The impact of emergency medical services in acute heart failure

Background: Real-life data on the role of emergency medical services (EMS) in acute heart failure (AHF) are scarce. Our aim was to describe prehospital treatment of AHF and to compare patients using EMS with self-presented, non-EMS patients. Methods: Data were collected retrospectively from three university hospitals in Helsinki metropolitan area between July 1, 2012 and July 31, 2013. According to the use of EMS, patients were divided into EMS and non-EMS groups. Results: The study included 873 AHF patients. One hundred were (11.5%) EMS and 773 (88.5%) non-EMS. EMS patients more often had comorbidities. Initial heart rate (HR) and peripheral oxygen saturation (SpO(2)) differed between EMS and non-EMS patients; mean HR 89.2 (SD 22.5) vs. 83.7 (21.5)/min (p = 0.02) and SpO(2) 90.3 (8.6) vs. 92.9 (6.6)% (p= 0.01). However, on presentation to ED EMS patients' vital signs were similar to non-EMS patients'. On presentation to ED 46.0% were normotensive and 68.2% "warm and wet". Thirty-four percentage of EMS patients received prehospital medication. In-hospital mortality was 6.0% and 7.1% (p = 0.84) and length of stay (LOS) 7.7 (7.0) and 8.5 (7.9) days (p= 0.36) in EMS and non-EMS groups. Conclusion: The use of EMS and administration of prehospital medication was low. EMS patients had initially worse HR and SpO(2) than non-EMS patients. However, EMS patients' signs improved and were similar on presentation to ED. There were no differences in in-hospital mortality and LOS. This underscores the need for equal attention to any AHF patient independent of the arrival mode. (c) 2017 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

The emergency department arrival mode and its relations to ED management and 30-day mortality in acute heart failure : an ancillary analysis from the EURODEM study

Background Acute heart failure patients are often encountered in emergency departments (ED) from 11% to 57% using emergency medical services (EMS). Our aim was to evaluate the association of EMS use with acute heart failure patients' ED management and short-term outcomes. Methods This was a sub-analysis of a European EURODEM study. Data on patients presenting with dyspnoea were collected prospectively from European EDs. Patients with ED diagnosis of acute heart failure were categorized into two groups: those using EMS and those self-presenting (non- EMS). The independent association between EMS use and 30-day mortality was evaluated with logistic regression. Results Of the 500 acute heart failure patients, with information about the arrival mode to the ED, 309 (61.8%) arrived by EMS. These patients were older (median age 80 vs. 75 years, p 30/min in 17.1% patients vs. 7.5%, p = 0.005). The only difference in ED management appeared in the use of ventilatory support: 78.3% of EMS patients vs. 67.5% of non- EMS patients received supplementary oxygen (p = 0.007), and non-invasive ventilation was administered to 12.5% of EMS patients vs. 4.2% non- EMS patients (p = 0.002). EMS patients were more often hospitalized (82.4% vs. 65.9%, p < 0.001), had higher in-hospital mortality (8.7% vs. 3.1%, p = 0.014) and 30-day mortality (14.3% vs. 4.9%, p < 0.001). The use of EMS was an independent predictor of 30-day mortality (OR = 2.54, 95% CI 1.11-5.81, p = 0.027). Conclusion Most acute heart failure patients arrive at ED by EMS. These patients suffer from more severe respiratory distress and receive more often ventilatory support. EMS use is an independent predictor of 30-day mortality.Peer reviewe

