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      The difficult medical emergency call: A register-based study of predictors and outcomes

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          Abstract

          Background

          Pre-hospital emergency care requires proper categorization of emergency calls and assessment of emergency priority levels by the medical dispatchers. We investigated predictors for emergency call categorization as “unclear problem” in contrast to “symptom-specific” categories and the effect of categorization on mortality.

          Methods

          Register-based study in a 2-year period based on emergency call data from the emergency medical dispatch center in Copenhagen combined with nationwide register data. Logistic regression analysis (N = 78,040 individuals) was used for identification of predictors of emergency call categorization as “unclear problem”. Poisson regression analysis ( N = 97,293 calls) was used for examining the effect of categorization as “unclear problem” on mortality.

          Results

          “Unclear problem” was the registered category in 18% of calls. Significant predictors for “unclear problem” categorization were: age (odds ratio (OR) 1.34 for age group 76+ versus 18–30 years), ethnicity (OR 1.27 for non-Danish vs. Danish), day of week (OR 0.92 for weekend vs. weekday), and time of day (OR 0.79 for night vs. day). Emergency call categorization had no effect on mortality for emergency priority level A calls, incidence rate ratio (IRR) 0.99 (95% confidence interval (CI) 0.90–1.09). For emergency priority level B calls, an association was observed, IRR 1.26 (95% CI 1.18–1.36).

          Discussions

          The results shed light on the complexity of emergency call handling, but also implicate a need for further improvement. Educational interventions at the dispatch centers may improve the call handling, but also the underlying supportive tools are modifiable. The higher mortality rate for patients with emergency priority level B calls with “unclear problem categorization” could imply lowering the threshold for dispatching a high level ambulance response when the call is considered unclear. On the other hand a “benefit of the doubt” approach could hinder the adequate response to other patients in need for an ambulance as there is an increasing demand and limited resources for ambulance services.

          Conclusions

          Age, ethnicity, day of week and time of day were significant predictors of emergency call categorization as “unclear problem”. “Unclear problem” categorization was not associated with mortality for emergency priority level A calls, but a higher mortality was observed for emergency priority level B calls.

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          Most cited references22

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          System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.

          Timely reperfusion therapy is recommended for patients with ST-segment elevation myocardial infarction (STEMI), and door-to-balloon delay has been proposed as a performance measure in triaging patients for primary percutaneous coronary intervention (PCI). However, focusing on the time from first contact with the health care system to the initiation of reperfusion therapy (system delay) may be more relevant, because it constitutes the total time to reperfusion modifiable by the health care system. No previous studies have focused on the association between system delay and outcome in patients with STEMI treated with primary PCI. To evaluate the associations between system, treatment, patient, and door-to-balloon delays and mortality in patients with STEMI. Historical follow-up study based on population-based Danish medical registries of patients with STEMI transported by the emergency medical service and treated with primary PCI from January 1, 2002, to December 31, 2008, at 3 high-volume PCI centers in Western Denmark. Patients (N = 6209) underwent primary PCI within 12 hours of symptom onset. The median follow-up time was 3.4 (interquartile range, 1.8-5.2) years. Crude and adjusted hazard ratios of mortality obtained by Cox proportional regression analysis. A system delay of 0 through 60 minutes (n = 347) corresponded to a long-term mortality rate of 15.4% (n = 43); a delay of 61 through 120 minutes (n = 2643) to a rate of 23.3% (n = 380); a delay of 121 through 180 minutes (n = 2092) to a rate of 28.1% (n = 378); and a delay of 181 through 360 minutes (n = 1127) to a rate of 30.8% (n = 275) (P < .001). In multivariable analysis adjusted for other predictors of mortality, system delay was independently associated with mortality (adjusted hazard ratio, 1.10 [95% confidence interval, 1.04-1.16] per 1-hour delay), as was its components, prehospital system delay and door-to-balloon delay. System delay was associated with mortality in patients with STEMI treated with primary PCI.
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            A simple method to calculate the confidence interval of a standardized mortality ratio (SMR)

            K Ulm (1990)
            In analyzing standardized mortality ratios (SMRs), it is of interest to calculate a confidence interval for the true SMR. The exact limits of a specific interval can be obtained by means of the Poisson distribution either within an iterative procedure or by one of the tables. The limits can be approximated in using one of various shortcut methods. In this paper, a method is described for calculating the exact limits in a simple and easy way. The method is based on the link between the chi 2 distribution and the Poisson distribution. Only a table of the chi 2 distribution is necessary.
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              Improving door-to-needle times in acute ischemic stroke: the design and rationale for the American Heart Association/American Stroke Association's Target: Stroke initiative.

              The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time-dependent, and guidelines recommend a door-to-needle time of ≤60 minutes. However, fewer than one third of acute ischemic stroke patients who receive tPA are treated within guideline-recommended door-to-needle times. This article describes the design and rationale of Stroke, a national initiative organized by the American Heart Association/American Stroke Association in partnership with other organizations to assist hospitals in increasing the proportion of tPA-treated patients who achieve guideline-recommended door-to-needle times. The initial program goal is to achieve a door-to-needle time≤60 minutes for at least 50% of acute ischemic stroke patients. Key best practice strategies previously associated with achieving faster door-to-needle times in acute ischemic stroke were identified. The 10 key strategies chosen by Stroke include emergency medical service prenotification, activating the stroke team with a single call, rapid acquisition and interpretation of brain imaging, use of specific protocols and tools, premixing tPA, a team-based approach, and rapid data feedback. The program includes many approaches intended to promote hospital participation, implement effective strategies, share best practices, foster collaboration, and achieve stated goals. A detailed program evaluation is also included. In the first year, Stroke has enrolled over 1200 United States hospitals. Stroke, a multidimensional initiative to improve the timeliness of tPA administration, aims to elevate clinical performance in the care of acute ischemic stroke, facilitate the more rapid integration of evidence into clinical practice, and improve outcomes.
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                Author and article information

                Contributors
                +45 51903247 , tpm@dadlnet.dk
                thok@si-folkesundhed.dk
                viereck.soeren@gmail.com
                Doris.OEstergaard@regionh.dk
                fredrik.folke@regionh.dk
                ake@si-folkesundhed.dk
                freddy.lippert@regionh.dk
                Journal
                Scand J Trauma Resusc Emerg Med
                Scand J Trauma Resusc Emerg Med
                Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
                BioMed Central (London )
                1757-7241
                1 March 2017
                1 March 2017
                2017
                : 25
                : 22
                Affiliations
                [1 ]ISNI 0000 0001 0674 042X, GRID grid.5254.6, Emergency Medical Services Copenhagen, , University of Copenhagen, ; Telegrafvej 5, 2750 Ballerup, Denmark
                [2 ]ISNI 0000 0001 0728 0170, GRID grid.10825.3e, National Institute of Public Health, , University of Southern Denmark, ; Øster Farimagsgade 5A, 1353 København K, Denmark
                [3 ]ISNI 0000 0001 0674 042X, GRID grid.5254.6, Copenhagen Academy for Medical Education and Simulation, , University of Copenhagen, ; Herlev Ringvej 75, 2730 Herlev, Denmark
                Article
                366
                10.1186/s13049-017-0366-0
                5333377
                28249588
                81dfd0b7-15d5-452c-858d-8a5db2ee76a7
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 29 September 2016
                : 15 February 2017
                Categories
                Original Research
                Custom metadata
                © The Author(s) 2017

                Emergency medicine & Trauma
                emergency call,emergency medical dispatching,emergency medical services,pre-hospital emergency care,triage

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