Major trauma in Northern Finland

Abstract Trauma patients are a significant patient group for emergency medical services (EMS). Not only are injuries a significant cause of death, they also have a significant long-term impact on functionality and quality of life. Previous studies have shown that the injury-related mortality rate is higher in sparsely populated areas and that the majority of patients die before the arrival of EMS. Intensive care mortality is significant, and half of seriously injured patients develop multiple organ dysfunction. Airway management is one of the most important procedures that EMS provide for a critically injured patient, but making high-quality care available in a sparsely populated area is challenging. Seriously injured patients also appear to benefit from being transported directly to a trauma centre. In recent years particular attention has been given to the level and availability of EMS. Hospitals’ readiness to provide acute surgery is also being reorganised. More information is needed about the frequency, circumstances, outcome and acute care of serious and fatal injuries so that health care resources can be allotted appropriately and requirements for prevention can be identified. The purpose of this research was to investigate the frequency and circumstances of injury-related deaths in Northern Finland and the prognosis of trauma patients encountered by the Finnish helicopter emergency services (FinnHEMS). A particular objective was to examine differences between rural and urban areas. The National Advisory Committee for Aeronautics (NACA) severity score’s ability to predict 30-day mortality was also examined. The fourth part of the study aimed to investigate the pre-hospital airway management performed by non-physicians in Northern Finland. The study material was comprised of trauma deaths that occurred in Northern Finland in 2007–2011, trauma patients encountered by FinnHEMS units in Northern Finland in 2012–2013, patients encountered by HEMS in Northern Norway in 1999–2009 and a questionnaire regarding pre-hospital airway management to non-physicians. The study concluded that the rate of trauma deaths is high in Northern Finland, and the influence of alcohol was found in nearly half of pre-hospital trauma death cases. A larger portion of pre-hospital deaths also took place in rural areas. Trauma patients encountered by FinnHEMS units in urban areas who survived to hospital, appeared to have higher 30-day mortality than patients injured in rural areas. The most probable explanation for this difference is that patients injured in urban areas survive to hospital, while trauma patients in rural areas die pre-hospital. The NACA score was found to reliably predict 30-day mortality. Due to its simplicity, the NACA score can be used to compare patient material from different HEMS bases. It was found that non-physicians seldom performed airway management. On average, the frequency of performing airway management was low, and there is a need to improve maintenance of skills.Tiivistelmä Vammapotilaat ovat merkittävä ensi- ja tehohoidon potilasryhmä. Paisi, että vammautumiset ovat merkittävä kuolinsyy, aiheuttavat ne myös merkittäviä pitkäaikaisvaikutuksia toimintakykyyn ja elämänlaatuun. Aikaisemmissa tutkimuksissa on osoitettu, että vammakuolleisuus on yleisempää harvaanasutuilla seuduilla ja valtaosa potilaista kuolee jo ennen ensihoidon saapumista paikalle. Tehohoitokuolleisuus on merkittävää ja puolet vaikeasti loukkaantuneista potilaista kärsii monielinvauriosta. Ensihoidon tärkeimpiä tehtäviä kriittisesti vammautuneilla on hengitystien varmistaminen, mutta korkeatasoisen hoidon saatavuus harvaanasutulla seudulla on haasteellista. Vaikeasti vammautuneet potilaat näyttävät myös hyötyvän kuljetuksesta suoraan lopulliseen hoitopaikkaan. Viime vuosina ensihoidon tasoon ja saatavuuteen on kiinnitetty erityistä huomiota. Lisäksi sairaaloiden päivystysvalmiuden uudelleenorganisointi on käynnissä. Lisätietoa tarvitaan vakavien ja kuolemaan johtavien vammojen esiintyvyydestä ja olosuhteista, ennusteesta sekä akuuttihoidon toteutumisesta, jotta terveydenhuollon resursseja voitaisiin kohdentaa tarkoituksenmukaisesti ja ennaltaehkäisyn tarpeet voitaisiin tunnistaa. Tämän tutkimuksen tarkoituksena oli selvittää vammakuolemien esiintyvyyttä ja olosuhteita Pohjois-Suomessa sekä suomalaisten lääkintä- ja lääkärihelikopteriyksikköjen (FinnHEMS) kohtaamien vammapotilaiden ennustetta. Erityisenä tavoitteena oli tutkia maaseutu- ja kaupunkialueiden eroja. Lisäksi tutkittiin National Advisory Committee for Aeronautics (NACA)- vaikeusasteluokittelun kykyä ennustaa 30 päivän kuolleisuutta. Neljännen osatyön tavoitteena oli tutkia ensihoitajien suorittaman hengitystien varmistamisen käytäntöä Pohjois-Suomessa. Tutkimusaineisto koostui vuosina 2007‒2011 Pohjois-Suomessa tapahtuneista vammakuolemista, FinnHEMS:in yksiköiden kohtaamista vammapotilaista Pohjois-Suomessa vuosina 2012‒2013, Pohjois-Norjan pelastushelikopterin kohtaamista potilaista vuosina 1999‒2009 sekä ensihoitajille tehdystä kyselytutkimuksesta hengitystien hallintaan liittyen. Tutkimuksessa todettiin, että kuolemaan johtaneiden vammojen esiintyvyys on korkea Pohjois-Suomessa. Lisäksi havaittiin, että lähes puoleen sairaalan ulkopuolella tapahtuneisiin vammapotilaiden kuolintapauksiin liittyi alkoholi. Maaseudulla myös suurempi osa menehtyi sairaalan ulkopuolella. FinnHEMS:in yksiköiden kaupunkialueella kohtaamilla vammapotilailla, jotka selvisivät sairaalaan, havaittiin viitettä korkeampaan 30 päivän kuolleisuuteen verrattuna maaseudulla vammautuneihin. Ero johtuu todennäköisemmin siitä, että kaupunkialueella vammautuneet ehtivät sairaalaan kun taas maaseudulla vammapotilaat kuolevat jo ennen ensihoitopalvelun saapumista. NACA-vaikeusasteluokittelun todettiin ennustavan luotettavasti 30 päivän kuolleisuutta. Yksinkertaisuutensa vuoksi se soveltuu potilasmateriaalin vertailemiseen eri tukikohtien välillä. Ensihoitajan suorittama hengitystien varmistaminen havaittiin olevan harvinaista. Keskimääräisesti suoritteita tapahtui harvoin, ja taitojen ylläpitämisessä oli parantamisen varaa

