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Annals of Emergency Medicine Aug 2008Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search... (Review)
Review
Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.
Topics: Crowding; Emergency Service, Hospital; Health Services Accessibility; Humans; Operations Research; Quality of Health Care
PubMed: 18433933
DOI: 10.1016/j.annemergmed.2008.03.014 -
Resuscitation Mar 2020Heat stroke is an emergent condition characterized by hyperthermia (>40 °C/>104 °F) and nervous system dysregulation. There are two primary etiologies: exertional... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Heat stroke is an emergent condition characterized by hyperthermia (>40 °C/>104 °F) and nervous system dysregulation. There are two primary etiologies: exertional which occurs during physical activity and non-exertional which occurs during extreme heat events without physical exertion. Left untreated, both may lead to significant morbidity, are considered a special circumstance for cardiac arrest, and cause of mortality.
METHODS
We searched Medline, Embase, CINAHL and SPORTDiscus. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods and risk of bias assessments to determine the certainty and quality of evidence. We included randomized controlled trials, non-randomized trials, cohort studies and case series of five or more patients that evaluated adults and children with non-exertional or exertional heat stroke or exertional hyperthermia, and any cooling technique applicable to first aid and prehospital settings. Outcomes included: cooling rate, mortality, neurological dysfunction, adverse effects and hospital length of stay.
RESULTS
We included 63 studies, of which 37 were controlled studies, two were cohort studies and 24 were case series of heat stroke patients. Water immersion of adults with exertional hyperthermia [cold water (14-17 °C/57.2-62.6 °F), colder water (8-12 °C/48.2-53.6 °F) and ice water (1-5 °C/33.8-41 °F)] resulted in faster cooling rates when compared to passive cooling. No single water temperature range was found to be associated with a quicker core temperature reduction than another (cold, colder or ice).
CONCLUSION
Water immersion techniques (using 1-17 °C water) more effectively lowered core body temperatures when compared with passive cooling, in hyperthermic adults. The available evidence suggests water immersion can rapidly reduce core body temperature in settings where it is feasible.
Topics: Adult; Body Temperature; Child; Cold Temperature; Fever; First Aid; Heat Stroke; Humans; Hyperthermia
PubMed: 31981710
DOI: 10.1016/j.resuscitation.2020.01.007 -
JAMA Neurology Mar 2022So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care.
OBJECTIVE
To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS).
DATA SOURCES
MEDLINE, Cochrane Library, and Embase from 1960 to 2021.
STUDY SELECTION
Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies.
DATA EXTRACTION AND SYNTHESIS
Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses.
MAIN OUTCOMES AND MEASURES
The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days).
RESULTS
Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT.
CONCLUSIONS AND RELEVANCE
Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.
Topics: Brain Ischemia; Fibrinolytic Agents; Humans; Ischemic Stroke; Mobile Health Units; Stroke; Thrombolytic Therapy; Treatment Outcome
PubMed: 35129584
DOI: 10.1001/jamaneurol.2021.5321 -
International Journal of Biometeorology Oct 2023Ambulance data has been reported to be a sensitive indicator of health service use during hot days, but there is no comprehensive summary of the quantitative association... (Meta-Analysis)
Meta-Analysis Review
Ambulance data has been reported to be a sensitive indicator of health service use during hot days, but there is no comprehensive summary of the quantitative association between heat and ambulance dispatches. We conducted a systematic review and meta-analysis to retrieve and synthesise evidence published up to 31 August 2022 about the association between heat, prolonged heat (i.e. heatwaves), and the risk of ambulance dispatches. We initially identified 3628 peer-reviewed papers and included 48 papers which satisfied the inclusion criteria. The meta-analyses showed that, for each 5 °C increase in mean temperature, the risk of ambulance dispatches for all causes and for cardiovascular diseases increased by 7% (95% confidence interval (CI): 5%, 10%) and 2% (95% CI: 1%, 3%), respectively, but not for respiratory diseases. The risk of ambulance dispatches increased by 6% (95% CI: 4%, 7%), 7% (95% CI: 5%, 9%), and 18% (95% CI: 12%, 23%) under low-intensity, severe, and extreme heatwaves, respectively. We observed two potential sources of bias in the existing literature: (1) bias in temperature exposure measurement; and (2) bias in the ascertainment of ambulance dispatch causes. This review suggests that heat exposure is associated with an increased risk of ambulance dispatches, and there is a dose-response relationship between heatwave intensity and the risk of ambulance dispatches. For future studies assessing the heat-ambulance association, we recommend that (1) using data on spatially refined gridded temperature that is either very well interpolated or derived from satellite imaging may be an alternative to reduce exposure measurement bias; and (2) linking ambulance data with hospital admission data can be useful to improve health outcome classification.
