A practical method for predicting frequent use of emergency department care using routinely available electronic registration data.

Accurately predicting future frequent emergency department (ED) utilization can support a case management approach and ultimately reduce health care costs. This study assesses the feasibility of using routinely collected registration data to predict future frequent ED visits

The Impact of Emergency Medical Service Physicians on Patient Outcomes : with a focus on prehospital traumatic brain injury

Ensihoidolla tarkoitetaan äkillisesti sairastuneen tai loukkaantuneen potilaan kiireellistä hoitoa ja kuljettamista jatkohoitoon. Suomen ensimmäinen lääkäriyksikkö perustettiin Helsingissä vuonna 1972. 1980-luvulla lääkäriyksikkötoiminta laajeni ja ensimmäinen lääkärihelikopteri aloitti toimintansa vuonna 1992. Ensihoitoa sekä ensihoitojärjestelmän että sen osien toimintaa ja toiminnan tehokkuutta on haastavaa tutkia. Tämän väitöskirjan tavoitteena oli arvioida ensihoitolääkärin vaikutusta potilaan ennusteeseen ja erityisenä tutkimuskohteena olivat aivovammapotilaat. Väitöskirja koostuu neljästä osatyöstä, joista ensimmäinen käsitteli äkillisesti sairastuneen tai loukkaantuneen potilaan hoitoa ja ennustetta viiden vuoden (2007- 2011) ajanjaksolla (I). Tutkimuskohteena oli ensihoitolääkärin hoitamien 483:n äkillisesti sairastuneen tai loukkaantuneen potilaan pitkäaikaisennuste. Vuoden kestäneen seurantavaiheen aikana potilaiden kuolleisuus oli 35 % ja hyvään neurologiseen lopputulokseen (määriteltynä paluuna itsenäiseen elämään) toipui 55 % potilaista. Eloonjäänneistä 85 % ja valtaosa nuorista ikäryhmistä (määriteltynä alle 60 vuotiaat) toipuivat hyvin. Kolme muuta osatyötä keskittyvät aivovammapotilaisiin ja ensihoitolääkärin vaikutuksen arvioimiseksi vakavien aivovammapotilaiden hoito ja toipuminen selvitettiin kahdesta tutkimuskohteesta (Helsingin ja Uudenmaan sekä Pirkanmaan alueelta) vuosilta 2005-2010 ja 2012-2015 kolmessa eri asetelmassa: ensihoitojärjestelmä ilman ja ensihoitolääkärin kanssa (II), ennen ja jälkeen-asetelma (III) sekä kohteessa olleen ensihoitolääkärin vaikutus (IV). Vuoden 2011 tietoja ei sisällytetty mukaan tutkimuksiin johtuen Pirkanmaan lääkärihelikopterin aloituksesta vuonna 2011 ja sen aiheuttamasta vaikutuksesta paikalliseen ensihoitojärjestelmään. Kahden alueen erityyppisesti järjestettyjen ensihoitojärjestelmien vertailussa todettiin ensihoitolääkärin vähentävän vakavien aivovammapotilaiden kuolleisuutta ja monimuuttuja-analyysissä ensihoitojärjestelmä ilman ensihoitolääkäriä todettiin kuolleisuuteen vaikuttavana tekijänä, kun potilaat ikävakioitiin (II). Tulosten perusteella myös ensihoitolääkärin hoitamien potilaiden neurologinen toipuminen on parempaa ja vakioimattomassa analyysissä ensihoitolääkäri, nuorempi ikä ja turvattu hengitystie ovat yhteydessä hyvään neurologiseen toipumiseen (III). Edellisiin tuloksiin perustuen koottua tietoa vakavien aivovammapotilaiden hoidosta jatkoanalysoitiin binäärisellä logistisella regressioanalyysillä (IV). Kuolleisuus 651 potilaan osalta ja neurologinen lopputulos 634 potilaan osalta analysoitiin. Vakioimattomassa analyysissa korkeampi ikä, matalampi GCS kohdattaessa ja ensihoito ilman ensihoitolääkäriä olivat muuttujia, jotka olivat yhteydessä korkeampaan kuolleisuuteen. Monimuuttuja-analyysissa nämä muuttujat sekä matala verenpaine säilyivät kuoleman riskitekijöinä. Hyvään neurologiseen toipumiseen yhteydessä olevat tekijät olivat nuorempi ikä, korkeampi GCS kohdattaessa ja ensihoitolääkärin antama hoito. Vastaava tulos havaittiin myös monimuuttuja-analyysissa, jossa myös matala verenpaine oli yhteydessä huonoon ennusteeseen. Väitöskirjan johtopäätöksinä voidaan todeta, että ensihoitolääkärin hoitamien äkillisesti sairastuneiden tai loukkaantuneiden