Johtajien käsitykset e-palveluiden yleistymisen vaikutuksista hoidon tarpeen arviointitoimintaan:laadullinen tutkimus erikoissairaanhoidon yhteispäivystyksestä

Tiivistelmä Sähköisten terveydenhuoltopalveluiden (e-palvelut) yleistyminen muuttaa hoidon tarpeen arviointitoi-mintaa erikoissairaanhoidon yhteispäivystyksessä. Päivystyksellisellä hoidon tarpeen arvioinnilla tarkoi-tetaan ammattilaisen suorittamaa arviota potilaan tarvitsemasta päivystyshoidosta. E-palveluiden yleis-tyessä ihmiset arvioivat yhä useammin itse omaa hoidon tarvettaan sähköisillä työkaluilla ennen päivystykseen saapumista ja ilman kontaktia terveydenhuollon ammattilaiseen. E-palveluiden käyttöön-otto on haasteellista ilman ymmärrystä teknologian, ihmisten ja toimintaympäristön välisistä suhteista. Tämän tutkimuksen tarkoituksena on kuvata johtajien käsityksiä 1) päivystyksen hoidon tarpeen arvioin-titoiminnasta, 2) e-palveluiden yleistymisen vaikutuksista hoidon tarpeen arviointitoimintaan, 3) e-palveluiden yleistymisestä aiheutuvaan toiminnan muutokseen varautumisesta ja 4) toiminnan muutok-sen onnistumiseen vaikuttavista tekijöistä. Tutkimusaineisto kerättiin syksyllä 2019 teemahaastattelulla viiden yliopistosairaanhoitopiirin yhteis-päivystyksen operatiivisesta johtamisesta vastaavilta hoitotyön johtajilta ja lääkärijohtajilta (n=10). Ai-neisto analysoitiin sisällönanalyysillä. Tulosten mukaan e-palveluiden yleistymisen vaikutukset kohdistuvat yhteispäivystyksessä ihmisiin ja toimintaan. Ammattilaisten työ, asiakkaiden toimintamallit sekä hoidon tarpeen arviointitoiminta muut-tuvat ja päivystystoiminta kehittyy. Johtajat ymmärtävät e-palveluiden yleistymisen vaikutukset so-sioteknisen lähestymistavan mukaisena, koko yhteispäivystystä koskevana toiminnan muutoksena. E-palveluiden yleistymisestä aiheutuvaan toiminnan muutokseen on varauduttu, mutta siinä on myös haasteita. Varautumista pyritään edistämään ja siihen tarvitaan tukea. Yhteispäivystyksessä toiminnan muutoksen onnistumiseen vaikuttavat esimerkiksi asenne, hyötyjen osoittaminen, toimintaympäristö ja resurssit. Edellytykset e-palveluiden käyttöönoton onnistumiselle yhteispäivystyksen hoidon tarpeen arviointitoi-minnassa ovat optimistiset. Toiminnan muutokseen on tärkeää varautua ja huomioida muutoksen onnis-tumista edesauttavat ja estävät tekijät. Ilman riittävää taloudellista varautumista toiminnan muutoksen onnistuminen voi olla vaikeaa. Tuloksia voidaan hyödyntää e-palveluiden käyttöönotossa ja kehittämi-sessä yhteispäivystyksen hoidon tarpeen arviointitoimintaa tukeviksi sekä toiminnan muutosten enna-koinnissa ja johtamisen tehostamisessa.Abstract The increasing use of e-health (electronic health) services is changing the way the assessment of need for treatment is implemented in secondary care emergency departments. The assessment of need for treatment refers to the professional’s assessment of a patient’s need for emergency care. As the use of e-health services increases, the individuals more often assess their own need for treatment with the help of electronic tools before entering the emergency department and without contacting a healthcare professional. The deployment of e-services is challenging without proper understanding of the socio-technical relationship between technology, humans, and the operating environment. The purpose of this study is to describe the leaders’ perceptions on 1) the assessment of need for treatment in the emergency department; 2) the impact of the increasing use of e-health services on the assessment; 3) the preparation for the operational changes due to increased use of e-health services; and 