Topics: Humans; Ambulances; Hot Temperature; Temperature; Hospitalization; Cardiovascular Diseases
PubMed: 37495745
DOI: 10.1007/s00484-023-02525-0 -
F1000Research 2020: This review aims to describe the activities of nurse practitioners (NPs) and physician assistants (PAs) working in ambulance care, and the effect of these activities... (Review)
Review
: This review aims to describe the activities of nurse practitioners (NPs) and physician assistants (PAs) working in ambulance care, and the effect of these activities on patient outcomes, process of care, provider outcomes, and costs. : PubMed, MEDLINE (EBSCO), EMBASE (OVID), Web of Science, the Cochrane Library (Cochrane Database of Systematic Review), CINAHL Plus, and the reference lists of the included articles were systematically searched in November 2019. All types of peer-reviewed designs on the three topics were included. Pairs of independent reviewers performed the selection process, the quality assessment, and the data extraction. : Four studies of moderate to poor quality were included. Activities in medical, communication and collaboration skills were found. The effects of these activities were found in process of care and resource use outcomes, focusing on non-conveyance rates, referral and consultation, on-scene time, or follow-up contact s: This review shows that there is limited evidence on activities of NPs and PAs in ambulance care. Results show that NPs and PAs in ambulance care perform activities that can be categorized into the Canadian Medical Education Directives for Specialists (CanMED) roles of Medical Expert, Communicator, and Collaborator. The effects of NPs and PAs are minimally reported in relation to process of care and resource use, focusing on non-conveyance rates, referral and consultation, on-scene time, or follow-up contact. No evidence on patient outcomes of the substitution of NPs and PAs in ambulance care exists. : CRD42017067505 (07/07/2017).
Topics: Ambulances; Canada; Humans; Nurse Practitioners; Physician Assistants
PubMed: 33456765
DOI: 10.12688/f1000research.25891.1 -
Environmental Science and Pollution... Sep 2022Previous studies have quantified the associations between ambient temperature and dispatch of ambulances, but the conclusions are still controversial. Therefore, a... (Meta-Analysis)
Meta-Analysis
Previous studies have quantified the associations between ambient temperature and dispatch of ambulances, but the conclusions are still controversial. Therefore, a systematic review and meta-analysis were conducted to summarize all the current evidence. A systematic review of published literature was undertaken to characterize the effect of temperature on ambulance dispatch. We completed the literature search by the end of January 5, 2022. The pooled estimates for different temperature exposures were calculated using a random effects model. Differences among temperature pooled estimates were determined using subgroup analysis. This study was registered with PROSPERO under the number CRD42021284434. This is the first meta-analysis investigating the association between temperature and ambulance dispatch. A total of 25 studies were eligible for this study. The overall increased risks of high temperature, expressed as relative risks, were 1.734 (95% CI: 1.481-2.031). Subgroup analysis found that for the study using daily mean temperature, the high temperature increased the risk of ambulance dispatch by 15.2% (RR = 1.152, 95%CI: 1.081-1.228). In the ambulance dispatch of all-cause subgroups, the RR was 1.179 (95% CI: 1.085-1.282). The results also reported a significant association between low temperature and ambulance dispatch (RR = 1.130, 95% CI: 1.052-1.213). In the subgroup, the RR for cardiovascular disease was 1.209 (95% CI: 1.033-1.414), and respiratory disease was 1.126 (95% CI: 1.012-1.253). Sensitivity analysis indicated that the results were robust, and no obvious publication bias was observed. High temperature and low temperature are important factors influencing the dispatch of ambulances. These findings help improve the understanding of temperature effect on ambulance dispatch, demonstrating the need to consider wider surveillance of acute health outcomes in different environments.
