An observational study of patient characteristics associated with the mode of admission to acute stroke services in North East, England

Objective Effective provision of urgent stroke care relies upon admission to hospital by emergency ambulance and may involve pre-hospital redirection. The proportion and characteristics of patients who do not arrive by emergency ambulance and their impact on service efficiency is unclear. To assist in the planning of regional stroke services we examined the volume, characteristics and prognosis of patients according to the mode of presentation to local services. Study design and setting A prospective regional database of consecutive acute stroke admissions was conducted in North East, England between 01/09/10-30/09/11. Case ascertainment and transport mode were checked against hospital coding and ambulance dispatch databases. Results Twelve acute stroke units contributed data for a mean of 10.7 months. 2792/3131 (89%) patients received a diagnosis of stroke within 24 hours of admission: 2002 arrivals by emergency ambulance; 538 by private transport or non-emergency ambulance; 252 unknown mode. Emergency ambulance patients were older (76 vs 69 years), more likely to be from institutional care (10% vs 1%) and experiencing total anterior circulation symptoms (27% vs 6%). Thrombolysis treatment was commoner following emergency admission (11% vs 4%). However patients attending without emergency ambulance had lower inpatient mortality (2% vs 18%), a lower rate of institutionalisation (1% vs 6%) and less need for daily carers (7% vs 16%). 149/155 (96%) of highly dependent patients were admitted by emergency ambulance, but none received thrombolysis. Conclusion Presentations of new stroke without emergency ambulance involvement were not unusual but were associated with a better outcome due to younger age, milder neurological impairment and lower levels of pre-stroke dependency. Most patients with a high level of pre-stroke dependency arrived by emergency ambulance but did not receive thrombolysis. It is important to be aware of easily identifiable demographic groups that differ in their potential to gain from different service configurations

The STRANDS project: long-term autonomy in everyday environments

Thanks to the efforts of the robotics and autonomous systems community, the myriad applications and capacities of robots are ever increasing. There is increasing demand from end users for autonomous service robots that can operate in real environments for extended periods. In the Spatiotemporal Representations and Activities for Cognitive Control in Long-Term Scenarios (STRANDS) project (http://strandsproject.eu), we are tackling this demand head-on by integrating state-of-the-art artificial intelligence and robotics research into mobile service robots and deploying these systems for long-term installations in security and care environments. Our robots have been operational for a combined duration of 104 days over four deployments, autonomously performing end-user-defined tasks and traversing 116 km in the process. In this article, we describe the approach we used to enable long-term autonomous operation in everyday environments and how our robots are able to use their long run times to improve their own performance

EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

AbstractIntroductionThe aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.MethodsThis was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries.ResultsData on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge.ConclusionThe results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe.EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events

Introduction of the I-gel supraglottic airway device for prehospital airway management in a UK ambulance service

Aim To clinically review the use of basic and advanced airway management techniques within the North East Ambulance Service National Health Service Foundation Trust (NEAS) for cardiac arrests following the introduction of the i-gel. Method Two retrospective clinical audits were carried out over a monthly period (May 2011 and January 2012) using electronic and paper NEAS patient records. Results This audit confirmed that a range of basic and/or advanced airway management techniques are being successfully used to manage the airways of cardiac arrest patients. I-gel is emerging as a popular choice for maintaining and securing the airway during prehospital cardiopulmonary resuscitation. Success rates for i-gel insertion are higher (94%, 92%) than endotracheal (ET) tube insertion (90%, 86%). Documentation of the airway management method was poor in 11% of the records. The Quality Improvement Officers addressed this by providing individual feedback. Conclusions I-gel shows a higher success rate in cardiac arrest patients compared to the ET tube. Staff who chose to use methods other than i-gel indicated this was a confidence issue when using new equipment. The re-audit indicated an upward trend in the popularity of i-gel; insertion is faster with a higher success rate, which allows the crew to progress with the other resuscitation measures more promptly. Airway soiling and aspiration beforehand have been reasons staff resort to ET intubation. It is anticipated by the authors that i-gel will emerge as the first choice of airway management device in prehospital cardiac arrests. https://emj.bmj.com/content/emermed/31/6/505.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2012-20212

A comparison of actual versus predicted emergency ambulance journey times using generic Geographic Information System software

Study objective The planning of regional emergency medical services is aided by accurate prediction of urgent ambulance journey times, but it is unclear whether it is appropriate to use Geographical Information System (GIS) products designed for general traffic. We examined the accuracy of a commercially available generic GIS package when predicting emergency ambulance journey times under different population and temporal conditions. Methods We undertook a retrospective cohort study of emergency ambulance admissions to three emergency departments (ED) serving differing population distributions in northeast England (urban/suburban/rural). The transport time from scene to ED for all the highest priority dispatches between 1 October 2009 and 30 September 2010 was compared with predictions made by generic GIS software. Results For 10 156 emergency ambulance journeys, the mean prediction discrepancy between actual and predicted journey times across all EDs was an underprediction of 1.6 min (SD 4.9). Underprediction was statistically significant at all population densities, but unlikely to be of clinical significance. Ambulances in urban areas were able to exceed general traffic speed, whereas, the opposite effect was seen in suburban and rural road networks. There were minor effects due to travel outside the busiest traffic times (mean overprediction 0.8 min) and during winter months (mean underprediction 0.4 min). Conclusions It is reasonable to estimate emergency ambulance journey times using generic GIS software, but in order to avoid insufficient regional ambulance provision it would be necessary to make small adjustments because of the tendency towards systematic underprediction. https://emj.bmj.com/content/emermed/31/9/758.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2012-20224