potilaiden pitkäaikaisennuste on hyvä ja ensihoitolääkärin mukanaolo on yhteydessä aivovammapotilaan vähäisempään kuolleisuuteen ja parempaan ennusteeseen.Out-of-hospital emergency medical services (EMS), also known as prehospital EMS, typically refer to the delivery of medical care at the site of the adverse medical event. The first physician-staffed EMS-unit in Finland was introduced in the year 1972 in Helsinki. During the 1980’s other physician-staffed EMS units were founded and the first physician-staffed helicopter emergency medical service (HEMS) unit was introduced in 1992. As EMS systems and prehospital care are difficult to evaluate, the true efficacy and value of such systems are difficult to determine. This thesis evaluates the impact of physician-staffed EMS on patient outcome with a focus on prehospital traumatic brain injury (TBI). The thesis is based on four original publications. The first studied the long-term outcome of 483 critically ill or severely injured patients treated on-scene by EMS physicians over a five-year (2007-2011) period (I). The patients’ one-year mortality was 35 % and good neurological recovery (defined as the ability to live an independent life) was found in 55 % of the patients. After the incident, 85 % of the long-term survivors as well as most of the patients in the younger age groups (below 60 years of age) recovered well neurologically. To evaluate the role of EMS physician involvement, the prehospital treatment and outcomes of patients with severe TBI from 2005-2010 and 2012–2015 in two study locations (the Helsinki and Uusimaa region and in Pirkanmaa region in Finland) were determined in three different scenarios: paramedic- versus physician- staffed EMS (II), before and after the introduction of physicians into paramedic EMS (III) and pooled data considering the effect of an on-scene physician on the TBI patients’ outcome (IV). The data covering 2011 were excluded as a physician- staffed HEMS was implemented in the Pirkanmaa Hospital District that year and had a significant impact on the local EMS. When two regions with differently structured EMS systems were compared, the mortality was lower with EMS physician present on-scene, and the EMS system without EMS physician remained as a risk factor for mortality in the multivariable analysis after the patients were adjusted by age (II). The results also show better neurological outcomes in patients treated by EMS physicians, and in a univariate analysis of EMS physicians, a lower age and secured airway were associated with good neurological outcomes (III). Based on these findings, the gathered TBI patient data were further analysed with a binary logistic regression analysis (IV) as the mortality data for 651 patients and neurological outcome data for 634 patients were available for analysis. In the univariate analysis, increasing age, lower on-scene Glasgow Coma Scale (GCS) and prehospital treatment without the presence of EMS physicians were factors associated with higher mortality. In a multivariable analysis, these variables, with the addition of hypotension, remained significant factors for mortality. Factors associated with good neurological outcomes in the univariate analysis were lower age, higher on-scene GCS and the presence of an on-scene EMS physician. In the multivariable analysis, all these factors remained significant for good outcomes, while hypotension was associated with poor outcomes. Based on these studies, the following conclusions can be drawn: The overall prehospital one-year mortality of critically ill or severely injured patients treated on- scene by EMS physicians can be considered low, and prehospital on-scene EMS physicians treating severe TBI patients is associated with lower mortality and better neurological outcomes