Topics: Ambulances; Cold Temperature; Hot Temperature; Risk; Temperature
PubMed: 35499723
DOI: 10.1007/s11356-022-20508-3 -
Odontology Oct 2019Recently, sealers based on calcium silicates were developed as a new class of endodontic sealers. Inspired by the excellent sealing ability and biocompatibility of... (Review)
Review
Recently, sealers based on calcium silicates were developed as a new class of endodontic sealers. Inspired by the excellent sealing ability and biocompatibility of calcium silicate-based cements, these sealers establish a biological point of view on the obturation of root canals. No longer, the bacteria-tight seal against reinfection of the root canal is the only goal of root canal obturation. Antibacterial properties as well as bioactive inducement of periapical healing and hard tissue formation are added to the portfolio of sealers. Ready-to-use sealers consisting of only one component with a need for external water supply from, e.g., body fluid and two components sealers with internal water supply were introduced to the market. Both of these material types have the same setting reactions in common whereby a hydration reaction of the calcium silicate is followed by a precipitation reaction of calcium phosphate. Though the available sealers are all based on calcium silicates, they consist of different compositions. Due to this aspect, differences in their physical and chemical properties as well as in their in vitro characteristics were described. Studies addressing the clinical impact of calcium silicate-based sealers on outcome are still sparse. The bioactive potential of sealers based on calcium silicates is a consequence of the slight solubility of these materials even after setting, but solubility of the sealer might also compromise the quality of sealing a root canal against regrowth and reinfection. Further clinical investigations are required to evaluate the clinical relevance of the gulf between bioactivity and solubility.
Topics: Calcium Compounds; Drug Combinations; Epoxy Resins; Materials Testing; Root Canal Filling Materials; Root Canal Obturation; Silicates
PubMed: 30554288
DOI: 10.1007/s10266-018-0400-3 -
Resuscitation Nov 2022Objective: To conduct a systematic review of the published evidence related to family presence during adult resuscitation from cardiac arrest. (Review)
Review
AIM
Objective: To conduct a systematic review of the published evidence related to family presence during adult resuscitation from cardiac arrest.
METHODS
This review, registered with PROSPERO (CRD42021242384) and reported according to PRISMA guidelines, included studies of adult cardiac arrest with family presence during resuscitation that reported one or more patient, family or provider outcomes. Three databases (Medline, CINAHL and EMBASE) were searched from inception to 10/05/2022. Two investigators screened the studies, extracted data, and assessed risks of bias using the Mixed Method Appraisal Tool (MMAT). The synthesis approach was guided by Synthesis Without Meta-Analysis (SWiM) reporting guidelines and a narrative synthesis method.
RESULTS
The search retrieved 9,459 citations of which 31 were included: 18 quantitative studies (including two RCTs), 12 qualitative studies, and one mixed methods study. The evidence was of very low or low certainty. There were four major findings. High-certainty evidence regarding the effect of family presence during resuscitation on patient outcomes is lacking. Family members had mixed outcomes in terms of depression, anxiety, post-traumatic stress disorder (PTSD) symptoms, and experience of witnessing resuscitation. Provider experience was variable and resuscitation setting, provider education, and provider experience were major influences on family presence during resuscitation. Finally, providers reported that a family support person and organisational guidelines were important for facilitating family presence during resuscitation.
CONCLUSION
The effect of family presence during resuscitation varies between individuals. There was variability in the effect of family presence during resuscitation on patient outcomes, family and provider outcomes and perceptions.
