughly 69% were female (n=48/70). Forty-six percent of those seen in the main medical area were under the age of 19 years (n=32/70). The average length of stay in the main medical area was 70.8 minutes. The overall PPR was 4.09 per 1,000 attendees. The ATR with FA only would have been 1.98; ATR with HLC model was 0.52. The presence of an on-site HLC team had a significant positive effect on avoiding ambulance transfers. Twenty-nine ambulance transfers and ED visits were avoided by the presence of an on-site HLC medical team. Reduction of impact to the public health care system was substantial. Electronic dance music events have predictable risks and patient presentations, and appropriate on-site health care resources may reduce significantly the impact on the prehospital and emergency health resources in the host community.

G106(P) Inappropriate ambulance use in paediatrics

The use of the ambulance service and emergency department for non-urgent needs is considered a significant contributor to health system inefficiencies and a financial stressor. We performed a retrospective audit of children “inappropriately” transferred to a central London paediatric emergency department (PED) by ambulance during the period February to April of 2014. Inappropriate ambulance transfer was defined as children over the age of 2 years who did not require interventions or investigations in the PED, who had not been advised to call an ambulance by 111 or primary care services, and whose presenting complaints or diagnoses did not have any features which might be interpreted as worrying by non-medically trained caregivers. 512 patients were transferred to the PED by ambulance during the study period, of these 102 (20%) were admitted to hospital. 309 (60%) did not require any investigations or interventions (excluding observations and simple analgesia) and of these, 174 (33%) were thought to represent potentially avoidable and “inappropriate” ambulance transfers. With finite resources and pressures on both the London ambulance service and PED services, research identifying reasoning behind caregiver choices, their understanding of healthcare options and the provision of further education and health information represent worthwhile steps in tackling this issue.

On-site management of medical encounters during obstacle adventure course participation.

Obstacle adventure courses (OAC) are increasing in popularity. Although injuries are not uncommon, there is scant medical literature documenting the morbidity and mortality associated with these events. This manuscript describes a case series. Event demographics, medical coverage, and injuries/illnesses documented during four OAC events in British Columbia, Canada, are discussed - Tough Mudder™ (2012 and 2013) and Warrior Dash© (2011 and 2012). The patient presentation rate across all events ranged from 26.53 to 37.40 per 1,000 participants. Ambulance transfer rates were low (range = 0 to 5 per event day, 0% to 1.1% of patients seen). Although some illness presentations and injuries required a higher level of care, the majority of medical issues were related to musculoskeletal injuries of the lower limbs. Advanced knowledge about risks and patient presentations associated with participation in OAC may influence on-site staffing, deployment patterns, rescue equipment, and transfer to hospital planning for diagnostic imaging and definitive treatment.

Incidence of emergency department visits and complications after abortion.

To conduct a retrospective observational cohort study to estimate the abortion complication rate, including those diagnosed or treated at emergency departments (EDs). Using 2009-2010 abortion data among women covered by the fee-for-service California Medicaid program and all subsequent health care for 6 weeks after having an abortion, we analyzed reasons for ED visits and estimated the abortion-related complication rate and the adjusted relative risk. Complications were defined as receiving an abortion-related diagnosis or treatment at any source of care within 6 weeks after an abortion. Major complications were defined as requiring hospital admission, surgery, or blood transfusion. A total of 54,911 abortions among 50,273 fee-for-service Medi-Cal beneficiaries were identified. Among all abortions, 1 of 16 (6.4%, n=3,531) was followed by an ED visit within 6 weeks but only 1 of 115 (0.87%, n=478) resulted in an ED visit for an abortion-related complication. Approximately 1 of 5,491 (0.03%, n=15) involved ambulance transfers to EDs on the day of the abortion. The major complication rate was 0.23% (n=126, 1/436): 0.31% (n=35) for medication abortion, 0.16% (n=57) for first-trimester aspiration abortion, and 0.41% (n=34) for second-trimester or later procedures. The total abortion-related complication rate including all sources of care including EDs and the original abortion facility was 2.1% (n=1,156): 5.2% (n=588) for medication abortion, 1.3% (n=438) for first-trimester aspiration abortion, and 1.5% (n=130) for second-trimester or later procedures. Abortion complication rates are comparable to previously published rates even when ED visits are included and there is no loss to follow-up. II.