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions.Peer reviewe

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions.</p

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions

The impact of emergency medical services in acute heart failure

Background: Real-life data on the role of emergency medical services (EMS) in acute heart failure (AHF) are scarce. Our aim was to describe prehospital treatment of AHF and to compare patients using EMS with self-presented, non-EMS patients. Methods: Data were collected retrospectively from three university hospitals in Helsinki metropolitan area between July 1 2012 and July 31 2013. According to the use of EMS, patients were divided into EMS and non-EMS groups. Results: The study included 873 AHF patients. One hundred were (11.5%) EMS and 773 (88.5%) non-EMS. EMS patients tended to have more comorbidities. Initial heart rate (HR) and peripheral oxygen saturation (SpO2) differed between EMS and non-EMS patients; mean HR 89.2 (SD 22.5) vs. 83.7 (21.5) /min (p=0.02) and SpO2 90.3 (8.6) vs. 92.9 (6.6)% (p=0.01). However, on presentation to ED EMS patients' vital signs were similar to non-EMS patients'. On presentation to ED 46.0% were normotensive and 68.2% "warm and wet". Thirty-four percentage of EMS patients received prehospital medication. In-hospital mortality was 6.0% and 7.1% (p=0.84) and length of stay (LOS) 7.7 (7.0) and 8.5 (7.9) days (p= 0.36) in EMS and non-EMS groups. Conclusion: The use of EMS and administration of prehospital medication was low. EMS patients had initially worse HR and SpO2 than non-EMS patients. However, EMS patients' signs improved and were similar on presentation to ED. There was no difference in in-hospital mortality and LOS. This underscores the need for equal attention to any AHF patient independent of the arrival mode