Prediction and monitoring of in-hospital cardiac arrest

Background: In-hospital cardiac arrest (IHCA) is a global health concern of major importance, associated with a poor prognosis. IHCA is frequently heralded by a deterioration of vital signs, and many cases are considered preventable. Hence, prevention has become a key strategy. The overall aim of this thesis was to study the prevention of IHCA, by means of prediction and monitoring, with a view to improve patient safety. Methods: Study I and III are observational cohort studies, based on the Swedish Registry of Cardiopulmonary Resuscitation (SRCR). In study III, we also collected additional data from medical records in a small, hypothesis-generating group of patients. Study II and IV are prospective, observational cohort studies based on patients reviewed by Rapid Response Teams (RRTs) in 26 and 24 Swedish hospitals, respectively. In study IV, additional data on long-term survival was obtained from either medical records or the personal information directory, containing population registration data. Specific study aims and results: In study I, we investigated how 30-day survival after IHCA was influenced by ECG monitoring at the time of collapse, as well as clinical factors that determined whether patients were ECG monitored adjacent to cardiac arrest (CA). In all, 24,790 patients were enrolled in the SRCR between 2008 and 2017. After applying the exclusion criteria, 19,225 patients remained, of which 52% were monitored at the time of collapse. In all, 30-day survival was 30%. ECG monitoring at the time of CA was associated with a Hazard Ratio of 0.62 (95% Confidence Interval 0.60-0.64) for 30-day mortality. The strongest predictor of ECG monitoring adjacent to IHCA was location in hospital. There were tangible variations in the frequency of patients who were ECG monitored at the time of collapse between Swedish regions and across hospitals. In study II, we investigated the predictive power of NEWS 2, as compared to NEWS, in identifying patients at risk of Serious Adverse Events (SAEs) within 24 hours of an RRT-review. In all, 1,065 patients, reviewed by RRTs in general wards during the study period between October 2019 and January 2020, were included. After applying the exclusion criteria, 898 patients were eligible for complete case analyses. In all, 37% of the patients were admitted to the Intensive care unit (ICU) within 24 hours of RRT-review. In-hospital mortality and IHCA were uncommon (6% and 1% respectively). The Area Under the Receiver Operating Characteristic (AUROC) for both NEWS and NEWS 2 was 0.62 for the composite outcome, and 0.69/0.67 for mortality. Regarding the outcome unanticipated ICU admission, the AUROC was 0.59 and 0.60, respectively, while the AUROC for IHCA was 0.51 (NEWS) and 0.47 (NEWS 2), respectively. In study III, we investigated 30-day survival and ROSC in patients suffering from IHCA, who were reviewed by an RRT within 24 hours prior to the CA, as compared to those without such review. Furthermore, we studied patient centred factors prior to RRT activation, the timeliness of the RRT-review as well as the reason for the RRT-review. We also investigated the association between RRT interventions and outcome. During the study period between 2014 and 2021, 19,973 patents were enrolled in the SRCR. After applying the exclusion criteria, 12,915 patients remained. Among these IHCA patients, there was an RRT/ICU contact within 24 hours prior to the CA in 2,058 cases (19%). The adjusted 30-day survival was lower among patients reviewed by an RRT prior to IHCA (25% vs. 33%, p <0.001). Regarding ROSC, we did not observe any difference between the groups. The propensity score based Odds Ratio for 30- day survival was 0.92 for patients who were reviewed by an RRT (95% CI 0.90 to 0.94, p <0.001), as compared to those who were not RRT- reviewed within 24 hours prior to IHCA. A respiratory cause of CA was more common among IHCA patients who were reviewed by an RRT. In the small, explorative subgroup (n=82), 24% of the RRT activations were delayed, and respiratory distress was the most common RRT trigger. We observed a significantly lower 30-day survival among patients triaged to remain at ward compared to those triaged to a higher level of care (2% vs. 