PubMed: 36087636
DOI: 10.1016/j.resuscitation.2022.08.021 -
Scandinavian Journal of Trauma,... Jul 2017This systematic review aimed to describe non-conveyance in ambulance care from patient-safety and ambulance professional perspectives. The review specifically focussed... (Review)
Review
BACKGROUND
This systematic review aimed to describe non-conveyance in ambulance care from patient-safety and ambulance professional perspectives. The review specifically focussed at describing (1) ambulance non-conveyance rates, (2) characteristics of non-conveyed patients, (3) follow-up care after non-conveyance, (4) existing guidelines or protocols, and (5) influencing factors during the non-conveyance decision making process.
METHODS
We systematically searched MEDLINE, PubMed, CINAHL, EMBASE, and reference lists of included articles, in June 2016. We included all types of peer-reviewed designs on the five topics. Couples of two independent reviewers performed the selection process, the quality assessment, and data extraction.
RESULTS
We included 67 studies with low to moderate quality. Non-conveyance rates for general patient populations ranged from 3.7%-93.7%. Non-conveyed patients have a variety of initial complaints, common initial complaints are related to trauma and neurology. Furthermore, vulnerable patients groups as children and elderly are more represented in the non-conveyance population. Within 24 h-48 h after non-conveyance, 2.5%-6.1% of the patients have EMS representations, and 4.6-19.0% present themselves at the ED. Mortality rates vary from 0.2%-3.5% after 24 h, up to 0.3%-6.1% after 72 h. Criteria to guide non-conveyance decisions are vital signs, ingestion of drugs/alcohol, and level of consciousness. A limited amount of non-conveyance guidelines or protocols is available for general and specific patient populations. Factors influencing the non-conveyance decision are related to the professional (competencies, experience, intuition), the patient (health status, refusal, wishes and best interest), the healthcare system (access to general practitioner/other healthcare facilities/patient information), and supportive tools (online medical control, high risk card).
CONCLUSIONS
Non-conveyance rates for general and specific patient populations vary. Patients in the non-conveyance population present themselves with a variety of initial complaints and conditions, common initial complaints or conditions are related to trauma and neurology. After non-conveyance, a proportion of patients re-enters the emergency healthcare system within 2 days. For ambulance professionals the non-conveyance decision-making process is complex and multifactorial. Competencies needed to perform non-conveyance are marginally described, and there is a limited amount of supportive tools is available for general and specific non-conveyance populations. This may compromise patient-safety.
Topics: Air Ambulances; Clinical Decision-Making; Humans; Patient Safety; Patient Selection
PubMed: 28716132
DOI: 10.1186/s13049-017-0409-6 -
The Journal of Hospital Infection Apr 2022Healthcare-associated infections (HAIs) are infections that patients acquire while receiving medical treatment in a healthcare facility. During ambulatory transport, the... (Review)
Review
Healthcare-associated infections (HAIs) are infections that patients acquire while receiving medical treatment in a healthcare facility. During ambulatory transport, the patient may be exposed to pathogens transmitted from emergency medical service (EMS) personnel or EMS surfaces.The aim of this study was to determine whether organisms commonly associated with HAIs have been detected on surfaces in the patient-care compartment of ambulances. Five electronic databases - PubMed, Scopus, Web of Science, Embase and Google Scholar were used to search for articles using inclusion and exclusion criteria following the PRISMA checklist. Inclusion criteria consisted of articles published in English, between 2009 and 2020, had positive samples collected from the patient-care compartment of a ground ambulance, and reported sample collection methods of either swab sampling and/or Replicate Organism Detection and Counting (RODAC) contact plates. Studies not meeting these criteria were excluded from this review. From a total of 1376 articles identified, 16 were included in the review. Organisms associated with HAIs were commonly detected in the patient-care compartment of ambulances across a variety of different surfaces, including blood pressure cuffs, oxygen apparatuses, and areas of patient stretchers. A high prevalence of pathogenic bacteria in ambulances suggests that standard protocols related to cleaning compliance may not be effective. The primary recommendation is that designated subject matter experts in infection prevention should be incorporated as liaisons in the pre-hospital setting, acting as a link between the pre-hospital (e.g., ambulance transport) and hospital environments.
Topics: Ambulances; Bacteria; Cross Infection; Emergency Medical Services; Humans
PubMed: 35031392
DOI: 10.1016/j.jhin.2021.12.020