4) the factors influencing the success of the change. The research material was collected during autumn 2019, with thematic interviews of nursing managers and medical directors responsible for the operational management of the secondary care emergency departments in five university hospital districts (n=10). The material was analyzed using qualitative con-tent analysis. The results show that the biggest impact of the increasing use of e-health services are on humans and functions. The work of professionals, the activities of customers, and the assessment of the need for treatment are changing, and the emergency care service is developing. Leaders agree with the socio-technical approach and see the impact of the increasing use of e-services as an operational change that has an effect on the entire emergency department. Preparations for this operational change and the subsequent need for better preparedness have been made, but there are challenges. Preparedness is being promoted and needs to be supported. Successful implementation of operational change is subject to many influencing factors such as attitude, demonstration of benefits, operational environment, and resources. The preconditions for successful deployment of e-services in the assessment of the need for treatment in the secondary care emergency department look optimistic. It is important to prepare for operational change and to consider all factors promoting or hindering its success. Without adequate financial pre-paredness, the success of operational change can be challenging. The insights of this study can be uti-lized in the implementation and development of e-services to support the assessment of the need for treatment, anticipating changes in operations and improving management efficiency

How to improve communication using technology in emergency medical services?:a case study from Finland

Abstract The field of emergency medical services (EMS) is a challenging environment for ensuring fluent information exchange between stakeholders because several different kinds of organizations are involved in EMS missions. Solutions for information and communication technology can vary significantly depending on the organization. This study aims to identify current communication bottlenecks between EMS professionals, understand the technological challenges behind them, and describe technologies that can improve EMS communication in the future. Information for the study about current EMS processes, technologies, and technology needs was collected from EMS professionals during three workshops, five personal interviews, and one email questionnaire. All surveyed health care professionals were working in the county of Northern Ostrobothnia. Information about proposed technologies for EMS was obtained from literature and interviews with five technology companies. The principal problem in EMS communication is scattered health data. This leads to a lack of common situational awareness for professionals and incomplete medical histories for patients. The reasons behind those problems are different information systems which do not communicate with each other and the lack of a common electronic patient care record (ePCR) for use by stakeholders. Personal health measurements, sensors, telemedicine, and artificial intelligence will create opportunities for further improving the flow of communication in EMS, provided those tools can be integrated into decision-making systems

Prehospital and hospital delays for stroke patients treated with thrombolysis:a retrospective study from mixed rural-urban area in Northern Finland