Incidence of peri-opiate nausea and vomiting in the pre-hospital setting: an intermediate analysis

Background Intravenous morphine is the preferred drug for the treatment of moderate to severe pain by paramedics. Nausea and vomiting are believed to be frequent side-effects and routine co-administration of metoclopramide is common. In the absence of pre-hospital data to support this practice, we sought to determine the incidence of peri-opiate nausea and vomiting in an ambulance service which does not administer anti-emetics. Methods This prospective observational study is currently assessing the incidence of emesis in 400 patients attended by the North East Ambulance Service, aged above 17 years and receiving morphine, using a patient-scored Nausea and Vomiting Score (NVS: 0=no nausea or vomiting, 1=slight nausea, 2=moderate nausea, 3=severe nausea, 4=vomited once, 5=vomited twice or more). Results To date 145 patients have been recruited. Median NVS before morphine was 0 (range 0 to 6, inter-quartile range (IQR) 0 to 1): 54/141 (38%) of patients had some degree of nausea or vomiting. Median NVS on hospital arrival (after morphine) was 0 (range of 0 to 6, IQR 0 to 1): 54/130 (42%) patients had some degree of nausea or vomiting. The differences pre- vs. post-morphine in median NVS (p=0.98) and proportion of patients suffering nausea and vomiting are not statistically significant (p=0.98 and p=0.54 respectively). There were no significant correlations between pre-morphine pain score and pre-morphine NVS; post-morphine pain score and post-morphine NVS; pre-morphine NVS and total morphine dose; and post-morphine NVS and total morphine dose (Spearman's rank correlation 0.09, p=0.274; 0.07, p=0.44; 0.10, p=0.25; and 0.10, p=0.24 respectively). Conclusion and recommendations To date this study has found no evidence that pre-hospital administration of morphine is associated with an increased incidence or severity of nausea and vomiting and therefore does not appear to support the routine co-administration of metoclopramide. https://emj.bmj.com/content/emermed/28/3/237.2.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emj.2010.108597.

07 Incidence of peri-opiate nausea and vomiting in the pre-Hospital setting: an intermediate analysis [Abstract]

Background Intravenous morphine is the preferred drug for the treatment of moderate to severe pain by paramedics. Nausea and vomiting are believed to be frequent side-effects and routine co-administration of metoclopramide is common. In the absence of pre-hospital data to support this practice, we sought to determine the incidence of peri-opiate nausea and vomiting in an ambulance service which does not administer anti-emetics. Methods This prospective observational study is currently assessing the incidence of emesis in 400 patients attended by the North East Ambulance Service, aged above 17 years and receiving morphine, using a patient-scored Nausea and Vomiting Score (NVS: 0=no nausea or vomiting, 1=slight nausea, 2=moderate nausea, 3=severe nausea, 4=vomited once, 5=vomited twice or more). Results To date 145 patients have been recruited. Median NVS before morphine was 0 (range 0 to 6, inter-quartile range (IQR) 0 to 1): 54/141 (38%) of patients had some degree of nausea or vomiting. Median NVS on hospital arrival (after morphine) was 0 (range of 0 to 6, IQR 0 to 1): 54/130 (42%) patients had some degree of nausea or vomiting. The differences pre- vs. post-morphine in median NVS (p=0.98) and proportion of patients suffering nausea and vomiting are not statistically significant (p=0.98 and p=0.54 respectively). There were no significant correlations between pre-morphine pain score and pre-morphine NVS; post-morphine pain score and post-morphine NVS; pre-morphine NVS and total morphine dose; and post-morphine NVS and total morphine dose (Spearman's rank correlation 0.09, p=0.274; 0.07, p=0.44; 0.10, p=0.25; and 0.10, p=0.24 respectively). Conclusion and recommendations To date this study has found no evidence that pre-hospital administration of morphine is associated with an increased incidence or severity of nausea and vomiting and therefore does not appear to support the routine co-administration of metoclopramide

Modeling outcomes following redirection of emergency stroke admissions from ten local stroke units to two neuroscience centres

Introduction: Pre-hospital redirection of patients to regional stroke centres has been proposed as a strategy to maximize the opportunity for intravenous thrombolysis. We developed a model to quantify the benefit of redirection away from local services that were already providing thrombolysis. Method: A micro-simulation on hospital and ambulance data from 1,884 consecutive emergency admissions to 10 local acute stroke units estimated the annualised effect of redirection to the nearest of two regional neuroscience centres. This reflected geographical information system calculation of new journey time, accuracy of pre-hospital stroke identification by Face Arm Speech Test and relative changes in thrombolysis eligibility, efficiency of patient selection and door-needle time between each local site and the nearest hub. A decision analytical model estimated the outcome for individual patients. All other aspects of care were considered equivalent. Results: Based upon actual site performance, 103 additional patients would have been treated annually following redirection of 1772 FAST true positive cases and 511 stroke mimics. 392 FAST false negative cases would have been transported to a local site. If treatment decisions at neuroscience centres were modelled on maximum, median and minimum clinical benefit there would have been a change in independent (modified Rankin Score 0–2) patients of +3.0% (26 people), +1.8% (16 people) and −0.003% (0.35 people) respectively. Conclusion: Except under the most pessimistic clinical assumptions, redirection could have improved outcomes. This reflected regional geography, higher treatment rates and/or shorter door to needle times at the neuroscience centres compared to local units