The role of pre-hospital management in acute heart failure

Acute heart failure (AHF) is one of the most common causes for hospitalization in people over 65 years of age worldwide. The prognosis of AHF has remained poor and AHF management relatively unchanged over the past decades. AHF management can be divided into three stages: pre-hospital, in-hospital, and predischarge. Initial management of AHF is provided in the pre-hospital setting by emergency medical services (EMS), and initial in-hospital management is provided in emergency departments (EDs). The number of AHF patients managed by EMS before ED arrival varies between countries. Conventional AHF management consists of supplementary oxygen, ventilatory support, diuretics, and vasodilators. These treatments can already be administered in the prehospital setting. However, to date there is no consensus about the use of prehospital AHF medications or optimal timing of AHF treatment initiation. The aim of this thesis was to study the AHF population managed by EMS and to compare them to AHF patients who self-present to the ED. In addition, we wanted to study the possibilities of treating and diagnosing AHF in the pre-hospital setting and to compare pre-hospital management possibilities at an international level. Furthermore, we aimed to illustrate the actualization of pre-hospital management of AHF. The studies included in the thesis are based on three different data sets: one Finnish, and two internationals. Study I was a comparison of AHF patients using EMS and those AHF patients self-presenting to the ED in the Helsinki metropolitan area. The pre-hospital treatments administered by EMS was analysed. The study showed that AHF patients’ use of EMS was rare, as was the administration of pre-hospital medications. AHF patients using EMS more often had cardiovascular comorbidities compared to those self-presenting at the ED. No major differences were seen in vital signs upon ED admission between the two patient groups. Furthermore, the length of hospital stays, and in-hospital mortality were similar in the two patient groups. Study II aimed to identify the readiness of different EMS levels to treat and diagnose AHF, and to examine the perceived diagnostic difficulties in EMS and dispatching centres at a multinational level. The study showed that pre-hospital management possibilities vary in different EMS units and regions. Pre-hospital AHF management protocols were common, but the contents differed between EMS regions. The perceived diagnostic difficulty in suspecting AHF – both de novo and acute decompensated heart failure – was considered easy to moderate, whereas suspicion of pulmonary embolism and sepsis were considered difficult, and stroke, ST-elevation myocardial infarction (STEMI), acute coronary syndrome, and asthma considered easy. Study III was a comparison of AHF patients using EMS and those self-presenting to the ED in different European EMS regions. Most AHF patients were shown to arrive at the ED via the EMS. These patients were older compared to those self-presenting, and they were more likely to be female. On admission to the ED, AHF patients using EMS had higher respiratory rates, higher pro-B-type natriuretic peptide levels, and suffered from confusion significantly more often. ED management differed only in ventilatory support; AHF patients using EMS received non-invasive ventilation significantly more often. Finally, patients using EMS had worse outcomes, and after adjusting for certain variables, EMS remained an independent predictor of 30-day mortality. Study IV was an evaluation of earlier studies comparing AHF patients using EMS and those self-presenting to the ED. Five studies fulfilling the inclusion criteria were found from the current literature including studies I and III of the thesis. The use of EMS varied between the studies, as did the use of pre-hospital medications. AHF patients using EMS formed a heterogenous population. These patients tended to be older, more likely to be female, and have more comorbidities compared to those AHF patients self-presenting to the ED. Furthermore, the in-hospital and 30-day mortality tended to be higher among patients using EMS compared to those AHF patients self-presenting to the ED. In conclusion, pre-hospital AHF management protocols are common and readiness for pre-hospital AHF management within EMS seems sufficient. The perceived difficulty level for EMS in diagnosing AHF is reported to be easy. However, the use of pre-hospital AHF management is scarce and varies between different EMS regions. The ED management of patients using EMS and those self-presenting does not differ greatly. Finally, AHF patients using EMS tend to be older, have more comorbidities, and have worse outcomes.Akuutti (äkillinen) sydämen vajaatoiminta (ASV) on maailmanlaajuisesti yksi yleisimmistä sairaalahoidon