Abstract Background: Thrombolysis improves stroke outcome, but efficacy of the treatment is limited by time. Therefore, recognition of stroke symptoms by dispatch centres and by emergency medical services (EMS) is crucial, as is minimization of pre-hospital delays. We investigated the pre-hospital delays in patients with stroke treated with thrombolysis and compared the delays between rural and urban patients. Methods: Patients that had received thrombolysis at Oulu University Hospital (OUH) between 1 January 2013 and 31 December 2015 were identified. Patients were divided into urban and rural based on the site of the EMS mission. Pre-hospital charts and medical records were reviewed. Onset-to-dispatch, dispatch-to-arrival of EMS, on-scene, transport and door-to-needle times were studied. Results: Three hundred one stroke patients were treated with thrombolysis at OUH, and 232 of them were included in the study. Positive Face Arm Speech Test (FAST) findings, priority dispatch code and transport code were associated with shorter transport delays. The priority dispatch was not used in 12.5% of stroke patients treated with thrombolysis. The rural patients had a four minutes longer dispatch-to-arrival delay and 50 (34, 74) minutes longer transport time. The door-to-needle time was 8 (5, 14) minutes shorter in rural patients than in urban patients. Conclusions: Positive FAST findings and the use of priority dispatch code and priority transport code were associated with shorter transport delays. There is room for improvement in door-to-needle time and in stroke recognition by the dispatch centre and EMS providers. For the rural population, helicopter transportation could reduce the long pre-hospital time

Accuracy of dispatch and prehospital triage performance in poisonings:a retrospective study from northern Finland

Abstract Background: Increasing numbers of dispatches place a burden on EMS; this study sought to assess the prehospital evaluation of poisoned patients transported to hospital. The primary aim of this study was to measure dispatch centre and EMS provider performance as well as factors contributing to the recognition of poisoning among prehospital patients. The secondary aim was to compare triage performance between dispatch centres and EMS providers. Methods: A retrospective single-centre study in Northern Finland was conducted. Patients suspected as poisonings by dispatch centres as well as other EMS-transported patients who received a diagnosis of poisoning in hospital between June 1, 2015 and June 1, 2017, were included. Results: There were a total of 1668 poisoning-related EMS missions. Dispatch centres suspected poisonings with sensitivity of 79.9% (95% CI 76.7–82.9) and specificity of 98.9% (95% CI 98.9–99.0) when all EMS missions were taken into account. In a logistic regression model, decreased state of consciousness as dispatch code (OR 7.18, 95% CI 1.90–27.05) and intravenous fluid resuscitation (OR 6.58, 95% CI 1.34–32.37) were associated with EMS transport providers not recognizing poisoning. Overtriage rate appeared significantly higher (33.6%, 95% CI 28.6–39.2) for dispatch when compared with transport (17.8%, 95% CI 13.9–22.6). Conclusion: Dispatch centres seem to suspect poisonings fairly accurately. Poisonings unrecognized by EMS providers may be linked with intravenous fluid resuscitation and decreased patient consciousness. Overtriage appears to resolve somewhat from dispatch to transport. There were no fatal poisonings in this study population

Early impact of the COVID-19 pandemic and social restrictions on ambulance mission

Abstract Background:The SARS-CoV-2 coronavirus disease 2019 (COVID-19) has had a major impact on health care services globally. Recent studies report that emergency departments have experienced a significant decline in the number of admitted patients in the early phase of the pandemic. To date, research regarding the influence of COVID-19 on emergency medical services (EMS) is limited. This study investigates a change in the number and characteristics of EMS missions in the early phase of the pandemic. Methods:All EMS missions in the Northern Ostrobothnia region, Finland (population 295 500) between 1 March to 30 June 2020 were screened and analyzed as the study group. A control group was composed from the EMS calls between the corresponding months in the years 2016–19. Results:A total of 74 576 EMS missions were screened for the study. Within the first 2 months after the first COVID-19 cases in the study area, the decline in the number of EMS missions was 5.7–13% compared with the control group average. EMS time intervals (emergency call to dispatch, dispatch, en-route, on-scene and hospital handover) prolonged in the COVID-19 period. Dispatches concerning mental health problems increased most in the study period (+1.2%, P < 0.001). Only eleven confirmed COVID-19 infections were encountered by EMS in the study period. Conclusions: Our findings suggest that the present COVID-19 pandemic and social restrictions lead to changes in the EMS usage. These preliminary findings emphasize the importance of developing new strategies and protocols in response to the oncoming pandemic waves

Fatal poisonings in Northern Finland:causes, incidence, and rural-urban differences