20%, p 0.016). In study IV, we explored the impact of age on the ability of NEWS 2 to predict IHCA, unanticipated ICU-admission, or death, and the composite of these three SAEs, within 24 hours of review by an RRT. Furthermore, we aimed to investigate 30-, 90- and 180-day mortality, and the discriminative ability of NEWS 2 in the prediction of long-term mortality among RRT-reviewed patients. In this multi-centre study based on data prospectively collected by RRTs, the NEWS 2 scores of all patients were retrospectively, digitally calculated by the study team. Age was analysed as a continuous variable, in a spline regression model, and categorized into five different models, subsequently explored as additive variables to NEWS 2. The discriminative ability of NEWS 2 in predicting 30-day mortality improved by adding age as a covariate (from AUROC 0.66, 0.62-0.70 to 0.70, 0.65-0.73, p=0.01). There were differences across age groups, with the best predictive performance identified among patients aged 45-54 years. The 30-, 90-and 180-day mortality was 31%, 33%, and 36%, respectively. Conclusion: ECG monitoring at the time of IHCA was associated with a 38% reduction of adjusted mortality. Despite this finding, only one in two IHCA patients were ECG monitored. The most important factor influencing ECG monitoring was which type of hospital ward the patient was admitted to. The tangible variations in the frequency of ECG monitoring adjacent to IHCA observed between Swedish regions and across hospitals need to be investigated in future studies. Guidelines for the monitoring of patients at risk of CA could contribute to an improved outcome. The prognostic accuracy of NEWS 2 in predicting mortality within 24 hours of an RRT-review was acceptable, whereas the discriminative ability in prediction of unanticipated ICU-admission and the composite outcome was rather weak. Regarding the prediction of IHCA, NEWS 2 performed poorly. There was no difference in the prognostic accuracy between NEWS and NEWS 2; however, the discriminative ability was not considered sufficient to serve as a triage tool in RRT-reviewed patients. In-hospital cardiac arrest among patients who were reviewed by an RRT prior to CA was associated with a poorer prognosis, and a more frequent respiratory aetiology of the CA. In the explorative sub-group of patients, RRT activation was frequently delayed, the most common trigger for RRT-review was respiratory distress, and escalation of the level of care was associated with an improved prognosis. Early identification of patients with abnormal respiratory vital signs, followed by a timely response, may have a potential to improve the prognosis for patients reviewed by an RRT and prevent IHCA. Adding age as a covariate improved the discriminative ability of NEWS 2 in the prediction of 30-day mortality among RRT-reviewed patients. The ability differed across age categories. Overall, the long-term prognosis of RRT-reviewed patients was poor. Our results indicate that age merits further validation as a covariate to improve the performance of NEWS 2

DEEDS

Data Elements for Emergency Department Systems, Release 1.0 (DEEDS) is the result of contributions by participants in the National Workshop on Emergency Department Data, held January 23-25, 1996, in Atlanta, Georgia, subsequent review and comment by individuals who read Release 1.0 in draft form, and finalization by a multidisciplinary writing committee. DEEDS is a set of recommendations published by the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention.Introduction -- Section 1. Patient identification data -- Section 2. Facility and practitioner identification data -- Section 3. ED payment data -- Section 4. ED arrival and first assessment data -- Section 5. ED history and physical examination data -- Section 6. ED procedure and result data -- Section 7. ED medication data -- Section 8. ED disposition and diagnosis data -- Technical Notes -- References -- Appendix: DEEDS data elements grouped into HL7 segments for message transmission"Release 1.0."Includes bibliographical references (p. 245-247).National Center for Injury Prevention and Control. Data elements for emergency department systems, release 1.0. Atlanta, GA: Centers for Disease Control and Prevention, 1997