syistä yli 65-vuotiailla. ASV:n ennuste on pysynyt huonona ja sen hoidot lähes muuttumattomina vuosikymmenten ajan. ASV:n hoito voidaan jakaa kolmeen osaan: ennen sairaalaan saapumista annettava hoito, sairaalassa annettava hoito, ja ennen kotiutumista annettava hoito. Alkuvaiheen hoito toteutetaan sairaalan ulkopuolella ensihoidon toimesta ja sairaalassa päivystyspoliklinikoilla. ASV:aa sairastavien potilaiden ensihoidon käyttö vaihtelee maittain. Perinteinen ASV:n hoito koostuu happilisästä, hengityksen tukihoidoista, nesteenpoistolääkityksestä, ja verisuonia laajentavasta lääkityksestä. Nämä hoidot voidaan aloittaa jo ensihoidossa. Toistaiseksi ei kuitenkaan ole syntynyt yhdenmukaista näkemystä siitä, mikä sairaalan ulkopuolella annetavan hoidon merkitys on ASV:ssa ja milloin hoito tulisi aloittaa. Tämän väitöskirjatyön tavoitteena oli selvittää ja kuvata ensihoidossa hoidettavia ASV:aa sairastavia potilaita ja verrata näitä potilailta omalla kyydillä päivystykseen saapuviin ASV:aa sairastaviin potilaisiin. Lisäksi halusimme selvittää ensihoidon valmiuksia hoitaa ja diagnosoida ASV:aa sekä verrata eri ensihoitoalueiden hoitomahdollisuuksia kansainvälisellä tasolla. Halusimme myös kartoittaa ASV:n hoidon toteutumista ensihoidossa. Väitöskirjan osatutkimukset perustuvat kolmeen eri aineistoon: yhteen suomalaiseen ja kahteen kansainväliseen. Osatyössä I verrattiin pääkaupunkiseudulla ambulanssilla ja omalla kyydillä päivystykseen saapuvia ASV:aa sairastavia potilaita. Lisäksi arvioimme ensihoidossa annettua hoitoa. Tutkimus osoitti, että ensihoidon käyttö ASV:aa sairastavien potilaiden keskuudessa oli vähäistä, kuten myös ensihoidossa annettu hoito. Sydän- ja verisuonisairaudet olivat yleisempiä ensihoitoa käyttävien potilaiden keskuudessa verrattuna omalla kyydillä päivystykseen saapuviin potilaisiin. Päivystyspoliklinikalle saapuessa potilasryhmien elintoiminnoissa ei havaittu merkittäviä eroja. Myöskään sairaalahoidon kestossa ja sairaalakuolleisuudessa ei ollut merkittäviä eroavaisuuksia. Osatyössä II selvitettiin ASV:n hoitovalmiuksia eri ensihoitoyksiköissä- ja alueilla kansainvälisellä tasolla. Lisäksi keräsimme tietoa koetusta ASV:n diagnostiikan vaikeudesta ensihoidossa ja hälytyskeskuksissa. Tutkimus osoitti, että ensihoidon hoitovalmiudet vaihtelivat eri yksiköiden ja alueiden välillä. ASV:n hoitoprotokollat olivat yleisiä ensihoidossa, mutta niiden sisällöt vaihtelivat. ASV:n diagnosointi koettiin keskivaikeaksi (sekä de novon että kroonisen dekompenaation), aivohalvauksen, ST-nousu infarktiin ja akuutin sepelvaltimokohtaukseen diagnosointi puolestaan helpoksi ja astman ja verenmyrkytykseen diagnosointi vaikeaksi. Osatyö III vertasi ambulanssilla ja omalla kyydillä päivystykseen saapuvia ASV:aa sairastavia potilaita eurooppalaisessa potilasaineistoissa. Yli puolet potilaista käytti ensihoidon palveluita. Nämä potilaat olivat tyypillisesti vanhempia kuin omalla kyydillä päivystykseen saapuvat potilaat. Päivystyspoliklinikalle saapuessa ensihoidon potilaiden hengitystaajuudet sekä pro-B-tyypin natriureettisen peptidin tasot olivat korkeammat. Lisäksi sekavuus oli yleisempää ensihoidon potilaiden keskuudessa päivystykseen saapuessa. Päivystyspoliklinikalla annettu hoito erosi ainoastaan hengityksen tukihoidon osalta: ensihoidon potilaat saivat useammin non-invasiivistä hengityksen tukihoitoa verrattuna omalla kyydillä saapuviin potilaisiin. Sairaala- ja 30 päivän kuolleisuus oli yleisempää ensihoidon potilailla. Ensihoito oli itsenäinen 30 päivän kuolleisuuden riskitekijä. Osatyö IV arvioi ja vertasi aiempia tutkimuksia, joiden keskiössä oli verrata ambulanssilla ja omalla kyydillä päivystykseen saapuvia ASV:aa sairastavia potilaita. Kirjallisuushaun avulla löysimme viisi tutkimusta, mukaan lukien väitöskirjan I ja III osatyöt. Osatyö osoitti, että ensihoitoa käyttävät ASV:aa sairastavat potilaat ovat heterogeeninen ryhmä. Nämä potilaat olivat tyypillisesti vanhempia ja useammin naisia, joilla oli enemmän perussairauksia. Lisäksi sairaala- ja 30 päivän kuolleisuus olivat ensihoidon potilailla merkittävästi suurempia kuin omalla kyydillä saapuneilla valtaosassa tutkimuksia. Yhteenvetona voidaan todeta, että ASV:n hoitoprotokollat ensihoidossa ovat yleisiä sekä ensihoidon valmiudet hoitaa ASV:aa riittävät. ASV:n diagnosointi koetaan verrattain helpoksi ensihoidossa. Kuitenkin ensihoidossa annettava hoito on vähäistä ja vaihtelee eri ensihoidon alueiden välillä. Päivystyspoliklinikalla annettu ASV:n hoito ei juuri eroa ambulanssilla ja omin avuin päivystykseen saapuvien potilaiden välillä. Ensihoidon hoitamat ASV:aa sairastavat potilaat vaikuttavat olevan sairaampia ja iäkkäämpiä ja näiden potilaiden ennusteet huonompia verrattuna omalla kyydillä päivystykseen saapuviin

Pre‐hospital management protocols and perceived difficulty in diagnosing acute heart failure

International audienc