Abstract Background: In this study we evaluate differences between rural and urban areas in the causes and incidence of fatal poisonings. Methods: Data from all fatal poisonings that occurred in Northern Finland from 2007 to 2011 were retrieved from Cause of Death Registry death certificates provided by Statistics Finland. The demographics and causes of fatalities were compared between rural and urban areas. Incidences were calculated based on the population data. Results: There were a total of 684 fatal poisonings during the study period and 57.9% (n = 396) occurred in the urban population. Ethanol was the most common primary poisoning agent in cases of fatal poisoning, accounting for 47.5% of cases in urban areas and 68.1% in rural areas (P < 0.001). Fatal poisonings caused by psychoactive pharmaceutical products and opioids were more common in urban areas (28.3% compared to 18.0%, P < 0.001). The crude incidence of fatal poisonings in the study area was 18.8 (17.4–20.2) per 100,000 inhabitants per year and there was no difference in incidence between urban and rural areas. In the youngest age group (15 to 24 years), the incidence of fatal poisonings observed in urban areas was two times higher than that in rural areas. Discussion: Higher rate of fatal ethanol poisonings in rural areas could be linked to higher alcohol consumption in rural areas and also differences in drinking behaviour. Higher incidence of poisoning suicides in urban areas could be due to availability of different toxic agents as a suicidal method. Preventive measures could be key in reducing the number of fatal poisonings in both areas, as most of the fatal poisonings still occur outside hospital. Conclusion: There was a higher rate of fatal ethanol poisoning in rural areas and higher rate of fatal poisoning related to psychoactive pharmaceutical products and opioids in urban areas. There were twice as many fatal poisonings in the youngest age group (15–24 years) in urban areas compared to rural areas, and suicide was more common in urban areas

Do pre-hospital poisoning deaths differ from in-hospital deaths?:a retrospective analysis

Abstract Background: Most fatal poisonings occur outside the hospital and the victims found dead. The purpose of this study was to determine the general pattern and patient demographics of fatal poisonings in Northern Finland. In particular, we wanted to analyze differences between pre-hospital and in-hospital deaths. Methods: All fatal poisonings that occurred in Northern Finland in 2007–2011 were retrieved from the Cause of Death Registry provided by Statistics Finland. We noted the patient demographics, causal agents, and other characteristics of the poisoning events. Results: A total of 689 fatal poisonings occurred during the study period, of which only 42 (6.1%) reached the hospital alive. Those who died pre-hospital were significantly younger (50 vs. 56 years, p = 0.04) and more likely to be male (77% vs. 57%, p = 0.003). Cardiopulmonary resuscitation was attempted less often in pre-hospital cases (9.9% vs. 47.6%, p < 0.001). Ethanol was more frequently the main toxic agent in pre-hospital deaths (58.4% vs. 26.2%, p < 0.001), and multiple ingestions were more common (52.2% vs. 35.7%, p < 0.001) in pre-hospital deaths. Discussion: Most of the pre-hospital fatal poisoning victims are found dead and the majority of in-hospital victims are admitted to hospital in an already serious condition. According to results of this and former studies, prevention seems to be the most important factor in reducing deaths due to poisoning. Conclusions: The majority of poisoning-related deaths occur pre-hospital and are related to alcohol intoxication and multiple ingestions

Telephone triage performed by nurses reduces non‐urgent ambulance missions:a prospective observational pilot study in Finland

Abstract Background: The increased workload in emergency medical services (EMS) is a global phenomenon in welfare states. It has been suggested that telephone triage by nurses may reduce the increasing use of EMS services, by directing patient flow to appropriate care. This study aimed to investigate whether, after an emergency medical communication centre (EMCC) provider assessed risk, a telephone nurse could assess the patient’s needs and guide patients to social and health care services in non‐urgent cases. Methods: This prospective observational study was performed in the Kainuu Hospital District in northern Finland from March to April 2018. All EMS requests classified as non‐urgent by the EMCC were transferred to a telephone triage nurse. Subsequent patient guidance was recorded. The International Classifications of Primary Care categories were recorded. Results: We studied phone calls of 700 patients with non‐urgent needs. Of these, the nurse transferred 63.7% to EMS and 17.3% were guided to other social and health care services. Nineteen per cent of the calls were handled over the phone by the nurse, who provided health advice and instructions. The most common needs for care were general and unspecified symptoms, musculoskeletal symptoms, mental health problems and substance abuse. Conclusion: By providing telephone counseling, care instructions and patient guidance to other social and health services than EMS, the telephone triage reduced non‐urgent EMS missions by one third. The results imply that telephone triage could be a viable model for managing non‐urgent missions. Patient safety issues should be monitored when developing new service concepts